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Planned informational and supportive nursing interventions to reduce the effects of treatment stress… Peeling, Barbara Joan 1977

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PLANNED INFORMATIONAL AND SUPPORTIVE NURSING INTERVENTIONS TO REDUCE THE EFFECTS OF TREATMENT STRESS IN BURN PATIENTS by BARBARA JOAN PEELING B.Sc.N., U n i v e r s i t y o f T o r o n t o , 1970 A THESIS SUBMITTED IN PARTIAL FULFILLMENT 'OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING i n THE SCHOOL OF NURSING We a c c e p t t h i s t h e s i s as c o n f o r m i n g t o t h e r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA May, 1977 (jp Barbara Joan P e e l i n g , 1977 In p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l l m e n t o f the r e q u i r e m e n t s f o r an advanced degree a t the U n i v e r s i t y o f B r i t i s h Columbia, I agree t h a t the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g o f t h i s t h e s i s f o r s c h o l a r l y purposes may be g r a n t e d by the Head o f my Department o r by h i s r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g o r p u b l i c a t i o n o f t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n p e r m i s s i o n . Department o f The U n i v e r s i t y o f B r i t i s h Columbia Vancouver 8, Canada Date fljr»jjt, / ? 7 7 i i ABSTRACT Planned I n f o r m a t i o n a l and S u p p o r t i v e N u r s i n g I n t e r v e n t i o n s To Reduce the E f f e c t s o f Treatment S t r e s s i n Burn P a t i e n t s S t r e s s a s s o c i a t e d w i t h t r e a t m e n t s i s a p o t e n t i a l cause o f a n x i e t y i n the burn p a t i e n t . T h i s d e s c r i p t i v e study examined the emotional r e a c t i o n s to the e f f e c t s o f t r e a t m e n t s t r e s s i n f i v e a d u l t burn v i c t i m s d u r i n g h o s p i t a l i z a t i o n . The purpose o f the s t u d y was t o i n v e s t i g a t e the e f f e c t i v e n e s s o f an i n s t r u c t i o n a l program p r o v i d i n g t r e a t m e n t i n f o r m a t i o n f o l l o w e d by p s y c h o l o g i c a l s u p p o r t i n r e d u c i n g the e f f e c t s o f t r e a t m e n t s t r e s s i n burn p a t i e n t s . I d e n t i f i c a t i o n and a c c u m u l a t i o n o f i n f o r m a t i o n about a n x i e t y p r o d u c i n g s t r e s s o r s d u r i n g h o s p i t a l i z a t i o n as p e r c e i v e d by the burn p a t i e n t s was one outcome o f the s t u d y . The i n s t r u c t i o n a l program i n c l u d e d an a u d i o - v i s u a l t e a c h i n g program d e p i c t i n g v a r i o u s t r e a t m e n t s i n burn c a r e f o l l o w e d by a d i s c u s s i o n between the i n v e s t i g a t o r and the p a t i e n t . The d e s i g n o f the study was a one group p r e - t e s t , m u l t i p l e p o s t - t e s t approach. S e v e r a l v a r i a b l e s w i t h i n the group were compared from two p e r s p e c t i v e s . C o r r e l a t i o n a l s t a t i s t i c s were a p p l i e d t o i n d i c a t e the r e l a t i o n s h i p o f t h e s e v a r i a b l e s i n the r e a l i t y o f the ongoing s i t u a t i o n o f burn c a r e . B r i e f l y , the n u l l hypotheses c h a l l e n g e d were: 1. There i s no measurable change i n t r a i t a n x i e t y o v e r u n i t time .... 2. There i s no measurable r e d u c t i o n o f s t a t e a n x i e t y o v e r u n i t time i i i 3. There i s no measurable i n c r e a s e i n hours o f s l e e p o v e r u n i t time 4. There i s no measurable r e d u c t i o n i n e x p r e s s e d need f o r a n a l g e s i c and s e d a t i v e m e d i c a t i o n o v e r u n i t time 5. T h e r e i s no measurable i n d i c a t i o n o f i n c r e a s e d r e p o r t e d w e l l - b e i n g o v e r u n i t time 6. There i s no c o r r e l a t i o n between the n u r s e s ' assessment o f the p a t i e n t s t r a i t a n x i e t y l e v e l and the t r a i t a n x i e t y measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s . 7. There i s no c o r r e l a t i o n between the n u r s e s ' assessment o f the p a t i e n t s ' s t a t e a n x i e t y and the s t a t e a n x i e t y measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s . Date c o l l e c t i n g i n s t r u m e n t s measured the v a r i a b l e s o f o b j e c t i v e and s u b j e c t i v e s t r e s s . Such v a r i a b l e s were s t a t e and t r a i t a n x i e t y , q u a n t i t y o f s l e e p and need f o r m e d i c a t i o n . A n a l y s i s o f the data r e v e a l e d t h a t t h e r e was a d i s t i n c t t r e n d t o r e d u c t i o n i n s t a t e a n x i e t y and l i t t l e change i n t r a i t a n x i e t y d u r i n g h o s p i t a l i z a t i o n . However, t h e r e was no measurable i n c r e a s e i n the hours o f s l e e p and no measurable d e c r e a s e i n e x p r e s s e d need f o r m e d i c a t i o n . P a t i e n t s ' comments i n the d a i l y d i a r i e s , as w e l l as o t h e r i n d i c a t o r s o f the h e l p f u l n e s s o f the i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t , were a n o t h e r s o u r c e o f e v i d e n c e t h a t planned i n f o r m a t i o n a l and s u p p o r t i v e n u r s i n g i n t e r v e n t i o n s reduced t h a t a n x i e t y a t t r i b u t a b l e to the e f f e c t s o f t r e a t m e n t s t r e s s . Furthermore, t h e r e were many a n x i e t y p r o d u c i n g s t r e s s o r s d u r i n g h o s p i t a l i z a t i o n as p e r c e i v e d by t h e s e p a t i e n t s . G e n e r a l l y , the s t r e s s o r s were a s s o c i a t e d w i t h burn t r e a t m e n t and p a t i e n t - n u r s e r e l a t i o n s h i p s . Trends and phases o f r e c o v e r y were seen among a l l t h e s e p a t i e n t s t h r o u g h o u t i v the e n t i r e d a t a c o l l e c t i o n p e r i o d . The f i n d i n g s o f the study i n d i c a t e d t h a t even l e s s s e v e r e l y burned p a t i e n t s s u f f e r i n t e n s e p s y c h o l o g i c a l r e sponse to burn i n j u r y . Planned n u r s i n g i n t e r v e n t i o n s , p r o v i d e d by a person not r e s p o n s i b l e f o r d a i l y p h y s i c a l c a r e , was p e r c e i v e d by the p a t i e n t s under s t u d y as r e d u c i n g t h a t a n x i e t y a t t r i b u t a b l e to t h e e f f e c t s o f t r e a t m e n t s t r e s s . V TABLE OF CONTENTS ABSTRACT i i LIST OF TABLES v i i ACKNOWLEDGEMENTS v i i i C h a p t e r 1. INTRODUCTION .; Statement o f the Problem Purposes o f the Study N u l l Hypotheses S i g n i f i c a n c e o f the Study D e f i n i t i o n o f Terms Assumptions L i m i t a t i o n s Overview o f Methodology Development o f Remaining C h a p t e r s 2. REVIEW OF THE LITERATURE 14 P s y c h o l o g i c a l I m p l i c a t i o n s o f Burn Care P a i n and I t s R e l a t i o n s h i p t o A n x i e t y The Concept o f A n x i e t y The I m p l i c a t i o n s f o r an A u d i o - V i s u a l T e a c h i n g P l a n on a Burn U n i t The T h e r a p e u t i c N u r s e - P a t i e n t R e l a t i o n s h i p The E f f e c t o f A n x i e t y on Sl e e p P a t t e r n s Summary 3. THE STUDY , 42 ",The S e t t i n g The Sample Method o f Data C o l l e c t i o n D e l i n e a t i o n o f V a r i a b l e s Data G a t h e r i n g Instruments Method o f Data A n a l y s i s vi-C h a p t e r 4. THE FINDINGS 61 I n t r o d u c t i o n E v a l u a t i o n o f the Planned N u r s i n g I n t e r v e n t i o n s from Data C o l l e c t i n g Instruments E v a l u a t i o n o f the Planned N u r s i n g I n t e r v e n t i o n s from P a t i e n t Comments S t a t i s t i c a l A n a l y s i s o f the F i n d i n g s P s y c h o l o g i c a l Phases o f Burn Care i n H o s p i t a l i z e d P a t i e n t s D i s c u s s i o n o f the F i n d i n g s Summary 5. SUMMARY, RECOMMENDATIONS, CONCLUSIONS 118 Summary Recommendations I m p l i c a t i o n s f o r F u r t h e r Study C o n c l u s i o n s BIBLIOGRAPHY 124 APPENDICES A Consent Form 132b B S t a t e - T r a i t A n x i e t y I n v e n t o r y 133b C S c r i p t o f the A u d i o - V i s u a l Program 135b D E v a l u a t i o n o f the I n s t r u c t i o n a l Program 151b E S l e e p Record 157b F M e d i c a t i o n Record 158b G Nurses' Assessment o f P a t i e n t A n x i e t y 159b H P a t i e n t ' s P e r s o n a l D i a r y 160b VI 1 LIST OF TABLES TABLE 1 INTERPRETATION OF THE STAI SCORES 1-1 SCORES OF THE STAI 1-2 SCORES OF THE STAI 1-3 SCORES OF THE STAI 1-4 SCORES OF THE STAI 1-5 SCORES OF THE STAI 2 TOTAL SCORES OF THE "TRAIT" PORTION OF THE STATE-TRAIT ANXIETY INVENTORY , TOTAL SCORES OF THE "STATE" PORTION OF THE 6 STATE-TRAIT ANXIETY INVENTORY AND TOTAL SCORES OF THE DIARY SCORES OF THE "TRAIT" PORTION OF THE STATE-TRAIT 4 ANXIETY INVENTORY AND SCORES OF THE NURSES' ASSESSMENT OF TRAIT ANXIETY 5 SCORES OF THE "STATE" PORTION OF THE STATE-TRAIT ANXIETY INVENTORY AND SCORES OF THE NURSES' ASSESSMENT OF STATE ANXIETY. VI1 1 ACKNOWLEDGEMENTS The a u t h o r g r a t e f u l l y e x p r e s s e s a p p r e c i a t i o n f o r t he a s s i s t a n c e g i v e n by many pe o p l e d u r i n g t he p r e p a r a t i o n o f t h i s t h e s i s . S i n c e r e g r a t i t u d e i s extended to Dr. Ruth Z i t n i k and Dr. Ja c k Yensen f o r the hours spent i n c o n s u l t a t i o n d u r i n g t he p r e p a r a t i o n o f t h i s s t u d y . T h e i r t i r e l e s s e f f o r t s and s u p p o r t were d e e p l y a p p r e c i a t e d . S p e c i a l thanks a r e extended t o the p a t i e n t s , nurses and o t h e r s t a f f members o f the burn u n i t f o r t h e i r w i l l i n g c o o p e r a t i o n and i n t e r e s t . The a u t h o r would l i k e t o e x p r e s s s i n c e r e a p p r e c i a t i o n t o Mrs. W i n i f r e d M i l l e r , c l i n i c a l d i r e c t o r o f p s y c h i a t r i c n u r s i n g , f o r her genuine i n t e r e s t and c o n t r i b u t i o n t h r o u g h o u t t he p r e p a r a t i o n o f t h i s t h e s i s . G r a t i t u d e i s conveyed t o Miss P r i m r o s e G o n t i e r f o r t y p i n g t he ma n u s c r i p t . Chapter 1 INTRODUCTION Stress associated with treatments i s a potent ia l cause of anxiety in the burned pat ient . The ef fects of treatment stress vary among ind iv idua ls . Every burn pat ient reacts d i f f e ren t l y to the stressors in a burn unit and every pat ient experiences a d i f fe ren t level of anxiety. The problem is posed: Would nursing intervent ions comprised of psychological support and an ins t ruc t iona l program providing information about treatments, reduce anxiety in selected burn pat ients? The purpose of th i s study was to invest igate the ef fect iveness of an ins t ruc t iona l program providing treatment information and psychological support in re l i ev ing the ef fects of treatment stress for burn pat ients . Iden t i f i ca t ion and accumulation of information about anxiety-producing stressors during hosp i t a l i za t i on , as perceived by the pat ien ts , was the other major purpose of th is study. "A buJin accident can be doMOuhzd a& a mommt ojj coJidlQJ>&nQAi>, iottovizd by 30 6zconcU> oft acute. tzKKoh. and thm a tiiztimn o$ dl&^QuJiemznt and di^abiLity."^ Burns are among the most devastating in ju r ies sustained by man. Burns not only a f fect an i nd i v idua l ' s physio logical state but also his psychological s ta te . Once a burn has occurred, medical therapy and nursing intervent ions are di rected toward restorat ion and repai r of t i ssues . L i fe -sus ta in ing measures are paramount. Once they are D.M. Jackson, "Reconstruction and Rehabi l i ta t ion After Burning," Nursing Mirror (March 21, 1969), p.30. 1 2 i n i t i a t e d , i t i s usual ly possib le to attend to the psychological process of adjust ing to a burn in jury . During the i n i t i a l few days post i n ju ry , e f fo r ts are di rected toward resolut ion of immediate problems resu l t ing from the burn in ju ry . Innumerable systemic changes take p lace, the most important of which i s the a l te ra t ion in f l u i d and e lec t ro l y te balance. Hypovolemic shock, airway obst ruc t ion, impaired c i r cu l a t i on to extremit ies d i s ta l to c i rcumferent ia l burns are some of the other major problems which may occur.^ •3 Jacoby's object ives of burn care summarize p r i o r i t y problems. The prevention and treatment of shock and the a l l e v i a t i on to f pain are paramount. Control of bacter ia l growth on the burn wound and wi th in the body as well as conversion of the open wound to a closed wound are major object ives of a long term treatment program. Preservation of body function and appearance are continuous object ives from the time of admission to a burn uni t . Of equal importance, however, i s the restorat ion of the mental and emotional equi l ibr ium of the pat ient . I t i s to th is l as t object ive that th i s study i s d i rec ted. Serious emotional problems ex is t in extensively burned pat ients . The management of these problems i s an integral part of overa l l therapy. Betty G. McGranahan, "Nursing Care of the Burned Pa t ien t , " Journal  of the American Operating Room Nurses 20 (November 1974, p.792. Florence G. Jacoby, Nursing Care of the Pat ient With Burns (St. Louis : C.V. Mosby C o . , 1972), p.4. 3 When a severely burned pat ient i s admitted to hosp i t a l , he i s not only in a state of great physical pain but i s also undergoing serious accompanying emotional disturbances. Many of these pat ients are d i f f i c u l t to manage because of t he i r i n a b i l i t y to adjust to the i r changed physical state and the hospital environment. C l i n i c a l experience has demonstrated that emotional factors have considerable 4 inf luence on the pa t ien t ' s rate of physical recovery. An emotional state which has been disrupted in burn pat ients produces anxiety. Anxiety due to fear of the unknown, anxiety due to the p o s s i b i l i t y of deformity, anxiety due to the stress of treatments, these are a l l prevalent. Anxiety may overshadow the pat ient from the moment of his conscious awareness of his accident to months a f te r discharge from the hosp i ta l . The amount of anxiety experienced by an ind iv idual i s a highly personal matter determined by many fac to rs . The fo l lowing incident i l l u s t r a t e s th i s point . The invest igator was observing two burn baths on a burn unit of a large c i t y hosp i ta l . One pat ien t , a 15 year o ld boy, severely burned with tar to 50% of his body was washing and debriding (removing dead t issue from) his own burns with no overt sign of pain. He crawled around in the tank as i f he were enjoying a da i l y tub bath. The next pat ient to go into the burn bath was a 50 year old man. He was burned less severely and to a lesser extent than the teenager. He lay r i g i d on the stretcher being lowered David Hamburg and Cur t is Artz et a l , " C l i n i c a l Importance of Emotional Problems in the Care of Pat ients with Burns," New England Journal  of Medicine 248 (February 26, 1953), p.355. 4 into the tank. He did not move un t i l asked t o , was thoroughly fr ightened and in obvious pain. The d is t ress experienced by th is man was great and i t hindered the debridement of his wounds as well as his a b i l i t y to re lax in the warm whir lpool tank. This example i l l u s t r a t e s that each ind iv idual reacts d i f f e ren t l y to the ef fects of treatment st ress and every ind iv idual experiences a d i f fe rent level of anxiety in s im i l a r s i tua t ions . Statement of the Problem The problem i s stated as a quest ion. Does the use of planned nursing in tervent ions, providing psychological support and treatment informat ion, reduce the ef fects of treatment stress as measured by various indicators of anxiety? Purposes of the Study The purpose of th i s study was to : 1. Investigate the ef fect iveness of an ins t ruc t iona l program providing treatment information and psychological support in re l i ev ing the ef fects of treatment s t ress . 2. Ident i fy and accumulate information about anxiety-producing stressors during hosp i ta l i za t ion as perceived by burn pat ients . Null Hypotheses The fo l lowing nul l hypotheses were considered. 1. There i s no measurable change in t r a i t anxiety over unit time in a sample of burn pat ients receiv ing exposure to an ins t ruc t iona l program and psychological support during the course of treatments as measured by the Sta te-Tra i t Anxiety Inventor ies. 5 2. There i s no measurable reduction of state anxiety over unit time in a sample of burn pat ients receiv ing exposure to an ins t ruc t iona l program and psychological support during the course of treatments as measured by the Sta te-Tra i t Anxiety Inventories and as indicated by the pa t ien ts ' personal d i a r i e s . 3. There i s no measurable increase in the hours of sleep over uni t time in a sample of burn pat ients receiv ing exposure to an ins t ruc t iona l program and psychological support as measured by the nurses' observation on the sleep record and as indicated in the pat ien ts ' personal d i a r i e s . 4. There i s no measurable reduction in expressed need for analgesic and sedative medication over uni t time i n a sample of burn pat ients receiv ing exposure to an ins t ruc t iona l program and psychological support as measured by the nurses' observation on the medication record and as indicated by the pat ien ts ' personal d i a r i e s . 5. There i s no measurable ind icat ion of increased reported wel l -being over unit time in a sample of burn pat ients receiv ing exposure to an ins t ruc t iona l program and psychological support as indicated in the pat ients ' personal d i a r i e s . 6. There is no cor re la t ion between the nurses' assessment of the pat ients ' t r a i t anxiety leve ls and the t r a i t anxiety measured by the Sta te-Tra i t Anxiety Inventor ies. 7. There i s no cor re la t ion between the nurses' assessment of the pat ients ' state anxiety and the state anxiety measured by the Sta te-Tra i t Anxiety Inventories. 6 Signi f icance of the Study The l i t e ra tu re substantiates the problem of anxiety as a var iab le in the care of burn pat ients . Very few studies have been s p e c i f i c a l l y designed to study the psychological problems of burn pat ients . In reviewing the l i t e ra tu re on the nursing care of the burned pa t ien t , systematic approaches to intervent ions in th i s domain, based on assessment of the unique needs of each pat ient , are lack ing . The research aim, therefore, i s to test nursing intervent ions s p e c i f i c a l l y designed to reduce the ef fects of treatment stress in burn pat ients . Def in i t ion of Terms Anxiety - a pers is tent fee l ing of dread, apprehension and 5 impending d isas ter . State Anxiety - a t ransient mood re f l ec t i ng awareness of an impending unpleasant occurrence at any given moment in time.*' T ra i t Anxiety - a predisposi t ion to the react ion of anxiety to a var ie ty of s t imul i and s i tua t ions . "Lawrence C. Kolb and Arthur P. Noyes, Modern C l i n i c a l Psychiatry (Toronto, Ontar io: W. B. Saunders Co . , 1973), p.82. ^Linford Rees, "Anxiety Factors in Comprehensive Pat ient Care," Excerpta Medica Amsterdam (1973), p.2. 7 I b i d . , p.2. 7 Burn - loss of cont inu i ty of the body surface due to a coagulation and destruct ion of skin and subcutaneous t issues by thermal changes, inc luding both heat and o c o l d , by chemicals, by e l e c t r i c i t y and by rad ia t ion . F i r s t degree burn - an erythema of the area involved. Second degree burn - destruct ion of the epidermis with b l i s t e r formation due to the exudation of plasma from the deeper layer of dermis which elevates the epidermis. Third degree burn - destruct ion of the f u l l thickness of 9 the skin plus any subcutaneous t issues involved. Fear - an a f fec t i ve response to an actual current external danger which subsides with the e l iminat ion of the threatening s i t u a t i o n . ^ Instruct ional Program - an audio-visual a i d , in the form of a tape-s l ide program providing a general or ienta t ion as well as information about spec i f i c phases of burn care u t i l i z e d to f a c i l i t a t e the explanations and ant ic ipatory guidance by the nurse. Robert H. A l d r i c h , "Forensic Aspects of Burns," Annals of Surgery 117 (Apri l 1943), p.576. 9 I b i d . , p.577. °Kolb, Modern C l i n i c a l Psychia t ry , p.41. 8 S t r e s s - t h e n o n - s p e c i f i c r e s p o n s e o f t h e body t o any demand made upon i t . ^ T reatment S t r e s s - s i t u a t i o n a l s t r e s s a r i s i n g from burn t r e a t m e n t as measured by v a r i o u s i n d i c a t o r s such as the p a t i e n t ' s p e r s o n a l e v a l u a t i o n measured on a L i k e r t s c a l e , p a t i e n t comments, s t a f f o b s e r v a t i o n and the s c o r e s a c h i e v e d on the S t a t e - T r a i t A n x i e t y I n v e n t o r y . Assumptions The e x p l o r a t i o n o f t h e r e s o l u t i o n o f a n x i e t y due t o t h e e f f e c t s o f t r e a t m e n t s t r e s s i n burn p a t i e n t s i s based on s e v e r a l a s s u m p t i o n s . The p e r c e p t i o n o f p a i n , a c t u a l o r t h r e a t e n e d i s a prominent s o u r c e o f a n x i e t y . 1 2 A p a t i e n t who assumes an a c t i v e r o l e i n hits p h y s i c a l and e m o t i o n a l c a r e c o n t r i b u t e s t o h i s r e c o v e r y and p e r c e i v e s 13 h i s c a r e as e f f e c t i v e . R e l i e f o f s i t u a t i o n a l a n x i e t y i s the n u r s e ' s r e s p o n s i b i l i t y . Treatment s t r e s s e x i s t s i n burn p a t i e n t s . The e f f e c t s o f t r e a t m e n t s t r e s s i n p r o d u c i n g a n x i e t y can be measured. ^ L e n n a r t L e v i , " S t r e s s and D i s t r e s s i n Response t o P s y c h o s o c i a l S t i m u l i , " supp. 528 to A c t a Medica S c a n d i n a v i a 191 (1972), p.11. 19 George E n g e l , " P s y c h o l o g i c a l Responses o f Major En v i r o n m e n t a l S t r e s s , " i n P s y c h o l o g i c a l Development i n H e a l t h and D i s e a s e ( P h i l a d e l p h i a : W.B. Saunders Co., 1962), p.265. 13 P h y l l i s T r y o n and Robert L e o n a r d , " G i v i n g t h e P a t i e n t an A c t i v e R o l e , " S o c i a l I n t e r a c t i o n and P a t i e n t C a r e , ed. James, S k i p p e r and Leonard ( T o r o n t o : J.B. L i p p i n c o t t Co., 1965), p.125. 9 Treatment stress i s re f lec ted in sleep patterns and need for analgesic and sedative medications. Treatment stress can be assessed by subject ive observations by the s ta f f . Treatment stress can be assessed by object ive psychological tes t ing with an anxiety sca le . Pat ients can subject ive ly evaluate the i r feel ings of pa in , anxiety , sleeplessness and fear of treatments. Sta f f records report ing a pa t ien t ' s sleep pattern and medication needs re f l ec t treatment s t ress . L imitat ions As an exploratory study, the only intent was to examine var iables operating in burn care and generate speculat ive re la t ionsh ips among the i den t i f i ed var iab les . Since sample s i ze was contingent upon a v a i l a b i l i t y of those people burned who met the subject c r i t e r i a , the resul tant sample s ize i s smal l . I t was not the intent of the study to general ize the f indings to a l l burn pat ients . No inference of causa l i t y was intended between the nursing intervent ions and the reductiongof treatment s t ress . Internal v a l i d i t y may have been jeopardized due to the ef fects of h is to ry , maturation and instrument decay. The uniqueness of the da i l y d iary does not lend i t s e l f to v a l i d i t y and r e l i a b i l i t y tes t i ng . Medication records are considered highly va l id and r e l i a b l e . 10 In many cases, however, i t was d i f f i c u l t to ascertain i f medication was requested or rout inely given. The nurses' recordings of the pat ien ts ' sleep was not tested for r e l i a b i l i t y and v a l i d i t y . The study of anxiety i s d i f f i c u l t at t imes. The a l l encompassing nature of pain and the appearance of a burn would further complicate the i den t i f i ca t i on of anxiety leve ls by those car ing for these pat ients . Overview of Methodology The research took place on a burn unit of a large general teaching hospital in Canada from October 1976 to February 1977. Each pat ient meeting the subject c r i t e r i a , admitted to the burn unit during the months from October to February, was approached and an explanation of the study given before being requested to par t i c ipa te in the study. A few days a f ter admission, the pat ient was assessed in an intake interview. The purpose of the b r ie f v i s i t was to c o l l e c t information about the pat ient and his react ions to his care and treatments. The invest igator establ ished her ro le as a nurse s p e c i a l i s t studying burn care, not involved in the day to day care , but gathering information on the reactions of burn pat ients to the i r treatments. She v i s i t ed eight times during the period of each pa t ien t ' s hosp i ta l i za t ion to answer any quest ions, provide emotional support as needed and prepare him for new phases in his treatment. Since each pat ient i s an unique i n d i v i d u a l , ant ic ipatory guidance and emotional support was an ind iv idual process dependent on such things as the pa t ien t ' s background experience, thought pat terns, vocabulary and 11 his a b i l i t y to understand what i s going to happen. Short ly a f ter admission, the Sta te-Tra i t Anxiety Inventory (see Appendix B) was administered. Part I of a tape-s l ide program "Orientat ion to the Burn Unit" was shown (see Appendix C) . This spec i f i c sect ion of the tape-s l ide program and the discussion fo l lowing were evaluated by means of the evaluat ion tool for the ins t ruc t iona l program (see Appendix D). A l so , at th is t ime, the s ta f f nurses began recording sleep and medications in records prepared for th is study,(see Appendix E and F) . The nurse, car ing for the pa t ien t , was asked to assess the pa t ien t ' s level of state and t r a i t anxiety and rate her subject ive observations of the pa t ien t ' s anxiety level on a L iker t scale (see Appendix G). The pat ient began to keep a da i l y d iary . This day to day subject ive evaluation on a L iker t scale reported the pain experienced, need for analgesic medication, s leep , personal concerns and wel l -be ing. These factors were considered in a composite score to indicate anxiety leve l for that day (see Appendix H). During a spec i f ied time period of not less than three weeks, appropriate sections of an ins t ruc t iona l program were shown to the pat ient by the invest igator . Depending on the treatment the pat ient was rece iv ing , the appropriate port ion of the tape-s l ide program and the discussion fo l lowing were evaluated by the pat ient in a structured interview with the invest igator . The Sta te-Tra i t Anxiety Inventory was administered to the pat ient at two in terva ls before a treatment session and a two in terva ls a f te r a treatment session. The invest igator v i s i t ed each pat ient not only at the time of the administrat ion of the Sta te-Tra i t Anxiety Inventory, but twice during the course of the study. The purpose of these eight v i s i t s was to review and assess da i l y diary progress, to encourage the pat ient to verbal ize his fears and anxiet ies as expressed in the content of the d ia ry , to o f fe r appropriate explanations and to answer any quest ions. The ind iv idual emotional support and encouragement given to the pat ient and his family was planned to support the care implemented by the s ta f f nurses. At the end of a spec i f ied time period from admission, the pat ient was interviewed again and the f i na l Sta te-Tra i t Anxiety Inventory administered by the invest igator . The s leep, medication records and da i l y diary were terminated. (The pat ient was given the option to continue his diary i f he so wished, a f ter the resu l ts were compiled). The nurse, caring for the pat ien t , was asked to again assess the pa t ien t ' s anxiety level on a L iker t sca le . In most cases the termination of data co l l ec t i on coincided with discharge. Thus discharge planning became part of the ins t ruc t iona l program and psychological support given to the pat ient during the study. 13 Development of Remaining  Chapters This study i s reported in f i ve chapters. The f i r s t chapter introduces the problem of anxiety due to the ef fects of treatment stress in burn pat ients . I t addresses the purpose and the s ign i f i cance of the study, the assumptions, the l im i ta t ions and overview of methodology. Chapter two presents a review of the l i t e r a t u r e . It discusses the research studies that have been conducted to fur ther knowledge of the psychological impl icat ions of burn care , the re la t ionsh ip of pain to anxiety and the phenomena of anxiety. Implications for audio-v isual aids to a s s i s t in pat ient teaching on burn un i t s , the therapeutic nurse-patient re la t ionsh ip and the e f fec t of anxiety on sleep patterns are b r i e f l y discussed. Chapter three describes the methodology of the study. Sample se lec t i on , del ineat ion of var iab les , the research p lan , data co l l ec t i ng instruments and method of data analys is are presented. Analysis and in terpreta t ion of the data and f indings are discussed in chapter four. The f i na l chapter includes a summary, plus recommendations and impl icat ions for fur ther study. C h a p t e r 2 14 REVIEW OF LITERATURE S e l e c t e d l i t e r a t u r e was r e v iewed t o s u p p o r t t h e development o f t h e s t u d y . P l a s t i c surgeons and n u r s e s were i n t e r v i e w e d i n T o r o n t o , O n t a r i o i n 1975 i n o r d e r t o i d e n t i f y some p r i o r i t y problems i n burn u n i t s . The i n v e s t i g a t o r ' s working e x p e r i e n c e s i n burn u n i t s i n T o r o n t o and Vancouver have f u r t h e r s u b s t a n t i a t e d the problem o f i n c r e a s e s t a t e a n x i e t y due t o the s t r e s s o f t r e a t m e n t s i n many burn p a t i e n t s . Numerous comments by p a t i e n t s have r e i n f o r c e d the p o t e n t i a l s i g n i f i c a n c e o f t h e s t u d y o f t h i s problem. The r e v i e w o f the l i t e r a t u r e s u p p o r t e d the need f o r t h i s s t u d y . I t w i l l d i s c u s s , f i r s t l y , t h e p s y c h o l o g i c a l i m p l i c a t i o n s o f burn c a r e ; s e c o n d l y , t h e r e l a t i o n s h i p o f p a i n t o a n x i e t y ; t h i r d l y , the c o n c e p t o f a n x i e t y ; f o u r t h l y , t h e i m p l i c a t i o n s o f a u d i o - v i s u a l a i d s t o a s s i s t p a t i e n t t e a c h i n g and f i f t h l y , t h e t h e r a p e u t i c n u r s e - p a t i e n t r e l a t i o n s h i p . F i n a l l y , the e f f e c t s o f a n x i e t y on s l e e p p a t t e r n s w i l l be p r e s e n t e d . C o n s i d e r a b l e a t t e n t i o n has been f o c u s e d on t h e b a s i c n u r s i n g c a r e and s u r g i c a l t e c h n i q u e s n e c e s s a r y f o r t h e t r e a t m e n t o f thermal i n j u r i e s . L i t t l e r e s e a r c h a t t e n t i o n has been g i v e n to the emotional problems o f burn p a t i e n t s . ^ The numerous s t u d i e s c o n c e r n i n g t h e c a r e o f the s e v e r e l y burned p a t i e n t have emphasized t h e problems r e l a t e d t o i n - h o s p i t a l c a r e , such as r e s u s c i t a t i o n , d e b r idement, t o p i c a l a n t i m i c r o b i a l t h e r a p y and s k i n S.R. Lewis e t a l . , " P s y c h o l o g i c a l S t u d i e s i n Burn P a t i e n t s , " P l a s t i c  and R e c o n s t r u c t i v e S u r g e r y 31 ( A p r i l 1963), p.323. g r a f t i n g . While t h e immediate p s y c h o l o g i c a l a s p e c t s o f a v e r y s e v e r e bu i n j u r y have been r e c o r d e d d u r i n g h o s p i t a l i z a t i o n , t h e l o n g t e r m outcome o f th e s e p a t i e n t s ' p h y s i c a l and s o c i a l a d j u s t m e n t s has not been w e l l documented. Because o f t h e c u r r e n t l a c k o f i n f o r m a t i o n i n t h i s a r e a , the burn p a t i e n t i s s u b j e c t e d to t h e s t r e s s o f u n c e r t a i n t y d u r i n g h i s e a r l y management which commonly a f f e c t s h i s p h y s i c a l and p s y c h o l o g i c a l r e c o v e r y . The problem i s o f p a r t i c u l a r importance i n view o f t h e e v e r i n c r e a s i n g number o f t r e a t m e n t m o d a l i t i e s as w e l l as t h e i m p r o v i n g I c s u r v i v a l s t a t i s t i c s as a r e s u l t o f more s o p h i s t i c a t e d burn c a r e . The i n v e s t i g a t o r found few n u r s i n g s t u d i e s d i s c u s s i n g t h e p s y c h o l o g i c a l r e a c t i o n s o f l e s s s e v e r e l y burned p a t i e n t s to t h e i r c a r e . Recent s t u d i e s have tended to f o c u s on e p i d e m i o l o g y and on methods o f t r e a t m e n t management. 1 6 T h e r e has been r e s e a r c h c o n d u c t e d by n u r s e s s t u d y i n g p a i n c o n t r o l on burn u n i t s . From t h e s e s t u d i e s , F a g e r h a u g h 1 7 r e p o r t e d t h a t s t r e s s and a n x i e t y l e v e l s i n c r e a s e d p a i n and o f t e n t h e mode o f p a i n e x p r e s s i o n stemmed l a r g e l y from a n x i e t y . She c o n c l u d e d i n her s t u d y t h a t i f p a t i e n t s were i n f o r m e d about what to e x p e c t d u r i n g v a r i o u s phases o f burn c a r e , t h e i r p e r c e p t i o n o f p a i n would be reduced. F r e d e r i c Chang and B r i a n t Herzog, "Burn M o r b i d i t y : A Follow-up Study o f P h y s i c a l and P s y c h o l o g i c a l D i s a b i l i t y , " A n n a ls o f S u r g e r y 183 ( J a n u a r y 1976), p.34. N.J. Andreasen and A. S. N o r r i s , " I n c i d e n c e o f Long Term P s y c h i a t r i c C o m p l i c a t i o n s i n S e v e r e l y Burned A d u l t s , " A n n a l s o f S u r g e r y 174 (November 1971), p.785. Shizuko Fagerhaugh, " P a i n E x p r e s s i o n and C o n t r o l on a Burn U n i t , " N u r s i n g O u t l o o k 22 (October 1974), pp.646-650. Davidson d e s c r i b e d some o f t h e e m o t i o n a l r e a c t i o n s o f p a t i e n t s d u r i n g t h e a c u t e phase f o l l o w i n g t h e burn a c c i d e n t and i n d i c a t e d some i m p l i c a t i o n s f o r n u r s i n g c a r e . She r e p o r t e d t h a t p a t i e n t s , who were a l l o w e d t o v e n t i l a t e i n t e n s e anger and f r u s t r a t i o n t o the r e s e a r c h team, b e n e f i t e d from t h i s form o f r e l e a s e . P s y c h o l o g i c a l I m p l i c a t i o n s o f Burn Care The c i t e d l i t e r a t u r e v a l i d a t e s t h e problem o f a n x i e t y on burn u n i t s i n s t u d i e s c o n d u c t e d by p h y s i c i a n s and n u r s e s . I n t e r e s t i n t h e p s y c h o l o g i c a l r e a c t i o n o f burn v i c t i m s was a r o u s e d by t h e Cocoanut Grove N i g h t c l u b f i r e i n Boston i n 1942. Cobb and Lindemann o b s e r v e d s e r i o u s emotional problems i n i t s v i c t i m s which A d l e r found t o p e r s i s t i n a f o l l o w - u p s t u d y 11 months l a t e r . 19 Cobb and Lindemann s t u d i e d 17 v i c t i m s o f t h e n i g h t c l u b d i s a s t e r a t t h e M a s s a c h u s e t t s General H o s p i t a l i n o r d e r t o l e a r n how t o r e c o g n i z e t h o s e p a t i e n t s who a r e l i a b l e t o e m o t i o n a l d i s o r d e r s and t o p r e v e n t such d i s o r d e r s as p o s s i b l e . Each p a t i e n t r e c e i v e d a n e u r o l o g i c and p s y c h i a t r i c exam on t h e e i g h t h day a f t e r t h e i r a d m i s s i o n t o h o s p i t a l . F o u r t e e n o f t h e s e p a t i e n t s p r e s e n t e d i n - h o s p i t a l n e u r o p s y c h i a t r y problems. The a u t h o r s d e s c r i b e d v a r i o u s r e a c t i o n s such as " o u t b u r s t s o f a g g r e s s i o n , p e r i o d s o f apathy and f l u c t u a t i o n i n mood." Other p a t i e n t s e x h i b i t e d an i n t e n s e f e a r o f b e i n g l e f t a l o n e as w e l l as f e a r o f impending d i s a s t e r . S h i r l e e P. D a v i d s o n , " N u r s i n g Management o f Emotional R e a c t i o n s o f S e v e r e l y Burned P a t i e n t s D u r i n g t h e A c u t e Phase," H e a r t and Lung 2 (May/June 1973), p.373. i S t a n l e y Cobb and E r i c h Lindemann; " N e u r o p s y c h i a t r i c O b s e r v a t i o n i n Management o f the Cocoanut Grove Burns a t the M a s s a c h u s e t t s General H o s p i t a l , " A n n a ls o f S u r g e r y 117 (June 1943), pp.814-824. 17 Cobb sug g e s t e d t h a t d u r i n g t h e c o n v a l e s c e n t phase, t h e p a t i e n t s h o u l d be p r o v i d e d w i t h c o u n s e l l i n g i n h i s t r a n s i t o r y problems and h i s e f f o r t s t o a d j u s t t o h i s s i t u a t i o n . 20 A d l e r made p s y c h i a t r i c o b s e r v a t i o n s on 46 p a t i e n t s a d m i t t e d to Boston C i t y H o s p i t a l a f t e r the n i g h t c l u b f i r e . These p a t i e n t s were f o l l o w e d up e l e v e n months l a t e r . No e s s e n t i a l d i f f e r e n c e s o f e m o t i o n a l r e a c t i o n s o r p s y c h i a t r i c end r e s u l t s between male and female p a t i e n t s were not e d . O b s e r v a t i o n s , t h e r e f o r e , a p p l y t o both sexes. Of t h e s e 46 p a t i e n t s , 20 d i d not m a n i f e s t p s y c h i a t r i c c o m p l i c a t i o n s a t any time a f t e r w a r d . T w e n t y - s i x p a t i e n t s p r e s e n t e d symptoms o f g e n e r a l n e r v o u s n e s s and a n x i e t y n e u r o s i s l a s t i n g t h r e e months. A f t e r n i n e months, 32 d i d not show any a b e r r a t i o n from p r e t r a u m a t i c p e r s o n a l i t y whereas 13 s t i l l s u f f e r e d g e n e r a l n e r v o u s n e s s and a n x i e t y n e u r o s i s . Of t h e 20 p a t i e n t s who d i d not d e v e l o p p s y c h i a t r i c c o m p l i c a t i o n s , 15 had l o s t c o n s c i o u s n e s s . Twelve o f t h e s e 15 had p r o l o n g e d u n c o n s c i o u s n e s s beyond one hour. In the 26 p a t i e n t s w i t h p s y c h i a t r i c c o m p l i c a t i o n s , 13 had l o s t c o n s c i o u s n e s s below one hour. T h i s s u g g e s t s t h a t u n c o n s c i o u s n e s s , and i n p a r t i c u l a r p r o l o n g e d u n c o n s c i o u s n e s s , was an e s s e n t i a l f a c t o r i n p r e v e n t i n g t h e development o f f u r t h e r p s y c h i a t r i c d i f f i c u l t i e s . These s t u d i e s , c o n d u c t e d by Cobb, Lindemann and A d l e r b u i l t t he f o u n d a t i o n f o r f u r t h e r r e s e a r c h i n t h e a r e a o f e m o t i o n a l r e a c t i o n s o f burned p a t i e n t s . These broad d e s c r i p t i o n s o f p s y c h i a t r i c c o m p l i c a t i o n s d u r i n g t h e i n - h o s p i t a l p e r i o d and p o s t - d i s c h a r g e p e r i o d l e d o t h e r i n v e s t i g a t o r s t o f o c u s more c l e a r l y on t h e a c u t e phase o f burn c a r e . A l e x a n d e r A d l e r , " N e u r o p s y c h i a t r i c C o m p l i c a t i o n s i n V i c t i m s o f Boston's Cocoanut Grove D i s a s t e r , " J o u r n a l o f the American Medical. A s s o c i a t i o n 123 (December 25, 1943), pp.1098-1101. In 1953, Hamburg d e s c r i b e d and c l a s s i f i e d the types o f e m o t i o n a l problems o c c u r r i n g d u r i n g h o s p i t a l i z a t i o n a f t e r making a d e t a i l e d s t u d y o f the adjustment r e a c t i o n s o f s e v e r e l y burned a d u l t s . Over a 1 y e a r p e r i o d , 12 p a t i e n t s (10 males and 2 f e m a l e s ) were s t u d i e d i n t e n s i v e l y a t the Burn C e n t r e i n Brooke Army H o s p i t a l . Hamburg's e x t e n s i v e r e s e a r c h i n t o the a d a p t i v e problems o f t h e s e p a t i e n t s r e v e a l e d t h a t many emot i o n a l d i f f i c u l t i e s were e n c o u n t e r e d i n r e l a t i o n t o t h e i r t r e a t m e n t s . These d i f f i c u l t i e s a d v e r s e l y a f f e c t e d the p a t i e n t ' s c o o p e r a t i o n and 22 c o u r s e o f i l l n e s s . Hamburg a l s o r e p o r t e d t h a t , a f t e r t h e immediate problem o f t h e q u e s t i o n o f s u r v i v a l , the p a t i e n t wondered how l o n g h i s h o s p i t a l i z a t i o n would be. T h i s c o n c e r n p e r s i s t e d 6 t o 8 weeks w h i l e s o u r c e s o f s t r e s s accumulated. Hamburg l i s t e d t h e s e s t r e s s o r s a s : i n a d e q u a t e communication between t h e p a t i e n t and p h y s i c i a n r e g a r d i n g the i n j u r y , absence o f f a m i l y and f r i e n d s , t h r e a t t o t h e c a p a c i t y t o be l o v e d by o t h e r s and dependence on o t h e r s . ?3 Hamburg" a l s o s t a t e d t h a t each p a t i e n t seemed to d e v e l o p an e a r l y r e a l i z a t i o n t h a t t h e r e were o t h e r p e o p l e u n d ergoing t h e same e x p e r i e n c e and t h e r e were o t h e r s who had been s i m i l a r l y i n j u r e d and had r e c o v e r e d . When t h i s r e a l i z a t i o n was combined w i t h i m p r e s s i v e v i s u a l e v i d e n c e o f a n o t h e r p a t i e n t ' s e x t e n s i v e r e c o v e r y , t h e e f f e c t was o f t e n p r o f o u n d . S e v e r a l p a t i e n t s l a t e r s t a t e d t h a t t h e most e n c o u r a g i n g s i n g l e e x p e r i e n c e was c o n t a c t w i t h a n o t h e r p a t i e n t who had s u f f e r e d e q u a l l y D a v i d Hamburg, " A d a p t i v e Problems and Mechanisms i n S e v e r e l y Burned P a t i e n t s , " P s y c h i a t r y 16 ( F e b r u a r y 1953), p . l . I b i d . , p.3. I b i d . , p.11. 19 s e v e r e burns as m a n i f e s t e d by photographs o r by d e s c r i p t i o n s and had r e c o v e r e d s a t i s f a c t o r i l y . Hamburg's emphasis, i n h i s s t u d y , was i n t h e e m o t i o n a l problems o f the s e v e r e l y burned p a t i e n t i n the a c u t e phase. Many a u t h o r s seem to p r e f e r t h i s t i m e p e r i o d . I t i s i n t e r e s t i n g t o note t h a t Hamburg a l l u d e d to t h e f a c t t h a t e m o t i o n a l d i f f i c u l t i e s a r e e n c o u n t e r e d due to the e f f e c t s o f t r e a t m e n t s and may a f f e c t the c o u r s e o f r e c o v e r y . No o t h e r a u t h o r s d i s c u s s the e f f e c t s o f t r e a t m e n t s t r e s s on the burned p a t i e n t though t h e y seem t o be aware t h a t i t does e x i s t . A n o t h e r i n t e r e s t i n g p o i n t t h a t Hamburg r e p o r t s , i s t h a t p a t i e n t s were encouraged r e m a r k a b l y when v i s u a l e v i d e n c e o f r e c o v e r y was 24 d i s p l a y e d t h r o u g h photographs. B r a n t ! c o n f i r m s t h i s by s t a t i n g t h a t photographs o f o t h e r burn p a t i e n t s , showing t h e improvement made i n t i m e , w i l l o f t e n h e l p a l l a y a p p r e h e n s i o n . The use o f a u d i o - v i s u a l a i d s t o a s s i s t i n p a t i e n t t e a c h i n g w i l l be d i s c u s s e d l a t e r i n t h i s c h a p t e r . 25 A s t u d y c o n d u c t e d by Andreasen and Noyes examines emotional r e a c t i o n s o f a d u l t burn v i c t i m s i n l i g h t o f c u r r e n t t r e a t m e n t methods. The r e p o r t i s based on o b s e r v a t i o n s made on a l l a d u l t p a t i e n t s a d m i t t e d t o the U n i v e r s i t y o f Iowa's Burn U n i t o v e r a n i n e month p e r i o d . A l l p a t i e n t s and t h e i r r e l a t i v e s were i n t e r v i e w e d i n t e n s i v e l y soon a f t e r a d m i s s i o n . T h e r e a f t e r they were v i s i t e d on d a i l y rounds t h r o u g h o u t t h e i r h o s p i t a l c o u r s e by a team c o n s i s t i n g o f 2 p s y c h i a t r i s t s , a V i r g i n i a B r a n t l , "The Care o f P a t i e n t s w i t h Burns," N u r s i n g O u t l o o k 6 ( J u l y 1958), p.385 N. J . Andreasen and R u s s e l l Noyes, "Management o f Emotional R e a c t i o n s i n S e v e r e l y Burned A d u l t s , " New England J o u r n a l o f M e d i c i n e 286 (January 13, 1972), p.65. p s y c h i a t r i c n u r s e and a p s y c h i a t r i c s o c i a l worker. A v a r i e t y o f management problems c r e a t e d by emotional c o m p l i c a t i o n s were noted and a p p r o p r i a t e methods o f h a n d l i n g them were recommended. R e a c t i o n s such as a n x i e t y , d e p r e s s i o n , r e g r e s s i o n , e m o t i o n a l l a b i l i t y , n ightmares and f e a r o f d e f o r m i t y were noted i n n e a r l y a l l p a t i e n t s d u r i n g t h e i r h o s p i t a l c o u r s e . Andreasen and Noyes c o n c l u d e d t h a t i f t h e m e d i c a l s t a f f had some i n s i g h t i n t o the n a t u r e and causes o f t h e s e r e a c t i o n s , emotional problems c o u l d p r o b a b l y be handled w i t h o u t p s y c h i a t r i c c o n s u l t a t i o n . The a u t h o r s a l s o s t a t e d t h a t t h e p a t i e n t needed t o a i r h i s c o n c e r n s i n a c o n f i d e n t i a l one t o one r e l a t i o n s h i p and t h a t the p a t i e n t s h o u l d be warned w e l l i n advance o f s u r g i c a l p r o c e d u r e s and be g i v e n a broad p e r s p e c t i v e o f h i s t r e a t m e n t program. I t i s t h i s i n v e s t i g a t o r ' s i n t e n t to p r o v i d e the p a t i e n t w i t h the o p p o r t u n i t y t o a i r h i s c o n c e r n s as w e l l as g i v e him a b e t t e r i d e a o f h i s t r e a t m e n t program by means o f an a u d i o - v i s u a l a i d and e x p l a n a t i o n . R e l a t i v e t o Andreasen's comment, " i f the medical s t a f f had some i n s i g h t i n t o the n a t u r e o f r e a c t i o n s t o burn trauma, emotional problems c o u l d p r o b a b l y be handled w i t h o u t p s y c h i a t r i c c o n s u l t a t i o n , " i t i s t h i s i n v e s t i g a t o r ' s b e l i e f t h a t p r o b a b l y t h e l e s s s e v e r e l y burned p a t i e n t i n t h e p o s t a c u t e phase needs an o p p o r t u n i t y t o v e n t i l a t e h i s f r u s t r a t i o n s and emotions. I t seems t h a t the l e s s s e v e r e l y burned p a t i e n t does not need a p s y c h i a t r i c c o n s u l t a t i o n but r a t h e r an adequate s u p p o r t system. D u r i n g the c o u r s e o f a y e a r , Davidson s t u d i e d the e m o t i o n a l r e a c t i o n s o f 33 s e v e r e l y burned p a t i e n t s d u r i n g t h e a c u t e phase a t t h e S h i r l e e D a v i d s o n , " N u r s i n g Management o f Emotional R e a c t i o n s o f S e v e r e l y Burned P a t i e n t s D u r i n g t h e A c u t e Phase," Heart and Lung 2 (May/June 1973), pp.371-373. U n i v e r s i t y o f Iowa H o s p i t a l Burn U n i t . She found t h a t t h e s e p a t i e n t s seemed t o e x p e r i e n c e t r a u m a t i c n e u r o s i s , s l e e p l e s s n e s s , d e c r e a s e d a b i l i t y t o f o c u s a t t e n t i o n , p e r i o d s o f d i s o r i e n t a t i o n , r e g r e s s i o n and i n c r e a s e d c o m p l a i n t s o f p a i n accompanied w i t h a n x i e t y . I t was e v i d e n t t h a t , i f t h e p a t i e n t ' s means o f c o p i n g w i t h h i s a c u t e phase o f i l l n e s s r e s u l t e d i n an extreme d e p l e t i o n o f p h y s i c a l and emotional e n e r g y , then the c o n v a l e s c e n t phase a l s o became a s t r u g g l e f o r s u r v i v a l w i t h t h e burn 27 p a t i e n t h a v i n g many s p e c i f i c needs r e q u i r i n g unique n u r s i n g c a r e . 28 A s t u d y by S c h l i c h t m a n n p r e s e n t e d a t the American Nurses A s s o c i a t i o n C l i n i c a l S e s s i o n i n New York i n 1968 p r e d a t e d Davidson's f i n d i n g s . S c h l i c h t m a n n a n a l y z e d 4 s e v e r e l y burned p a t i e n t s ' v e r b a l s t a t e m e n t s i n o r d e r to i d e n t i f y t h e a d a p t i v e mechanisms t h e y used and t o c a t e g o r i z e t h e s e mechanisms as emergency o r r e c o v e r y mechanisms. From tape r e c o r d e d n o n d i r e c t i v e i n t e r v i e w s d u r i n g t h e e a r l y and l a t e p e r i o d s o f h o s p i t a l i z a t i o n , S c h l i c h t m a n n s u g g e s t e d t h a t methods o f t r e a t m e n t used may have p r e s e n t e d e n v i r o n m e n t a l c l u e s t o t h e p a t i e n t t h a t i n f l u e n c e d h i s a d a p t i v e mechanism. The p r i n c i p l e f i n d i n g s c o n c u r w i t h the c o n c l u s i o n s found i n the l i t e r a t u r e r e g a r d i n g a d a p t a t i o n t o s t r e s s and the p s y c h o l o g i c a l impact brought on by burn i n j u r i e s . The f o u r p a t i e n t s i n S c h l i c h t m a n n ' s s t u d y r e a c t e d t o s t r e s s f i r s t by m i n i m i z i n g t h e impact o f the s i t u a t i o n , s e c o n d, by employing such emergency mechanisms as d e n i a l , d e l u s i o n and i l l u s i o n . As t h e y became Da v i d s o n , " N u r s i n g Management o f Emotional R e a c t i o n s o f S e v e r e l y Burned P a t i e n t s D u r i n g the A c u t e Phase," p.375. Kathryn A. S c h l i c h t m a n n , " A d a p a t i v e Mechanisms i n a S e l e c t e d Group o f Burned P a t i e n t s , " N u r s i n g Research ( A b s t r a c t ) 18 ( J u l y / A u g u s t 1969) p.379. 22 aware o f r e a l i t y , emergency mechanisms were r e p l a c e d by mechanisms t h a t f a c i l i t a t e d r e c o v e r y . Andreasen's D a v i d s o n ' s , and S c h l i c h t m a n n ' s s t u d i e s , as j u s t c i t e d , i n v e s t i g a t e d the e m o t ional r e a c t i o n o f s e v e r e l y burned p a t i e n t s i n the immediate a c u t e phase. In a l l s t u d i e s , e x t e n s i v e i n t e r v i e w s were conduct e d w i t h t h e p a t i e n t to e v a l u a t e h i s p s y c h o l o g i c a l s t a t u s p r e - i n j u r y and p o s t - i n j u r y . S i n c e i t i s i m p o s s i b l e t o " p r e d i c t " a burn i n j u r y , i t i s i m p o s s i b l e to c o m p l e t e l y a s s e s s t h e p a t i e n t ' s p r e - i n j u r y p e r s o n a l i t y o r h i s e x p e r i e n c e and methods o f c o p i n g w i t h s t r e s s f u l s i t u a t i o n s . Moreover, i n r e v i e w i n g t h e l i t e r a t u r e , t h e r e seemed t o be no s t u d i e s o f t h e e m o t i o n a l r e a c t i o n s o f l e s s s e v e r e l y burned p a t i e n t s even i n t h e p o s t - a c u t e phase o f r e c o v e r y . Therefore,.concl u s i o n s drawn from t h e above s t u d i e s s h o u l d n o t be g e n e r a l i z e d t o a l l burn p a t i e n t s o r to the burn p o p u l a t i o n i n t h i s s t u d y . I t was a l s o n o t e d , i n r e v i e w i n g t h e s e s t u d i e s , t h a t l i t t l e mention was g i v e n t o the e f f e c t s o f t r e a t m e n t s on t h e s e p a t i e n t s . I t i s t h i s i n v e s t i g a t o r ' s b e l i e f t h a t t r e a t m e n t s t r e s s i s a p r e c u r s o r o f e m o t i o n a l r e a c t i o n s e x h i b i t e d by burn v i c t i m s . Authors' c o n c l u s i o n s from v a r i o u s p s y c h o l o g i c a l s t u d i e s conducted on burn u n i t s do seem t o emphasize one i m p o r t a n t i n t e r v e n t i o n i n burn c a r e - namely, i n f o r m a t i o n g i v i n g and the p r o v i s i o n o f e m o t i o n a l s u p p o r t as b e i n g paramount t h r o u g h o u t the c o u r s e o f burn c a r e . One o f t h e o b j e c t i v e s o f burn c a r e i s t h e p r e s e r v a t i o n o f t h e 29 e m o t i o n a l e q u i l i b r i u m o f the p a t i e n t . J a coby s t a t e d t h a t d u r i n g t h e F l o r e n c e J a c o b y , N u r s i n g Care o f t h e P a t i e n t With Burns ( S t . L o u i s : C.V. Mosby Co., 1972), p.60. 23 h o s p i t a l i z a t i o n p e r i o d p r i o r t o t h e c l o s u r e o f the burn wound by p r i m a r y h e a l i n g o r by t h e use o f s k i n g r a f t s , t h e t r u e p e r s o n a l i t y o f t h e p a t i e n t does not m a n i f e s t i t s e l f . The p a t i e n t may become v e r y d e p r e s s e d . P a i n f u l t r e a t m e n t s , f e a r o f d i s f i g u r e m e n t , worry about f i n a n c i a l needs and g u i l t a r e a few o f t h e f a c t o r s p r o d u c i n g s t r e s s . S u p p o r t i v e h e l p i s needed and s h o u l d be s t a r t e d a t t h e time o f a d m i s s i o n . The p a t i e n t must be g u i d e d t o f o c u s away from c o n s t a n t comtemplation o f s e l f . He needs a g r e a t deal o f v e r b a l r e a s s u r a n c e , e x p l a n a t i o n and moral s u p p o r t . 30 J a c k s o n r e p o r t e d t h a t answering q u e s t i o n s i s i m p o r t a n t i n t u r n i n g a p a t i e n t who i s immobile w i t h f e a r i n t o someone who w i l l c o - o p e r a t e w i t h t r e a t m e n t s . R e h a b i l i t a t i o n must b e g i n on a d m i s s i o n . R e l i e v i n g t h e p a t i e n t ' s f e a r s o f the unknown and unanswered q u e s t i o n s a r e o f g r e a t importance. 31 Noyes and Andreasen f u r t h e r e d t h i s c o n c l u s i o n from t h e i r o b s e r v a t i o n o f 11 s e v e r e l y burned a d u l t s i n t h e Burn U n i t o f t h e U n i v e r s i t y o f Iowa H o s p i t a l . They o b s e r v e d t h a t p a t i e n t s who knew what t o e x p e c t and when t o e x p e c t i t i n t h e i r t r e a t m e n t program seemed g r e a t l y r e l i e v e d by t h i s knowledge. T h e i r e x i s t e n c e took on a g r e a t e r c e r t a i n t y and t h e i r sense o f mastery was i n c r e a s e d when th e y f e l t t h a t t h e y were p a r t i c i p a t i n g i n t h e i r t r e a t m e n t s by making o b s e r v a t i o n s and s h a r i n g d e c i s i o n s . The morale o f t h e s e p a t i e n t s was m a i n t a i n e d by t h e r e a l i z a t i o n t h a t , as l o n e l y as t h e i r s u f f e r i n g seemed, t h e y were not a l o n e but one o f a company o f p e r s o n s , some o f whom were more s e r i o u s l y i l l . These same a u t h o r s c o n c l u d e d D.M. J a c k s o n , " R e c o n s t r u c t i o n and R e h a b i l i t a t i o n A f t e r B u r n i n g , " N u r s i n g M i r r o r (March 21, 1969), p.30. R u s s e l l Noyes and N. J . Andreasen, "The P s y c h o l o g i c a l R e a c t i o n t o Severe Burns," P s y c h o s o m a t i c s 12 (November-December 1971), p.421. 24 t h a t " p a t i e n t s b e n e f i t from e d u c a t i o n r e g a r d i n g what t h e y a r e e x p e r i e n c i n g 32 both p h y s i c a l l y and p s y c h o l o g i c a l l y . " ' Based on the f i n d i n g s o f t h e i r f o l l o w - u p s t u d y o f the p h y s i c a l and 33 p s y c h o l o g i c a l d i s a b i l i t i e s o f former burn p a t i e n t s , Chang and Herzog c o n c l u d e d t h a t e m o t i o n a l s u p p o r t i n some form s h o u l d be g i v e n on a r e g u l a r b a s i s d u r i n g h o s p i t a l i z a t i o n . Most i n v e s t i g a t o r s s u g g e s t t h a t t h e b e h a v i o u r a l r e s p o n s e t o t h e burn wound i s i n f l u e n c e d more by p s y c h o s o c i a l i m p l i c a t i o n s o f t h e i n j u r y t h a n by p h y s i o l o g i c a l c h a n g e s . 3 ^ Such i m p l i c a t i o n s go beyond the q u e s t i o n o f s u r v i v a l and t h e d i s t r e s s o f p h y s i c a l p a i n . The p a t i e n t q u e r i e s the e f f e c t o f h i s i n j u r y on h i s f a m i l y , h i s j o b , h i s f u t u r e and body appearance. The emotional r e s p o n s e to t h e trauma i n the s e v e r e l y burned a d u l t i n t h e a c u t e phase has been w e l l d e s c r i b e d . A u t h o r s have r e p e a t e d l y s t r e s s e d t h e h e i g h t e n e d a n x i e t y a s s o c i a t e d w i t h f e a r o f t h e unknown. A few have s u g g e s t e d s p e c i f i c i n t e r v e n t i o n s t o be c o n s i d e r e d i n an attempt to l e s s e n a n x i e t y as w e l l as p r o v i d e emotional s u p p o r t . L i t t l e a t t e n t i o n , however, has been f o c u s e d on the emotional r e a c t i o n s o f t h e l e s s s e v e r e l y burned p a t i e n t d u r i n g the l e n g t h y h o s p i t a l i z a t i o n o f t h e p o s t a c u t e r e c o v e r y phase. R u s s e l l Noyes and N. J . A n d r e a s e n , "The P s y c h o l o g i c a l R e a c t i o n t o S evere Burns," P s y c h o s o m a t i c s 12 (November/December 1971), p.421. ' F r e d e r i c Chang and B r i a n t Herzog, "Burn M o r b i d i t y : A Follow-up Study o f P h y s i c a l and P s y c h o l o g i c a l D i s a b i l i t y , " p.37. A l f r e d Weisz, " P s y c h o t h e r a p e u t i c S u p p o r t o f Burned P a t i e n t s , " Modern Treatment 4 (November 1967), p.129. 25 P a i n and I t s R e l a t i o n s h i p t o A n x i e t y C o n s i d e r a t i o n must be g i v e n t o the r o l e o f p a i n as an a n x i e t y - p r o d u c i n g s t r e s s o r . P a i n i s t h e c r u x o f t h e burn e x p e r i e n c e . A u t h o r s have d e s c r i b e d t h e p a i n e x p e r i e n c e i n r e l a t i o n t o a n x i e t y i n both t h e burn p a t i e n t and the s u r g i c a l p a t i e n t . I n d i v i d u a l p a i n t h r e s h o l d s v a r y c o n s i d e r a b l y as does e x t e n t and depth o f burn. No broad t r u i s m s a r e a p p l i c a b l e t o t h e n a t u r e o r s e v e r i t y o f p a i n t h a t t he average p a t i e n t e x p e r i e n c e s a f t e r a burn. The p a i n t h r e s h o l d and the c a p a c i t y t o t o l e r a t e p a i n appears t o d e c r e a s e o v e r t he c o u r s e o f h o s p i t a l i z a t i o n . P a i n i s i n c r e a s e d by a n x i e t y . A n x i o u s e x p e c t a t i o n o f p a i n i s the s a l i e n t f a c t o r i n c a u s i n g i t s p r o g r e s s i v e 35 i n c r e a s e . Fagerhaugh s t u d i e d p a i n e x p r e s s i o n and c o n t r o l on a burn u n i t i n a San F r a n c i s c o h o s p i t a l . C h a r a c t e r i s t i c s o f burn p a i n were c a t e g o r i z e d as i n t e n s i t y and l o n g d u r a t i o n , d e p e n d i n g on the e x t e n t and l o c a t i o n o f t h e b u r n , a n x i e t y l e v e l and p a i n t o l e r a n c e . Peaks o f i n t e n s e p a i n o c c u r r e d d u r i n g t u b b i n g , debridement, d r e s s i n g changes and p h y s i o t h e r a p y . When s k i n g r a f t s were t a k e n , donor s i t e p a i n was s e v e r e but g e n e r a l p a i n was n o t i c e a b l y reduced. S t r e s s and a n x i e t y l e v e l s i n c r e a s e d p a i n and o f t e n t h e mode o f p a i n e x p r e s s i o n stemmed l a r g e l y from a n x i e t y . T h i s a u t h o r c o n c l u d e d i n her s t u d y t h a t , i f p a t i e n t s were informed about what to e x p e c t d u r i n g phases o f burn c a r e , t h e i r p e r c e p t i o n o f p a i n would be r e d u c e d . 3 7 35 N.J. Andreasen and R u s s e l l Noyes, "Management o f Emotional R e a c t i o n s i n S e r i o u s l y Burned A d u l t s , " p.66. 36 S h i z u k o Fagerhaugh, " P a i n E x p r e s s i o n and C o n t r o l on a Burn U n i t , " p.646. 3 7 I b i d . , p.650. Even t h e e x p r e s s i o n o f p a i n can be a s t r e s s o r i n i t s e l f . Nurses have had e x p e r i e n c e s w i t h both s t o i c and h i g h l y e x p r e s s i v e p a t i e n t s . J a n i s 38 s t a t e s t h a t a pe r s o n ' s s o c i a l background presumably i n f l u e n c e s t h e way i n which a p a i n f u l e x p e r i e n c e i s p e r c e i v e d and a s s i m i l a t e d , t h a t i s , whether he w i l l f r e e l y e x p r e s s h i s emotional a g i t a t i o n o r t r y t o keep i t hidden from o t h e r s . 39 In t h e i r s t u d y , Hamburg and A r t z found t h a t p h y s i c a l p a i n i s c o n s i d e r a b l y l e s s s e v e r e than i s g e n e r a l l y supposed; on t h e o t h e r hand, e m o t i o n a l l y i n d u c e d p a i n and a n x i e t y a r e a much more s e r i o u s problem than i s g e n e r a l l y r e c o g n i z e d . P a t i e n t s f r e q u e n t l y do not d i s t i n g u i s h between p h y s i c a l p a i n and emotional t e n s i o n . They r e p o r t a l l d i s c o m f o r t , r e g a r d l e s s o f o r i g i n , as p a i n . I t i s o f g r e a t importance to r e a l i z e t h a t t h e p a t i e n t needs not o n l y r e l i e f o f p a i n but r e l i e f o f f e a r as w e l l . 40 Bruegel found t h a t p e r c e p t i o n s o f p a i n v a r y g r e a t l y from pe r s o n to pe r s o n . A n x i e t y , enhanced by p a i n , i s c o n s i d e r e d a s i g n i f i c a n t f a c t o r i n v i r t u a l l y a l l d i s c u s s i o n s o f t h e p a i n e x p e r i e n c e . H i l l and K o r n e t s k y ^ c o n c l u d e d from t h e i r s t u d i e s t h a t under c o n d i t i o n s which promote a n x i e t y o r f e a r o f p a i n , s u b j e c t s appear t o o v e r e s t i m a t e t he i n t e n s i t i e s o f p a i n f u l s t i m u l i . T h i s e f f e c t may d e r i v e I r v i n g L. J a n i s , P s y c h o l o g i c a l S t r e s s , (New York: John W i l e y and Sons., I n c . , 1958), p.9. Da v i d Hamburg and C u r t i s A r t z , e t a l . , " C l i n i c a l Importance o f Emotional Problems i n Care o f P a t i e n t s w i t h Burns," New England J o u r n a l  o f M e d i c i n e 248 ( F e b r u a r y 26, 1953), p.357. 'Mary Ann B r u e g e l , " R e l a t i o n s h i p o f P r e - O p e r a t i v e A n x i e t y t o P e r c e p t i o n o f Post-Op P a i n , " N u r s i n g Research 20 ( J a n u a r y / F e b r u a r y 1971), p.26. H. G. H i l l and C. H. Ko r n e t s k y e t a l . , "The E f f e c t s o f A n x i e t y and Morphine on D i s c r i m i n a t i o n o f I n t e n s i t i e s o f P a i n S t i m u l i , " J o u r n a l  o f C l i n i c a l I n v e s t i g a t i o n 31 (1952), p.473. from the tendency o f a n x i e t y t o narrow t h e f o c u s o f a t t e n t i o n , t h e r e b y r e d u c i n g the e f f e c t o f d i s t r a c t i n g s t i m u l i and thus making t h e n o x i o u s s e n s a t i o n h i g h l y s a l i e n t . 42 Moss and Meyer conduct e d a s t u d y which d e a l t w i t h t h e c a p a b i l i t y o f n u r s e s i n p r o v i d i n g c a r e which i s e f f e c t i v e i n r e d u c i n g o r r e l i e v i n g a p a t i e n t ' s p a i n w i t h o u t t h e use o f p a i n r e l i e v i n g d r u g s . The s t u d y was based on t h e c o n t e n t i o n t h a t , i f a p a t i e n t ' s p e r c e p t i o n o f p a i n f u l s t i m u l i can be m o d i f i e d , h i s r e s p o n s e t o t h e s t i m u l i can a l s o be m o d i f i e d . Thus, n u r s i n g c a r e p r e s c r i b e d p e r t a i n s t o a c t i o n s taken i n m o d i f y i n g a p a t i e n t ' s p e r c e p t i o n o f p a i n s t i m u l i . P a i n r e l i e f seems t o r e l a t e t o the i n t e r a c t i o n o r exchange o f r e s p o n s e s between a n u r s e and a p a t i e n t . The a u t h o r s c o n c l u d e d t h a t a p e r s o n ' s a t t i t u d e appears t o be s t r e n g t h e n e d when measures a r e t a k e n t o reduce o r r e l i e v e the f e e l i n g o f p a i n . I f r e s p o n s e s which cope d i r e c t l y w i t h the s t i m u l i r a t h e r than w i t h the s i g n s o f p a i n can be provoked from the p a t i e n t and r e i n f o r c e d , then the tendency to p e r c e i v e such s t i m u l i as p a i n - r e l a t e d may be a l t e r e d . I f one can a l t e r the a t t i t u d e o f the p e r s o n toward the s t i m u l i and h i s a b i l i t y t o cope w i t h the s t i m u l i , one can a l s o v a r y the p e r c e p t i o n o f the 43 s t i m u l i and the e x p e r i e n c e o f p a i n . Fagerhaugh s u b s t a n t i a t e s t h i s by the comment t h a t " a l t h o u g h a n x i e t y i n c r e a s e d p a i n p e r c e p t i o n , i t can be c o n t r o l l e d by a p o s i t i v e a t t i t u d e . " 44 M c C a f f e r y and Moss emphasize the importance o f d i s c u s s i n g p a i n w i t h the p a t i e n t i n o r d e r t o o b t a i n h i s t r u s t , t o m o b i l i z e h i s a d a p t i v e Fay T. Moss and Burton Meyer, "The E f f e c t s o f N u r s i n g I n t e r a c t i o n Upon P a i n R e l i e f i n P a t i e n t s , " N u r s i n g Research 15 ( F a l l 1966), p.303. 'Fagerhaugh,"Pain E x p r e s s i o n and C o n t r o l on a Burn U n i t , " p.648. Margo M c C a f f e r y and Fay Moss, " N u r s i n g I n t e r v e n t i o n f o r B o d i l y P a i n , " American J o u r n a l o f N u r s i n g 67 (June 1967), p.1225. mechanisms and t o change h i s a t t i t u d e toward p a i n r e l a t e d s t i m u l i . I n f o r m i n g t h e p a t i e n t o f what w i l l o c c u r b e f o r e a p a i n f u l t r e a t m e n t i s 45 i n i t i a t e d m o b i l i z e s h i s a d a p t i v e mechanisms. M c C a f f e r y and Moss emphasize t h e importance o f r e m a i n i n g w i t h t h e p a t i e n t . As a n x i e t y i n c r e a s e s , so does the d e s i r e t o be w i t h a n o t h e r p e r s o n . T h e r e f o r e , the pr e s e n c e o f t h e n u r s e i s i m p o r t a n t d u r i n g l a t t e r s t a g e s o f p a i n a n t i c i p a t i o n s i n c e a n x i e t y seems t o i n c r e a s e as t h e tim e approaches t o engage i n a s t r e s s f u l a c t i v i t y . 4 6 When p a i n s i g n a l s t o a man t h a t h i s l i f e i s hanging i n the b a l a n c e , he w i l l e x p e r i e n c e and communicate h i s a n x i e t y i n terms o f p a i n . A g r e a t d e a l o f p a i n i s r e l i e v e d by honest r e a s s u r a n c e r e g a r d i n g i t s meaning and the body's i n t e g r i t y . The l i s t e n e r must be p r e p a r e d f o r th e e x p r e s s i o n o f s t r o n g emotions. P a t i e n t s b e n e f i t from v e n t i l a t i o n o f such emotions and subsequent e x p l a n a t i o n r e g a r d i n g what t h e y a r e 47 e x p e r i e n c i n g p h y s i c a l l y and p s y c h o l o g i c a l l y . The Concept o f A n x i e t y The s u b j e c t o f a n x i e t y has been c o n s i d e r e d i n t h e l i t e r a t u r e from many v i e w p o i n t s . Those who have w r i t t e n about t h e measurement o f a n x i e t y have been p r e o c c u p i e d w i t h a s t a t i c e v a l u a t i o n o f a f i x e d moment o f a n x i e t y . 4 5 M c C a f f e r y and Moss, " N u r s i n g I n t e r v e n t i o n f o r B o d i l y P a i n , " p.1227. 4 6 S t a n l e y S c h a c h t e r , P s y c h o l o g i c a l A p p l i c a t i o n , ( S t a n f o r d : S t a n f o r d U n i v e r s i t y P r e s s , 1959), p.6b. 4 7 N o y e s and Andreasen, "The P s y c h o l o g i c a l R e a c t i o n t o Severe Burns," p.421. They have f a i l e d t o c o n s i d e r a n x i e t y o v e r t i m e , c h a n g i n g i n v a r y i n g degrees and assuming v a r i o u s d i r e c t i o n s . Other p s y c h o l o g i c phenomena must be c o n s i d e r e d i n r e l a t i o n s h i p t o a n x i e t y . Though v a r i o u s t e s t s can r e c o r d s t a t i c r e l a t i o n s h i p s between two o r more f a c t o r s a t a g i v e n i n s t a n c e w i t h g r e a t a c c u r a c y , t h e s e d a t a may not be v a l i d a t t h e v e r y next moment. A n x i e t y changes i n i n t e n s i t y from moment to moment. A n x i e t y i s f l u i d t o t i m e , q u a n t i t y , q u a l i t y , r a t e and d i r e c t i o n o f 48 change. The r e s e a r c h t r e n d s a r e r e f l e c t e d i n the a v a i l a b i l i t y o f i n c r e a s i n g numbers o f i n s t r u m e n t s and t e c h n i q u e s f o r measuring a n x i e t y . In r e v i e w i n g a n x i e t y l i t e r a t u r e , C a t t e l l and S c h i e r r e p o r t t h a t t h e y c o u n t e d more than 120 p e r s o n a l i t y - t y p e t e s t s which have been c l a i m e d t o measure 49 a n x i e t y . The s h e e r volume o f e m p i r i c a l r e s e a r c h on a n x i e t y p r e c l u d e s any attempt t o summarize i t . C r i t i c a l r e v i e w s o f r e s e a r c h on p s y c h o l o g i c a l s t r e s s c o n t a i n much t h a t i s r e l e v a n t t o t h e i n v e s t i g a t i o n o f a n x i e t y s i n c e a n x i e t y i s g e n e r a l l y r e g a r d e d as a p r o d u c t o f s t r e s s 50 and a m e d i a t o r o f i t s i n f l u e n c e on b e h a v i o u r . H i g h l y i n d i v i d u a l f a c t o r s d e t e r m i n e whether a p a r t i c u l a r s i t u a t i o n c o n s t i t u t e s a p s y c h o l o g i c a l s t r e s s f o r a p a r t i c u l a r i n d i v i d u a l . The judgement as t o whether o r n o t i t c o n s t i t u t e s a s t r e s s f o r an i n d i v i d u a l 51 cannot be made from t h e n a t u r e o f the e x t e r n a l event a l o n e . 48 S t a n l e y L e s s e , A n x i e t y : I t s Components, Development, and T r e a t m e n t , (New York: Grune and S t r a t t o n , 1970), p.2-3. 49 C h a r l e s S p i e l b e r g e r , A n x i e t y and B e h a v i o r , (New York: Academic P r e s s , 1966), p.7. 50 D U I b i d . , p.8. 51 George E n g e l , " P s y c h o l o g i c a l Responses o f Major Environmental S t r e s s , " i n P s y c h o l o g i c a l Development i n H e a l t h and D i s e a s e , ( P h i l a d e l p h i a : W.B. Saunders, 1962), p.264. 30 I t r e q u i r e s knowledge o f the r e s p o n s e as w e l l as knowledge o f t h a t p e r s o n ' s p e r s o n a l i t y makeup, r e g a r d i n g t h e way t h e y r e a c t to a s i t u a t i o n such as burn t r e a t m e n t . 52 L e v i has done c l a s s i c s t u d i e s on s t r e s s . L e v i ' s t a t e d t h a t " e v e r y p s c y h o s o c i a l o r p h y s i c a l e n v i r o n m e n t a l change can be s t r e s s f u l and evoke a n x i e t y . The h i g h e s t s t r e s s l e v e l s a r e u s u a l l y found a t t h e extremes o f t h e s t i m u l u s continuum, t h a t i s , d u r i n g exposure t o o v e r - o r u n d e r - s t i m u l a t i o n . " L e v i concedes t h a t t h e r e a r e d i f f i c u l t i e s i m p l i e d i n a l l attempts t o p a r t i a l out t h e p r i m a r y e f f e c t s o f such p u r e l y p h y s i c a l s t i m u l i , as trauma, from the s e c o n d a r y e f f e c t s e l i c i t e d by p s y c h o s o c i a l r e a c t i o n s t o them. I t i s w e l l e s t a b l i s h e d t h a t t h e sympathoadreno-medullary system i s i n f l u e n c e d by a g r e a t v a r i e t y o f p s y c h o s o c i a l s t i m u l i i n man. I f t h e s t i m u l u s l a s t s too l o n g o r i s r e p e a t e d too o f t e n , t h e r e s u l t w i l l be f u n c t i o n a l d i s t u r b a n c e s i n v a r i o u s organs and organ systems. Such a d y s f u n c t i o n , i f l o n g - s t a n d i n g o r i n t e n s e , may r e s u l t i n permanent s t r u c t u r a l changes o f p a t h o g e n i c s i g n i f i c a n c e , a t l e a s t t o p r e d i s p o s e d i n d i v i d u a l s . To i l l u s t r a t e t he a p p l i c a t i o n o f t h i s t h e o r y , t h e m a j o r i t y o f p a t i e n t s on a burn u n i t i n a p a r t i c u l a r Vancouver H o s p i t a l a r e g i v e n m i l k and M a a l o x ^ e v e r y hour i n o r d e r t o p r e v e n t g a s t r i c s t r e s s u l c e r s from d e v e l o p i n g . A m b i g u i t y i n the c o n c e p t u a l s t a t u s o f a n x i e t y a r i s e s from the more o r l e s s i n d i s c r i m i n a t e use o f t h e term t o r e f e r t o two v e r y d i f f e r e n t t y p e s o f c o n c e p t s . A n x i e t y i s most commonly used i n an e m p i r i c a l s e nse t o denote a complex r e a c t i o n o r r e s p o n s e -- a t r a n s i t o r y s t a t e o r c o n d i t i o n o f t h e o r g a n i s m t h a t v a r i e s i n i n t e n s i t y and f l u c t u a t e s o v e r time. L e n n a r t L e v i , " S t r e s s and D i s t r e s s i n Response t o P s y c h o s o c i a l S t i m u l i , " Supplement No. 528 to A c t a Medica S c a n d i n a v i a 191, ( Stockholm 1972,) pp.14-15. The term a n x i e t y , however, i s a l s o used t o r e f e r t o a p e r s o n a l i t y t r a i t , t h a t i s , t o i n d i v i d u a l d i f f e r e n c e s i n the e x t e n t t o which d i f f e r e n t p e o p l e a r e c h a r a c t e r i z e d by a n x i e t y s t a t e s and by prominent d e f e n s e s 53 a g a i n s t such s t a t e s . E m p i r i c a l e v i d e n c e o f d i f f e r e n t t y p e s o f a n x i e t y c o n c e p t s have emerged from t h e f a c t o r a n a l y t i c s t u d i e s o f C a t t e l l and S c h i e r . These i n v e s t i g a t o r s i d e n t i f i e d two d i s t i n c t a n x i e t y f a c t o r s which t h e y l a b e l e d t r a i t a n x i e t y and s t a t e a n x i e t y . The t r a i t a n x i e t y f a c t o r was i n t e r p r e t e d as measuring s t a b l e i n d i v i d u a l d i f f e r e n c e s i n a u n i t a r y , r e l a t i v e l y permanent p e r s o n a l i t y c h a r a c t e r i s t i c . The s t a t e a n x i e t y f a c t o r was based on a p a t t e r n o f v a r i a b l e s t h a t c o v a r i e d o v e r o c c a s i o n s o f measurement, d e f i n i n g a t r a n s i t o r y s t a t e o r c o n d i t i o n o f the or g a n i s m which f l u c t u a t e d o v e r time. Research on the c o n c e p t o f a n x i e t y would seem t o r e q u i r e t h a t a n x i e t y r e a c t i o n s o r s t a t e s be o p e r a t i o n a l l y and c o n c e p t u a l l y d i s t i n g u i s h e d from t h e s t i m u l u s c o n d i t i o n s t h a t a r o u s e them and the c o g n i t i v e and b e h a v i o r a l manoeuvres t h a t a r e l e a r n e d because t h e y l e a d t o a n x i e t y r e d u c t i o n . I t would appear t h a t r e s e a r c h on a n x i e t y a l s o r e q u i r e s t h a t a d i s t i n c t i o n be made between a n x i e t y as a t r a n s i t o r y s t a t e t h a t f l u c t u a t e s o v e r time and 55 as a p e r s o n a l i t y t r a i t t h a t remains r e l a t i v e l y s t a b l e o v e r time. 56 Downs and Newman b e l i e v e t h a t s t u d i e s a r e needed t o compare the 53 C h a r l e s D. S p i e l b e r g e r , A n x i e t y and B e h a v i o r , p. 12. 5 4 I b i d . , p.13. 5 5 I b i d . , p.15. 56 F l o r e n c e Downs and Ma r g a r e t Newman, A Source Book o f N u r s i n g Research ( P h i l a d e l p h i a : F.A. D a v i s Co., 1973), p.11. 32 e f f e c t s o f an i n d i v i d u a l i z e d approach f o r p a t i e n t s who appear t o be a f f e c t e d by h i g h l e v e l s o f s t r e s s w i t h an i n f o r m a t i v e approach f o r t h o s e who i n d i c a t e t h e e f f e c t s o f i n i t i a l low o r moderate l e v e l s o f s t r e s s . Every i n d i v i d u a l r e a c t s d i f f e r e n t l y t o t h e s t r e s s o r s i n a burn u n i t as i n d i c a t e d a n e c d o t a l l y i n t h e burn bath i n c i d e n t i n C h a p t e r I. D e v i s i n g ways t o reduce s t a t e a n x i e t y i s a need r e c o g n i z e d by t h o s e c a r i n g f o r burn p a t i e n t s . The I m p l i c a t i o n s f o r an A u d i o - V i s u a l T e a c h i n g Tool t o  Supplement P a t i e n t T e a c h i n g on a Burn U n i t I t has l o n g been r e c o g n i z e d by v a r i o u s a u t h o r s t h a t e x p l a n a t i o n o f a p r o c e d u r e i s l i k e l y t o d e c r e a s e a n x i e t y i n t h e p r e - s u r g i c a l p a t i e n t . 57 A c c o r d i n g t o S a y l o r , p r e - s u r g i c a l a n x i e t y i s r o o t e d i n f e a r o f the unknown. T h e r e f o r e , t h e a l l e v i a t i o n o f a n x i e t y w i l l be seen i n p r o p o r t i o n to t h e i n f o r m a t i o n and s u p p o r t g i v e n t o the p a t i e n t . I t has been assumed t h a t v i s u a l e v i d e n c e o f the p r o c e d u r e accompanying t h e t e a c h i n g w i l l enhance the e x p l a n a t i o n o f t h e t r e a t m e n t o r p r o c e d u r e . In r e f e r e n c e to t h e burn p a t i e n t , Andreasen s t a t e d t h a t p a t i e n t s s h o u l d be warned w e l l i n advance o f any p r o c e d u r e and g i v e n a broad p e r s p e c t i v e 59 o f t h e i r t r e a t m e n t program. W i l l i a m s s u p p o r t e d t h i s s t a t e m e n t by her b e l i e f t h a t a burn p a t i e n t has a need t o know what t o e x p e c t o f h i s h e a l i n g burn wound, why p o s i t i o n i n g and a c t i v i t y a r e n e c e s s a r y i n p r o t e c t i n g g r a f t s i t e s and t h a t p r e v e n t i n g c o n t r a c t u r e s i s i m p o r t a n t . 57 Dennis S a y l o r , " U n d e r s t a n d i n g P r e - S u r g i c a l A n x i e t y , " J o u r n a l o f the  American O p e r a t i n g Room Nurses 22 ( O c t o b e r , 1975), p.626. 58 Andreasen and Noyes, "Management o f Emo t i o n a l R e a c t i o n s i n S e v e r e l y Burned A d u l t s , " p.69. 59 B a r b a r a W i l l i a m s , "The Burned P a t i e n t ' s Need f o r T e a c h i n g , " N u r s i n g C l i n i c s  o f N orth America 6 ( D e c e m b e r ! 9 7 1 ) , p.616. A p a t i e n t i n W i l l i a m s ' s t u d y r e q u e s t e d the a u t h o r s t o h e l p him v i s u a l i z e what he would have to do and what would happen t o him. By e x p l a i n i n g t h e pr o c e d u r e b e f o r e h a n d , t h e p a t i e n t c o u l d p r e p a r e h i m s e l f m e n t a l l y f o r what was about t o o c c u r . T h e r e f o r e , f e a r o f the unknown was d i m i n i s h e d . 6 * ^ T h i s i s a l s o one o f t h e major o b j e c t i v e s o f t h i s i n v e s t i g a t o r ' s p r e s e n t s t u d y . Any new e v e n t which impinges on an i n d i v i d u a l a r o u s e s t e n s i o n and the p e r s o n s u b j e c t e d t o the s t r e s s employs v a r i o u s d e v i c e s t o a s s i s t him i n t h e r e d u c t i o n o f t e n s i o n . B a s i c t o the need t o a t t a c h some meaning t o the e v e n t i s the need to g i v e i t some c o g n i t i v e s t r u c t u r e . R e d u c t i o n o f e x c i t e m e n t i s e s s e n t i a l so t h a t t h e work o f w o r r y i n g can be done e f f e c t i v e l y . When the i n d i v i d u a l i s m i s i n f o r m e d , c o r r e c t i v e communication, r e a l i s t i c i n n a t u r e , can l e s s e n f e a r . 6 1 Nurses' a t t e m p t s t o g i v e t he p a t i e n t t o o l s f o r s t r u c t u r i n g s t r e s s f u l s i t u a t i o n s a r e n e c e s s a r y i n h e l p i n g t h e p a t i e n t f a c e t h i s s i t u a t i o n . CO Meyers s t a t e s t h a t l e s s t e n s i o n i s c r e a t e d when t h e p a t i e n t i s g i v e n s p e c i f i c i n f o r m a t i o n upon which he can s t r u c t u r e t h e impending e v e n t c a u s i n g him t o e x p e r i e n c e s t r e s s . To t e l l t h e p a t i e n t e x a c t l y what i s go i n g t o happen t o him may be h e l p f u l t o him. I t i s r e l a t e d t o the f a c t t h a t t h e p a t i e n t i s no l o n g e r a d e p e r s o n a l i z e d p a t i e n t b e i n g t r e a t e d i n a r o u t i n e way. R a t h e r , he i s b e i n g t r e a t e d as a per s o n o f i n t e l l i g e n c e whose c o o p e r a t i o n i s b e i n g sought by h i s n u r s e . 6 0 W i l l i a m s , "The Burned P a t i e n t ' s Need f o r T e a c h i n g , " p.638. 61M..E. Meyers, "The E f f e c t s o f Types o f Communication on P a t i e n t s ' R e a c t i o n s t o S t r e s s , " N u r s i n g Research 13 ( S p r i n g 1964), p.126. 6 2 I b i d . , p.129. Weisz commented t h a t p a t i e n t s , engaged i n an i n f o r m a t i o n g a t h e r i n g a c t i v i t y , g a i n a b e t t e r u n d e r s t a n d i n g o f the g o a l s o f t r e a t m e n t and a r e more h i g h l y m o t i v a t e d t o a c h i e v e t h e s e g o a l s . 64 Hamburg and A r t z s p e c i f i c a l l y endorsed the u t i l i z a t i o n o f photographs i n p r o v i d i n g emotional s u p p o r t and e x p l a n a t i o n to burn p a t i e n t s as r e l a t e d e a r l i e r i n t h i s c h a p t e r . Hamburg and A r t z s t a t e d t h a t v i s u a l e v i d e n c e o f t h e l i k e l i h o o d o f u n e v e n t f u l r e c o v e r y i s p a r t i c u l a r l y e n c o u r a g i n g i n the e a r l y phase o f h o s p i t a l i z a t i o n . S e e i n g o t h e r s who have a l s o been b a d l y burned tends t o make t h e p a t i e n t r e a l i z e t h e r e a r e o t h e r s who have gone throu g h the same k i n d o f e x p e r i e n c e and t h a t h i s i n j u r i e s can be s u c c e s s f u l l y t r e a t e d . Many p a t i e n t s a r e r e a s s u r e d by s e e i n g photographs t h a t show o t h e r burned p a t i e n t s a t the time o f i n j u r y and a f t e r r e c o v e r y . T h i s i m p r e s s i v e v i s u a l e v i d e n c e o f the p r o b a b i l i t y o f u l t i m a t e r e c o v e r y i s o f t e n more e f f e c t i v e than v e r b a l r e a s s u r a n c e but cannot t a k e i t s p l a c e . T h i s i n v e s t i g a t o r ' s c l i n i c a l e x p e r i e n c e s u p p o r t s the assumption t h a t i t i s p o s s i b l e t o reduce a n x i e t y due t o t h e e f f e c t s o f t r e a t m e n t s t r e s s t h r o u g h the use o f an a u d i o - v i s u a l program t h a t p r o v i d e s i n f o r m a t i o n about the t r e a t m e n t o f burns. Other a u t h o r s were i n a c c o r d w i t h t h i s b e l i e f . I t i s i m p e r a t i v e t h a t v e r b a l e x p l a n a t i o n and r e a s s u r a n c e accompany any a u d i o - v i s u a l t o o l used t o a s s i s t i n p a t i e n t t e a c h i n g . Weisz, " P s y c h o t h e r a p e u t i c S u p p o r t o f Burned P a t i e n t s , " p.1296. David Hamburg and C u r t i s A r t z , e t a l . , " C l i n i c a l Importance o f E m o t i o n a l Problems i n the Care o f P a t i e n t s w i t h Burns," New England J o u r n a l o f M e d i c i n e 248 ( F e b r u a r y 26, 1953), pp.356-357. The T h e r a p e u t i c N u r s e - P a t i e n t R e l a t i o n s h i p 35 In t h i s s t u d y , t h e i n v e s t i g a t o r e s t a b l i s h e d her r o l e t o t h e p a t i e n t as a nurse s p e c i a l i s t s t u d y i n g burn c a r e , n o t i n v o l v e d i n day t o day c a r e , but g a t h e r i n g i n f o r m a t i o n on the r e a c t i o n s o f burn p a t i e n t s t o t h e i r t r e a t m e n t s . Her purpose was t o v i s i t t h e p a t i e n t d u r i n g h i s h o s p i t a l i z a t i o n , answer any q u e s t i o n s , p r o v i d e emotional s u p p o r t as needed and p r e p a r e him f o r new phases o f h i s t r e a t m e n t . The p a t i e n t would be a b l e t o v e n t i l a t e h i s f r u s t r a t i o n s , f e a r s and a n x i e t i e s t o a p e r s o n r e s p o n s i v e t o h i s emotional needs. The l i t e r a t u r e s u p p o r t s the e s t a b l i s h m e n t o f t h e r a p e u t i c n u r s e - p a t i e n t 65 r e l a t i o n s h i p s . T r a v e l b e e d e v e l o p e d a theme o f n u r s i n g as a p r o f e s s i o n i n v o l v e d i n c a r i n g . She f e e l s t h a t a l l n u r s e s can l e a r n t o e s t a b l i s h and m a i n t a i n h e l p i n g r e l a t i o n s h i p s w i t h o t h e r s . T r a v e l b e e d e f i n e d n u r s i n g as an i n t e r p e r s o n a l p r o c e s s whereby t h e p r o f e s s i o n a l n u r s e p r a c t i t i o n e r a s s i s t s an i n d i v i d u a l , f a m i l y o r community t o p r e v e n t o r cope w i t h the e x p e r i e n c e o f i l l n e s s and s u f f e r i n g , and i f n e c e s s a r y , t o f i n d meaning i n t h e s e e x p e r i e n c e s . In a s s i s t i n g t h e i n d i v i d u a l to cope w i t h t h e e x p e r i e n c e o f i l l n e s s , a h e l p i n g r e l a t i o n s h i p i s b u i l t between the n u r s e and p a t i e n t . T h i s r e l a t i o n s h i p p r o v i d e s a f o u n d a t i o n upon which meaningful d i a l o g u e on s i g n i f i c a n t p e r s o n a l m a t t e r s can o c c u r . J o y c e T r a v e l b e e , I n t e r p e r s o n a l A s p e c t s o f N u r s i n g ( P h i l a d e l p h i a : F.A. Davis Co., 1971), pp.2-7. George M. Gazda, R i c h a r d P. W a l t e r s and W i l l i a m C. C h i l d e r s , Human  R e l a t i o n s Development - A Manual f o r H e a l t h S c i e n c e s ( B o s t o n : A l l y n and Bacon I n c . , 1975), p.103. Each n o r m a l l y f u n c t i o n i n g human b e i n g has a p o t e n t i a l f o r achievement and f o r s o l v i n g h i s own problems. H e l p i n g i s f r e q u e n t l y more a m a t t e r o f p r o v i d i n g e m o t i o n a l s u p p o r t and encouragement as w e l l as p r o v i d i n g an environment i n which t h e p a t i e n t can t h i n k t h r o u g h and make d e c i s i o n s on h i s own. Nurses can a s s i s t t h e p a t i e n t i n t h i s p r o c e s s by making i t e a s i e r f o r t h e p a t i e n t to d i s c u s s problems and e n c o u r a g i n g him t o 67 e x p l o r e h i s f e e l i n g s about i t . Lindemann and C a p l a n have o b s e r v e d t h a t t h e i n d i v i d u a l i s u s u a l l y i n a s t a t e o f h o m e o s t a s i s . H i s e q u i l i b r i u m i s m a i n t a i n e d by c o m p l i c a t e d i n t e r c h a n g e s between t h e i n d i v i d u a l and h i s environment and i s p a r t i c u l a r l y dependent upon t h e i n t e r p e r s o n a l t r a n s a c t i o n s t h r o u g h which he g r a t i f i e s h i s emotional needs. When t h e i n d i v i d u a l i s i n c a p a b l e o f s o l v i n g problems t h a t have been brought about by h i s l i f e s i t u a t i o n and t h e h o m e o s t a t i c mechanisms a r e u n s u c c e s s f u l i n r e s t o r i n g h i s p r e v i o u s e q u i l i b r i u m , a more o r l e s s p r o t r a c t e d p e r i o d o f emotional u p s e t ensues. T h i s c r i s i s i s c h a r a c t e r i z e d by an i n c r e a s e i n i n n e r t e n s i o n , u n p l e a s a n t a f f e c t and d i s o r g a n i z a t i o n o f b e h a v i o r . 6 ^ N u r s e s , t h e r e f o r e , can s t r i v e to a s s i s t t h e person i n r e s t o r i n g homeostasis o r t o a s s i s t t h e p a t i e n t i n 69 r e a c h i n g the h i g h e s t l e v e l o f f u n c t i o n i n g he i s c a p a b l e o f a t t h i s time. * The purpose o f t h e pl a n n e d i n t e r v e n t i o n s i n t h i s s t u d y i s t o a s s i s t the p a t i e n t i n m a i n t a i n i n g a l e v e l o f em o t i o n a l e q u i l i b r i u m o v e r t he Gazda, W a l t e r s and C h i l d e r s , Human R e l a t i o n s Development - A Manual F or  H e a l t h S c i e n c e s , p.72. Dorothy Mereness, P s y c h i a t r i c N u r s i n g , 2nd ed. (Dubuque: W i l l i a m C. Brown Co. P u b l i s h e r s , 1971), pp.66-67. I b i d . , p.71. 37 p e r i o d o f h o s p i t a l i z a t i o n f o r burn c a r e . By s h a r i n g t h e c o n c e r n s o f t h e p a t i e n t , by p r o v i d i n g e m o t i o n a l s u p p o r t as w e l l as i n f o r m a t i o n about t h e phases o f h i s burn t r e a t m e n t , t h e n u r s e s p e c i a l i s t s t r i v e s to e s t a b l i s h a t h e r a p e u t i c r e l a t i o n s h i p w i t h t h e p a t i e n t . Gazda e t a l 7 0 s t a t e d t h a t i t i s e s s e n t i a l t o keep t h e p a t i e n t w e l l i n f o r m e d o f h i s s c h e d u l e i n moving t h r o u g h phases o f t r e a t m e n t ; i f n o t , e v e r y t h i n g t h a t happens (o r does not happen as he t h i n k s i t s h o u l d ) w i l l add to h i s d i s c o m f o r t and i n c r e a s e h i s a n x i e t y . The n u r s e - p a t i e n t r e l a t i o n s h i p , t h e r e f o r e , i s an e s s e n t i a l component o f t h i s s t u d y . B a s i c t o t h i s r e l a t i o n s h i p i s t h e communication o f t h e b e l i e f i n the p o t e n t i a l o f t h e p a t i e n t as an i n d i v i d u a l c a p a b l e o f u n d e r s t a n d i n g and a s s i s t i n g i n h i s own c a r e . T h i s s h a r e d u n d e r s t a n d i n g f a c i l i t a t e s the e s t a b l i s h m e n t o f a t h e r a p e u t i c r a p p o r t between p a t i e n t and n u r s e . The E f f e c t o f A n x i e t y on S l e e p P a t t e r n s In r e c e n t y e a r s , t h e r e has been a g r e a t i n c r e a s e i n s l e e p r e s e a r c h . A l t h o u g h t h e e x p l o r a t i o n o f s l e e p i s v e r y new i n i t s c u r r e n t d i m e n s i o n s , the i m p l i c a t i o n s o f s l e e p r e s e a r c h f o r g e n e r a l m e d i c i n e a r e enormous.^ I t has been p o s t u l a t e d t h a t poor s l e e p p a t t e r n s a r e s e n s i t i v e i n d i c a t o r s o f i n c r e a s e d a n x i e t y . S l e e p d i s o r d e r s accompany p h y s i c a l and mental d i s e a s e . 7 0 G a z d a e t a l . , Human R e l a t i o n s Development, p.174 ^ U . S . Department o f H e a l t h , E d u c a t i o n and W e l f a r e . C u r r e n t Research on S l e e p  and Dreams. (Washington D.C.: Government P r i n t i n g O f f i c e , P u b l i c H e a l t h S e r v i c e P u b l i c a t i o n No.1389, 1973), p . l . 7 2 I b i d . , p.28. 73 Snyder and S c o t t noted t h a t t h e e f f e c t s o f a b i d i n g l e v e l s o f s t r e s s and a n x i e t y on s l e e p p r o f i l e s have been p a r t i c u l a r l y i n t e r e s t i n g t o p s y c h o p h y s i o l o g i s t s . However, t h e s e a u t h o r s d i d not s u p p o r t t h i s t h e o r y w i t h f a c t s . The l i t e r a t u r e r e l a t e d to s l e e p and a n x i e t y tends t o d i s c u s s t h e e f f e c t o f n e u r o t i c d e p r e s s i v e s t a t e s on s l e e p p a t t e r n s r a t h e r than "normal" a n x i e t y due t o s i t u a t i o n a l s t r e s s . Most o f the r e s e a r c h s t u d i e s c o n d u c t e d i n i n t e n s i v e c a r e u n i t s f o c u s e d on the e f f e c t s o f s l e e p d e p r i v a t i o n i n r e l a t i o n t o c r i t i c a l l y i l l p a t i e n t s . Luce and S e g a l 7 ^ r e p o r t e d t h a t t h e e f f e c t o f s t r e s s was e v i d e n t d u r i n g s l e e p . In e x p e r i m e n t a l s t r e s s s i t u a t i o n s , s u b j e c t s had l e s s d e l t a s l e e p and more g a l v a n i c s k i n a c t i v i t y ( c o n d u c t i v i t y o f t h e s k i n ) . The i n t e n s i t y o f s t r e s s was v i s i b l e i n s l e e p . E l e c t r o e n c e p h a l o g r a m s o f the s l e e p p a t t e r n s o f Luce's s u b j e c t s demonstrated t r a c i n g s d e p i c t i n g the t e n s i o n s and s t r e s s e s which o c c u r r e d d u r i n g d i s t u r b e d s l e e p . 75 C I i f t c o n c l u d e d t h a t , i n g e n e r a l , women s c o r e d somewhat h i g h e r on t e s t s o f a n x i e t y than men o f the same age. The women r e p o r t e d p o o r e r s l e e p . A l s o , sex d i f f e r e n c e s i n r e p o r t e d q u a l i t y o f s l e e p became g r e a t e r w i t h age. J o h n s 7 6 d i s c u s s e d v a r i o u s methods f o r a s s e s s i n g s l e e p . A l t h o u g h 73 F r e d e r i c k Snyder and Jimmy S c o t t , "The P s y c h o p h y s i o l o g y o f S l e e p , " Handbook  o f P s y c h o p h y s i o l o g y , ed. Norman G r e e n f i e l d and R i c h a r d S t e i n b a c h (New York: H o l t , R h i n e h a r t and Winston I n c . , 1972), p.680. 7 4 G a y G. Luce and J u l i u s S e g a l , Insomnia (Garden C i t y , New York: Doubleday and Co. I n c . , 1969), pp.62-63. 75 Anthony D. C l i f t , S l e e p D i s t u r b a n c e and H y n o t i c Drug Dependence (New York: American E l s e v i e r P u b l i s h i n g Co. I n c . , 1975), p.59. 7 6 M u r r a y W. Johns, "Methods F or A s s e s s i n g Human S l e e p , " A r c h i v e s o f  M e d i c i n e 127 (March 1971), p.485-491. 39 d a i l y s l e e p c h a r t s have the advantage o v e r q u e s t i o n n a i r e s o f g i v i n g i n f o r m a t i o n about d a i l y v a r i a t i o n s o f s l e e p o v e r p r o l o n g e d p e r i o d s , no s i n g l e method o f s l e e p assessment, whether s u b j e c t i v e o r o b j e c t i v e , can g i v e enough i n f o r m a t i o n t o p e r m i t n e g l e c t o f o t h e r methods. J o h n s 7 7 noted t h a t when d e p r e s s e d p a t i e n t s r a t e d t h e i r q u a l i t y o f s l e e p on a q u e s t i o n n a i r e , t h e y tended t o o v e r e s t i m a t e t h e i r degree o f s l e e p d i s t u r b a n c e . I t was d i f f i c u l t f o r t h e s e p a t i e n t s t o d i s t i n g u i s h s u b j e c t i v e l y between b r i e f p e r i o d s o f l i g h t s l e e p and w a k e f u l n e s s . The n u r s e must a s s e s s c a r e f u l l y whether o r n o t the p a t i e n t i s s l e e p i n g o r has s l e p t . The o b j e c t i v e r e p o r t o f the n u r s e t h a t the p a t i e n t s l e p t w e l l i s o f t e n not s u b s t a n t i a t e d by the s u b j e c t i v e r e p o r t o f the p a t i e n t t h a t he d i d n o t s l e e p w e l l . The n u r s e s h o u l d ask the p a t i e n t to e v a l u a t e t h e t y p e o f s l e e p he i s e x p e r i e n c i n g . O f t e n , under c o n d i t i o n s o f d i s c o m f o r t , t h e p e r s o n who says he s l e p t p o o r l y a c t u a l l y t a k e s l o n g e r t o f a l l a s l e e p , i s more r e s t l e s s and dreams l e s s . Dreaming i s c o n s i d e r e d n e c e s s a r y f o r the r e l e a s e o f s u p p r e s s e d i n t r a p s y c h i c t e n s i o n . Dreaming has been s u b s t a n t i a t e d by r e s e a r c h as o c c u r r i n g d u r i n g p e r i o d s o f Rapid Eye Movement (R.E.M.). A c e r t a i n 78 amount o f R a p i d Eye Movement i s an i m p o r t a n t a s p e c t o f good s l e e p . In t h i s i n v e s t i g a t o r ' s s t u d y , a r e c o r d was kept by the s t a f f n u r s e s o f t h e hours,'''of s l e e p and w a k e f u l n e s s o v e r the 12 hour time p e r i o d . The p a t i e n t was asked t o s u b j e c t i v e l y e v a l u a t e h i s q u a l i t y o f s l e e p on a d a i l y b a s i s . As the l i t e r a t u r e has i n d i c a t e d , t h e s l e e p p a t t e r n o f t h e p a t i e n t s h o u l d r e f l e c t the l e v e l o f s t a t e a n x i e t y he i s e x p e r i e n c i n g . 7 7 J o h n s , "Methods F o r A s s e s s i n g Human S l e e p , " p.485. 78 Margo M c C a f f e r y , N u r s i n g Management o f t h e P a t i e n t With P a i n ( T o r o n t o : J.B. L i p p i n c o t t Co., 1972), p.T33T. 40 Summary The r e v i e w o f l i t e r a t u r e encompasses many a r e a s o f c o n c e r n i n burn c a r e and burn r e s e a r c h . I t i s i m p o r t a n t t o know how t h e s t r e s s o f a new s i t u a t i o n can be reduced and what f a c t o r s need t o be c o n s i d e r e d to d i v e r t . . . 70 p a t i e n t s ' e n e r g i e s most e f f e c t i v e l y . I t i s i m p e r a t i v e t h a t t h e h e a l t h team be aware o f t h e emotional problems o f burned p a t i e n t s . T h e r e i s a need f o r a l l s t a f f t o un d e r s t a n d t h e s e p a t i e n t s ' b a s i c e m o t i o n a l p r o c e s s e s so t h a t t h e y can r e s p o n s i v e l y a p p l y t h e i r knowledge. A l l t h e e m p a t h e t i c t h i n k i n g t h a t can be mustered i s v i t a l t o t h e t r e a t m e n t o f burns and c l e a r l y a p p l i c a b l e i n the 80 p r o v i s i o n o f h u m a n i s t i c c a r e . A n x i e t y a r i s i n g from r e s p o n s e t o p e r c e p t i o n o f p a i n f u l s t i m u l i v a r y from p e r s o n t o p e r s o n . P a i n and a n x i e t y a r e i n t e r r e l a t e d . P a i n , as a s t r e s s o r , i n c r e a s e s a n x i e t y . Most p e o p l e respond t o s t r e s s f u l s i t u a t i o n s w i t h a r i s e i n t h e i r a n x i e t y l e v e l . A n x i e t y as a p r o c e s s needs t o be u n d e r s t o o d . Beyond t h i s must be added the d i s t i n c t i o n between a n x i e t y as a t r a n s i t o r y s t a t e v e r s u s a n x i e t y as a r e l a t i v e l y s t a b l e p e r s o n a l i t y t r a i t . A n x i e t y i s a l s o r e l a t e d t o d i s t u r b a n c e i n s l e e p p a t t e r n s . As a means o f d e c r e a s i n g s i t u a t i o n a l a n x i e t y , many a u t h o r s a g r e e t h a t t he p a t i e n t needs an o p p o r t u n i t y t o v e n t i l a t e h i s pent-up emotions and f r u s t r a t i o n s . E x p l a n a t i o n , emotional s u p p o r t and v i s u a l e v i d e n c e o f Meyers, "The E f f e c t s o f Types o f Communication i n P a t i e n t s ' R e a c t i o n s t o S t r e s s , " p.12. 'Norman B e r n s t e i n , "The Care o f Burned V i c t i m s , " New England J o u r n a l o f  M e d i c i n e 286 (January 13, 1972), p.102. 41 r e c o v e r y by means o f an a u d i o - v i s u a l t e a c h i n g t o o l , may h e l p a l l e v i a t e a n x i e t y . The r e v i e w o f the l i t e r a t u r e c l e a r l y s u b s t a n t i a t e s and v a l i d a t e s the problem o f i n c r e a s e d a n x i e t y due t o t h e e f f e c t s o f t r e a t m e n t s t r e s s i n burn p a t i e n t s . C h a p t e r 3 THE STUDY A d e s c r i p t i v e approach u s i n g p a r t i c i p a n t o b s e r v a t i o n , i n t e r v i e w s and s p e c i f i c d a t a c o l l e c t i n g i n s t r u m e n t s was used w i t h a one group p r e - t e s t , m u l t i p l e p o s t - t e s t r e s e a r c h p l a n . S e v e r a l v a r i a b l e s w i t h i n t he group were compared from two p e r s p e c t i v e s . C o r r e l a t i o n a l s t a t i s t i c s were a p p l i e d to i n d i c a t e the s t r e n g t h o f the r e l a t i o n s h i p o f the two p e r s p e c t i v e s t o th e s e v a r i a b l e s i n the r e a l i t y o f the on-going s i t u a t i o n o f burn c a r e . A case s t u d y approach was a l s o used s i m u l t a n e o u s l y . The S e t t i n g The s t u d y took p l a c e on the burn u n i t o f a l a r g e g e n e r a l t e a c h i n g h o s p i t a l i n Canada d u r i n g a f o u r month p e r i o d . T h i s burn u n i t was comprised o f a 3 bed i n t e n s i v e c a r e u n i t , 13 s i n g l e rooms and two open ward a r e a s , each w i t h 8 beds. The burn u n i t was s t a f f e d by t h r e e p l a s t i c s u r g e o n s , 'one burn r e s i d e n t " p h y s i c i a n , 30 n u r s e s , 2 p h y s i o t h e r a p i s t s and one o c c u p a t i o n a l t h e r a p i s t . A p s y c h i a t r i c nurse i s o f t e n c o n s u l t e d i f a p a t i e n t e x p r e s s e s s e v e r e emotional problems i n a d j u s t i n g t o the burn trauma. Burn Treatment: Usual t r e a t m e n t s , as i n d i c a t e d on an i n d i v i d u a l b a s i s , i n c l u d e s a l i n e compresses, d a i l y debridement o f e s c h a r and c o l l a g e n , burn baths i n a Hubbard ta n k , w h i r l p o o l arm b a t h s , and a p p l i c a t i o n o f an a n t i b i o t i c cream. S p l i n t s a r e made f o r 1 i m b e x t r e m i t i e s and a r e worn c o n s t a n t l y e x c e p t f o r f r e q u e n t p e r i o d s o f e x e r c i s e . S k i n g r a f t i n g o f t h i r d degree burns u s u a l l y takes p l a c e soon a f t e r debridement o f the burn i n j u r y . A f t e r s k i n g r a f t s 43 have been p l a c e d on the wounds, f r e q u e n t " r o l l i n g " w i t h Q - t i p s i s n e c e s s a r y i n o r d e r t o e x p r e s s accumulated f l u i d exudate from beneath the g r a f t . A t t i m e s , s u r g i c a l p i n n i n g o f a l i m b i s n e c e s s a r y . The p i n s , a t t a c h e d to t r a c t i o n , a r e n e c e s s a r y t o keep the limb e l e v a t e d and t o p r o t e c t s k i n g r a f t s from a c c i d e n t i a ! removal. The average l e n g t h o f h o s p i t a l i z a t i o n i s a p p r o x i m a t e l y one month f o r the l e s s s e v e r e l y burned p a t i e n t . The Sample Each p a t i e n t m e e t i n g / ' t h e " s u b j e c t c r i t e r i a , " a d m i t t e d to the burn u n i t o v e r the d a t a c o l l e c t i o n p e r i o d , was approached and an e x p l a n a t i o n o f the s t u d y g i v e n b e f o r e b e i n g r e q u e s t e d t o p a r t i c i p a t e i n the s t u d y . Sample s i z e was dependent upon the number o f burn v i c t i m s a d m i t t e d t o the burn u n i t o f the h o s p i t a l d u r i n g t h e r e s e a r c h p e r i o d . T h e r e f o r e , the sample o f t h i s s t u d y was comprised o f a t o t a l o f f i v e s u b j e c t s . S u b j e c t C r i t e r i a -1. A d u l t , 16 to 65 y e a r s o f age. I t was thought a s u b j e c t younger than 16 y e a r s o f age might not f u l l y u n d e r s t a n d the purpose o f the r e s e a r c h study o r the c o n t e n t o f the i n s t r u c t i o n a l program. A s u b j e c t o l d e r than 65 y e a r s o f age might confound the r e s u l t s o f the study s i n c e t h e r e i s a g r e a t e r i n c i d e n c e o f problems a s s o c i a t e d w i t h a g i n g . A d i s e a s e c o e x i s t i n g w i t h the burn might a f f e c t the a n x i e t y e x p e r i e n c e d by the p a t i e n t . 2. E x t e n t o f s u r f a c e a r e a burned - l e s s than 30%. A burn more e x t e n s i v e than 30% i n an a d u l t p a t i e n t would be c o n s i d e r e d c r i t i c a l and l i f e - t h r e a t e n i n g . The t h r e a t t o l i f e and the c o n d i t i o n s a s s o c i a t e d w i t h major burns would r e n d e r the s u b j e c t s u n s u i t a b l e f o r the study. A l s o , t he p a t i e n t may be too s e d a t e d t o comprehend the t e a c h i n g program. The p a t i e n t s h o u l d be a l e r t and o r i e n t e d i n o r d e r to r e c e i v e exposure t o the program. 3. Depth o f burn - second and/or t h i r d degree. P a t i e n t s w i t h o n l y f i r s t degree burns a r e u s u a l l y not a d m i t t e d t o h o s p i t a l . 4. Area o f s u r f a c e burned - a l l a r e a s i n c l u d i n g t he head. The p a t i e n t s were, i n no way, made t o f e e l o b l i g e d to p a r t i c i p a t e i n the s t u d y . W r i t t e n c o n s e n t was o b t a i n e d from each p a t i e n t a g r e e i n g t o p a r t i c i p a t e . (Appendix A ) . An e x p l a n a t i o n o f the purpose o f the st u d y was g i v e n . The p a t i e n t was informed t h a t he c o u l d withdraw from the study a t any time. A l l i n f o r m a t i o n c o l l e c t e d was s t r i c t l y c o n f i d e n t i a l and c i r c u l a t i o n o f the i n f o r m a t i o n l i m i t e d to thos e i n v o l v e d i n t h e s t u d y . A number, not the p a t i e n t ' s name,was used t o i d e n t i f y d a t a c o l l e c t i o n forms. A l l i n f o r m a t i o n c o l l e c t e d was n e c e s s a r y f o r the purposes o f the s t u d y . The r e s u l t s and c o n c l u s i o n s were made f r e e l y a v a i l a b l e t o the p a r t i c i p a n t s upon c o m p l e t i o n o f the s t u d y , i f r e q u e s t e d . U s u a l , r o u t i n e t r e a t m e n t d i d not i n c l u d e the i n s t r u c t i o n a l program. No n u r s i n g c a r e was o m i t t e d . 45 Method o f Data C o l l e c t i o n The p a t i e n t was approached a few days a f t e r a d m i s s i o n and an e x p l a n a t i o n o f the study g i v e n b e f o r e b e i n g r e q u e s t e d t o p a r t i c i p a t e i n the s t u d y . The i n v e s t i g a t o r e s t a b l i s h e d her r o l e as a nurse s p e c i a l i s t s t u d y i n g burn c a r e , not i n v o l v e d i n day t o day c a r e , but g a t h e r i n g i n f o r m a t i o n on the r e a c t i o n s o f burn p a t i e n t s t o t h e i r t r e a t m e n t s . She e x p l a i n e d t h a t she would v i s i t t he p a t i e n t not l e s s than e i g h t times d u r i n g the p a t i e n t ' s h o s p i t a l i z a t i o n , answer any q u e s t i o n s , p r o v i d e e m o t i o n a l s u p p o r t as needed and p r e p a r e him f o r new phases o f h i s t r e a t m e n t . I f the p a t i e n t agreed t o p a r t i c i p a t e i n the s t u d y , the w r i t t e n c o n s e n t form was s i g n e d by the p a t i e n t and t h e i n v e s t i g a t o r . The d a t a c o l l e c t i o n p e r i o d began the next day. The p a t i e n t was a s s e s s e d by the i n v e s t i g a t o r . The purpose o f t h i s b r i e f i n t e r v i e w was t o c o l l e c t i n f o r m a t i o n about the p a t i e n t as w e l l as r e a c t i o n s to c a r e and t r e a t m e n t s . A f t e r the assessment i n t e r v i e w , the S t a t e - T r a i t A n x i e t y I n v e n t o r y was a d m i n i s t e r e d by the i n v e s t i g a t o r . P a r t I o f the t a p e - s l i d e program, " E x p l a i n i n g Your Burn Care" was shown. (In t h r e e c a s e s , i t was n e c e s s a r y t o show subsequent p a r t s o f the program a t t h i s time s i n c e phases i n t r e a t m e n t o f the burn wound were p r o g r e s s i n g v e r y r a p i d l y . ) A f t e r the p r e s e n t a t i o n o f the program, the p a t i e n t was encouraged to ask q u e s t i o n s and e x p r e s s h i s c o n c e r n s . E x p l a n a t i o n and emotional s u p p o r t , based on the p a t i e n t ' s v o i c e d concerns,were p r o v i d e d by the i n v e s t i g a t o r a t t h i s t i me. The i n f o r m a t i o n a l and s u p p o r t components o f the i n s t r u c t i o n a l program were e v a l u a t e d by a data c o l l e c t i n g i n s t r u m e n t d e s i g n e d s p e c i f i c a l l y f o r t h i s purpose. The p a t i e n t was asked t o e n t e r comments i n a d a i l y d i a r y 46 around the same time e v e r y day. On t h i s f i r s t day o f the data c o l l e c t i o n p e r i o d , t he nurse c a r i n g f o r the p a t i e n t was asked to a s s e s s her p a t i e n t ' s l e v e l o f s t a t e and t r a i t a n x i e t y . She r a t e d her s u b j e c t i v e o p i n i o n o f the a n x i e t y l e v e l she p e r c e i v e d i n her p a t i e n t on a L i k e r t - t y p e s c a l e . S l e e p and m e d i c a t i o n r e c o r d s were p l a c e d on the f r o n t o f the p a t i e n t ' s c h a r t . The n u r s e s were i n f o r m e d t h a t t h i s p a r t i c u l a r p a t i e n t was a " r e s e a r c h s u b j e c t . " Not o n l y was the p a t i e n t ' s c h a r t c l e a r l y l a b e l l e d , a c a r d o f i n s t r u c t i o n s was a l s o p l a c e d i n t h e p a t i e n t ' s kardex. The purpose o f t h i s c a r d was to i n f o r m the nurses d u r i n g " r e p o r t " a t each change o f s h i f t t h a t t h i s p a t i e n t was a s u b j e c t i n a n u r s i n g s t u d y . D u r i n g t he dat a c o l l e c t i o n p e r i o d , t h e p a t i e n t was v i s i t e d by the i n v e s t i g a t o r e i g h t t i m e s . A p p r o p r i a t e s e c t i o n s o f the i n s t r u c t i o n a l program were shown t o the p a t i e n t depending on the t r e a t m e n t the p a t i e n t was t o r e c e i v e a t t h a t phase o f r e c o v e r y . The s p e c i f i c s e c t i o n o f the t a p e - s l i d e program and d i s c u s s i o n f o l l o w i n g were e v a l u a t e d by means o f the e v a l u a t i o n t o o l f o r the i n s t r u c t i o n a l program. These e i g h t v i s i t s were not a t random. Two v i s i t s took p l a c e i n the morning, b e f o r e t r e a t m e n t s were i n i t i a t e d . T h i s was c o n s i d e r e d a hig h s t r e s s p e r i o d . The S t a t e - T r a i t A n x i e t y I n v e n t o r y was a d m i n i s t e r e d by t he i n v e s t i g a t o r d u r i n g each v i s i t . The p a t i e n t was encouraged t o v e n t i l a t e h i s c o n c e r n s and f e a r s . S i n c e each p a t i e n t i s an unique i n d i v i d u a l , a n t i c i p a t o r y g u i dance and emotional s u p p o r t was an i n d i v i d u a l p r o c e s s dependent on such f a c t o r s as the p a t i e n t ' s background e x p e r i e n c e , v o i c e d c o n c e r n s and a b i l i t y t o r e l a t e t o the r e a l i t y o f the burn t r e a t m e n t s i t u a t i o n . 47 Two v i s i t s took p l a c e i n the a f t e r n o o n a f t e r t r e a t m e n t s f o r t h a t day had f i n i s h e d . T h i s was c o n s i d e r e d a low s t r e s s p e r i o d . The S t a t e - T r a i t A n x i e t y I n v e n t o r y was a d m i n i s t e r e d by the i n v e s t i g a t o r d u r i n g each v i s i t . The p a t i e n t was encouraged t o v e r b a l i z e h i s c o n c e r n s , f r u s t r a t i o n s and problems. T h i s i n t e r a c t i o n w i t h t he nurse s p e c i a l i s t was c o n s i d e r e d s u p p o r t i v e c a r e . Two v i s i t s d i d t a k e p l a c e a t random where the S t a t e - T r a i t A n x i e t y I n v e n t o r y was not a d m i n i s t e r e d . The p a t i e n t took t he l e a d i n d i s c u s s i n g whatever was on h i s mind. A t h e r a p e u t i c r a p p o r t was always sought by c r e a t i n g a s u p p o r t i v e environment on the p a r t o f the nurse s p e c i a l i s t . A f t e r each v i s i t , the i n v e s t i g a t o r c o l l e c t e d t he completed d i a r i e s . Nurses' notes were reviewed f o r d e s c r i p t i o n s o f b e h a v i o r i n d i c a t i n g an i n c r e a s e o r d e c r e a s e o f a n x i e t y and need f o r a n a l g e s i c , s e d a t i v e and s l e e p i n g m e d i c a t i o n s . S i n c e the v i s i t s were not tape r e c o r d e d , the i n v e s t i g a t o r e n t e r e d d a t a g a i n e d from c o n v e r s a t i o n w i t h the p a t i e n t i n on-g o i n g f i e l d n o t e s . On the f i n a l day o f the dat a c o l l e c t i o n p e r i o d , the s i x t h S t a t e - T r a i t A n x i e t y I n v e n t o r y was a d m i n i s t e r e d by the i n v e s t i g a t o r . The p a t i e n t was asked to e v a l u a t e the h e l p f u l n e s s o f t h e o p p o r t u n i t y t o v e n t i l a t e h i s thoughts and a n x i e t i e s . A r e v i e w o f the c o n t e n t s o f the d i a r i e s and S t a t e - T r a i t A n x i e t y I n v e n t o r i e s was g i v e n . The p a t i e n t was g i v e n t h e o p t i o n o f c o n t i n u i n g h i s d i a r i e s i f he so wished. The nurse c a r i n g f o r the p a t i e n t t h a t day was asked t o a g a i n a s s e s s the p a t i e n t ' s s t a t e and t r a i t a n x i e t y on t h e same L i k e r t - t y p e s c a l e u t i l i z e d a t the time o f a d m i s s i o n . The s l e e p and m e d i c a t i o n r e c o r d s were d i s c o n t i n u e d . 48 D e l i n e a t i o n o f V a r i a b l e s  Dependent V a r i a b l e : S t a t e A n x i e t y A n x i e t y i s one o f the c e n t r a l c o n c e p t s i n modern p s y c h o l o g y . I f a n x i e t y i s t o s e r v e a d e q u a t e l y as an e x p e r i m e n t a l v a r i a b l e , i t i s n e c e s s a r y t h a t s a t i s f a c t o r y t e c h n i q u e s be a v a i l a b l e f o r i t s i d e n t i f i c a t i o n and 81 measurement. D i f f e r e n t i a t i o n between c a t e g o r i e s o f a n x i e t y must be made s i n c e both s t a t e and t r a i t a n x i e t y a r e p r e v a l e n t when a burn p a t i e n t p e r c e i v e s h i s c a r e and t r e a t m e n t . " S t a t e " a n x i e t y i s c o n c e p t u a l i z e d as a t r a n s i t o r y e m o t i o n a l s t a t e o r c o n d i t i o n o f the human organism t h a t i s c h a r a c t e r i z e d by s u b j e c t i v e , c o n s c i o u s l y p e r c e i v e d f e e l i n g s o f t e n s i o n and a p p r e h e n s i o n . S t a t e a n x i e t y may vary i n i n t e n s i t y and f l u c t u a t e o v e r t i m e . I t i s an e m p i r i c a l p r o c e s s o r r e a c t i o n t a k i n g p l a c e a t a p a r t i c u l a r moment i n time and a t a g i v e n 82 l e v e l o f i n t e n s i t y . " T r a i t " a n x i e t y r e f e r s to r e l a t i v e l y s t a b l e i n d i v i d u a l d i f f e r e n c e s i n a n x i e t y p r o n e n e s s , t h a t i s , t o d i f f e r e n c e s between p e o p l e i n the tendency t o respond t o s i t u a t i o n s p e r c e i v e d as t h r e a t e n i n g w i t h e l e v a t i o n s i n " s t a t e " i n t e n s i t y . T r a i t a n x i e t y has the c h a r a c t e r i s t i c s o f a c q u i r e d b e h a v i o r a l d i s p o s i t i o n s . In o t h e r words, t r a i t a n x i e t y i n d i c a t e s d i f f e r e n c e s i n the s t r e n g t h o f the l a t e n t d i s p o s i t i o n t o m a n i f e s t a c e r t a i n t y p e o f r e a c t i o n . 81 Paul McReynolds, "The Assessment o f A n x i e t y - A Survey o f A v a i l a b l e T e c h n i q u e s . " Advances o f P s y c h o l o g i c a l Assessment ( P a l o A l t o : S c i e n c e and B e h a v i o r Books I n c . , 1968), p. 248. 82 C h a r l e s D. S p i e l b e r g e r and R i c h a r d L. Gorsuch e t a l , Manual f o r the  S t a t e - T r a i t A n x i e t y I n v e n t o r y (Palo A l t o : C o n s u l t i n g P s y c h o l o g i s t s P r e s s , 1968), p. 2. 8 3 I b i d . , p. 2. 49 In g e n e r a l , i t would be e x p e c t e d t h a t those who a r e h i g h i n " t r a i t " w i l l e x h i b i t " s t a t e " e l e v a t i o n s more f r e q u e n t l y than low " t r a i t " i n d i v i d u a l s because they t e n d t o p e r c e i v e a w i d e r range o f s i t u a t i o n s as dangerous o r t h r e a t e n i n g . High " t r a i t " persons a r e a l s o more l i k e l y t o respond t o s t r e s s f u l s i t u a t i o n s w i t h i n c r e a s e d " s t a t e " i n t e n s i t y . But whether o r not p e o p l e who d i f f e r i n " t r a i t " w i l l show c o r r e s p o n d i n g d i f f e r e n c e s i n " s t a t e " depends upon t h e e x t e n t t o which a s p e c i f i c s i t u a t i o n i s p e r c e i v e d by a p a r t i c u l a r i n d i v i d u a l as dangerous o r t h r e a t e n i n g , and t h i s i s g r e a t l y i n f l u e n c e d by an i n d i v i d u a l ' s p a s t 84 e x p e r i e n c e . I t i s w i d e l y a c c e p t e d t h a t most p e o p l e respond t o s t r e s s f u l s i t u a t i o n s w i t h i n c r e a s e d a n x i e t y and t h a t a n x i e t y r e a c t i o n s a r e c h a r a c t e r i z e d by f e e l i n g s o f a p p r e h e n s i o n , t e n s i o n and a c t i v a t i o n o f the autonomic nervous system. When a n x i e t y r e a c t i o n s a r e i n d u c e d by s t r e s s f u l s t i m u l i , a p a r t i c u l a r i n d e x by which the s t r e n g t h o f t h e s e emotional r e a c t i o n s t o 85 s t r e s s a r e t o be e v a l u a t e d must be s p e c i f i e d . T h e r e f o r e , a n x i e t y as a p r o c e s s r e f e r s t o a complex sequence o f c o g n i t i v e , a f f e c t i v e and b e h a v i o r a l events t h a t i s evoked by some form o f s t r e s s . S i n c e the c o n c e p t o f a n x i e t y as a p r o c e s s i m p l i e s a t h e o r y o f a n x i e t y t h a t i n c l u d e s s t r e s s and t h r e a t , s t a t e and t r a i t a n x i e t y can be c o n s i d e r e d as fundamental c o n s t r u c t s o r v a r i a b l e s . ^ 6 S t a t e a n x i e t y C h a r l e s D. S p i e l b e r g e r and R i c h a r d L. Gorsuch e t a l , Manual f o r the  S t a t e - T r a i t A n x i e t y I n v e n t o r y , p. 3. 'Charles D. S p i e l b e r g e r and I r w i n S a r a s o n , S t r e s s and A n x i e t y , (New York: John Wiley and Sons, 1975), V o l . 1, p. 129. I b i d . , pp. 137-139. 50 i n f l u e n c e d by the e f f e c t s o f t r e a t m e n t s t r e s s i s the dependent v a r i a b l e i n t h i s study. Independent V a r i a b l e : An i n s t r u c t i o n a l program i n c l u d i n g i n f o r m a t i v e and s u p p o r t i v e components. The i n f o r m a t i o n a l component o f a t a p e - s l i d e program, " E x p l a i n i n g Your Burn Care," was produced by the i n v e s t i g a t o r (Appendix C ) . The program was composed o f f a c t u a l b a s i c i n f o r m a t i o n about the phases o f burn c a r e . There were s i x p a r t s d e s c r i b i n g t h e s e phases o f tr e a t m e n t . The c o n t e n t a r e a s o f the i n f o r m a t i o n a l component i n c l u d e : PART I O r i e n t a t i o n To The Burn U n i t PART II The Burn Bath PART I I I The Arm Bath PART IV S k i n G r a f t i n g PART V S p l i n t i n g PART VI S u r g i c a l P i n n i n g A f t e r an e x p l a n a t i o n o f the purpose o f the program, a l l p a t i e n t s were shown P a r t I by the i n v e s t i g a t o r . Depending on each p a t i e n t ' s phase o f t r e a t m e n t , subsequent p a r t s were shown s e p a r a t e l y , b e f o r e the new tr e a t m e n t was i n i t i a t e d . I f the t r e a t m e n t was a l r e a d y i n p r o g r e s s , t h e p e r t i n e n t p a r t o f the program was shown to the p a t i e n t . A f t e r t he v i e w i n g o f each s e c t i o n o f the t a p e - s l i d e program, t h e p a t i e n t was encouraged to e x p r e s s h i s f e e l i n g s about h i s t r e a t m e n t s and t o ask q u e s t i o n s about h i s c a r e . S i n c e t he purpose o f the program was t o a l l o w the p a t i e n t to v i s u a l i z e h i s t r e a t m e n t and t h e s e t t i n g i n which i t would t a k e placer; b e f o r e the 51 t r e a t m e n t was i n i t i a t e d , i t was e x p e c t e d the p a t i e n t s h o u l d be a b l e t o more r e a d i l y a n t i c i p a t e the s i t u a t i o n i n advance. By r e c e i v i n g t h i s i n f o r m a t i o n , the p a t i e n t s h o u l d be a b l e t o c o n s t r u c t and r e h e a r s e r e a l i t y b e f o r e h i s d a i l y t r e a t m e n t s . T h i s approach was based on the premise t h a t a c c u r a t e e x p e c t a t i o n s and i n f o r m a t i o n about t r e a t m e n t s has t o be " f i t " by the p a t i e n t s i n t o t h e i r own framework o f u n d e r s t a n d i n g and 87 comprehension to p r e p a r e f o r the e x p e r i e n c e . The s u p p o r t i v e component c o n s i s t e d o f a n t i c i p a t o r y guidance about the p a t i e n t ' s e x p e c t a t i o n o f t r e a t m e n t s as p r o v i d e d by the i n v e s t i g a t o r , p l u s the answering o f h i s q u e s t i o n s . I t was hoped t h a t t h i s p s y c h o l o g i c a l s u p p o r t and f a c t u a l e x p l a n a t i o n f a c i l i t a t e d by the a u d i o - v i s u a l t e a c h i n g t o o l would reduce the e f f e c t s o f t r e a t m e n t s t r e s s as i n d i c a t e d by v a r i o u s measures. In summary, the independent v a r i a b l e was an i n s t r u c t i o n a l program comprised o f i n f o r m a t i o n a l and s u p p o r t i v e components. Data G a t h e r i n g Instuments L e v e l s o f a n x i e t y were mo n i t o r e d by v a r i o u s t y p e s o f d a t a c o l l e c t i n g i n s t r u m e n t s . As mentioned e a r l i e r , each s u b j e c t was t e s t e d w i t h the S t a t e - T r a i t A n x i e t y I n v e n t o r y s i x times by the i n v e s t i g a t o r . Each s u b j e c t kept a d a i l y d i a r y o v e r the l e n g t h o f the data c o l l e c t i o n p e r i o d . The n u r s e s were asked t o e n t e r symbols, a c c o r d i n g t o the keys, on the s l e e p and m e d i c a t i o n r e c o r d s p l a c e d on t h e f r o n t o f each p a t i e n t ' s c h a r t . The nurse c a r i n g f o r a p a t i e n t was a l s o asked t o a s s e s s the p a t i e n t ' s l e v e l o f s t a t e Jean E. Johnson, "The I n f l u e n c e o f P u r p o s e f u l N u r s e - P a t i e n t I n t e r a c t i o n on the P a t i e n t ' s P o s t - O p e r a t i v e Course" ( u n p u b l i s h e d r e p o r t Y a l e U n i v e r s i t y School o f N u r s i n g , 1965). and t r a i t a n x i e t y on a L i k e r t - t y p e s c a l e a t t h e b e g i n n i n g and a t the end o f the data c o l l e c t i o n p e r i o d . E v a l u a t i o n o f the i n f o r m a t i o n a l and s u p p o r t components o f the t a p e - s l i d e program and the d i s c u s s i o n f o l l o w i n g were c a r r i e d out by means o f a t o o l d e v e l o p e d f o r t h a t purpose. The i n v e s t i g a t o r a l s o made f i e l d n o tes f o l l o w i n g e v e r y v i s i t w i t h each p a t i e n t . The nu r s e s ' n o t e s f o r each p a t i e n t were reviewed f o r d e s c r i p t i o n s o f b e h a v i o r i n d i c a t i n g an i n c r e a s e o r d e c r e a s e o f s t a t e a n x i e t y as w e l l as need f o r a n a l g e s i c , s e d a t i v e and s l e e p i n g m e d i c a t i o n . These dat a g a t h e r i n g i n s t r u m e n t s were i n e f f e c t o v e r an average o f 25 days f o r a l l s u b j e c t s . J u s t i f i c a t i o n f o r the above dat a g a t h e r i n g i n s t r u m e n t s f o l l o w . 1. The S t a t e - T r a i t A n x i e t y I n v e n t o r y (STAI) was d e v e l o p e d by S p i e l b e r g e r , 1968. T e s t c o n s t r u c t i o n p r o c e d u r e s f o r the STAI were begun i n 1964 w i t h t h e goal o f d e v e l o p i n g a s i n g l e s c a l e t h a t would p r o v i d e o b j e c t i v e s e l f - r e p o r t measures o f both s t a t e and t r a i t a n x i e t y . I t was assumed t h a t items w i t h a demonstrated r e l a t i o n s h i p to o t h e r measures o f a n x i e t y would be most u s e f u l i n an i n v e n t o r y d e s i g n e d to measure both s t a t e 88 and t r a i t a n x i e t y . The STAI i s comprised o f s e p a r a t e s e l f - r e p o r t s c a l e s f o r measuring the two d i s t i n c t a n x i e t y c o n c e p t s . The STAI t r a i t s c a l e c o n s i s t s o f 20 stat e m e n t s t h a t ask p e o p l e to d e s c r i b e how th e y g e n e r a l l y f e e l . The s t a t e s c a l e a l s o c o n s i s t s o f 20 s t a t e m e n t s , but the i n s t r u c t i o n s r e q u i r e s u b j e c t s t o i n d i c a t e how they f e e l a t a p a r t i c u l a r moment i n ti m e . These s c a l e s a r e p r i n t e d on o p p o s i t e s i d e s o f a s i n g l e t e s t form. 88 S p i e l b e r g e r , Manual f o r the S t a t e - T r a i t A n x i e t y I n v e n t o r y , p.9. 53 The t r a i t s c a l e may be used as a r e s e a r c h t o o l f o r s e l e c t i n g s u b j e c t s who vary i n t h e i r d i s p o s i t i o n t o respond t o p s y c h o l o g i c a l s t r e s s w i t h d i f f e r e n t l e v e l s o f " s t a t e " i n t e n s i t y . I t has been demonstrated t h a t s c o r e s on the s t a t e s c a l e i n c r e a s e i n response t o v a r i o u s k i n d s o f s t r e s s 99 and d e c r e a s e as a r e s u l t o f r e l a x a t i o n t r a i n i n g . Regarding the r e l i a b i l i t y and v a l i d i t y o f the STAI, the t e s t -r e t e s t r e l i a b i l i t y ( s t a b i l i t y ) o f the t r a i t s c a l e i s r e l a t i v e l y high but s t a b i l i t y c o e f f i c i e n t s f o r the s t a t e s c a l e t e n d to be low. T h i s would be e x p e c t e d f o r a measure i n f l u e n c e d by s i t u a t i o n a l f a c t o r s . Both t r a i t and s t a t e s c a l e s have a hi g h degree o f i n t e r n a l c o n s i s t e n c y . E v i d e n c e o f the c o n c u r r e n t v a l i d i t y o f the STAI t r a i t s c a l e show t h a t c o r r e l a t i o n s between the STAI, I PAT and T a y l o r M a n i f e s t A n x i e t y S c a l e a r e mo d e r a t e l y h i g h . The t h r e e s c a l e s may be c o n s i d e r e d as a l t e r n a t e measures o f t r a i t a n x i e t y s i n c e the i n t e r c o r r e l a t i o n s among thes e s c a l e s approach the r e l i a b i l i t i e s o f the i n d i v i d u a l s c a l e s . 1 ^ E v i d e n c e b e a r i n g on the c o n s t r u c t v a l i d i t y o f the s t a t e ' s c a l e i s i m p r e s s i v e . The STAI s t a t e s c a l e was dev e l o p e d t o i n c l u d e items a t v a r i o u s l e v e l s o f i t e m - i n t e n s i t y s p e c i f i c i t y ( t h a t i s , d i f f e r e n c e s i n the a b i l i t y o f the i n d i v i d u a l s t a t e items to d i s c r i m i n a t e between c o n d i t i o n s c h a r a c t e r i z e d by d i f f e r e n t degrees and ki n d s o f s t r e s s and p s y c h o l o g i c a l s t a t e which v a r y i n i n t e n s i t y ) . 1 ^ The s c a l e may be used o v e r a wide range o f " s t a t e " i n t e n s i t i e s . 99 S p i e l b e r g e r , Manual f o r the S t a t e - T r a i t A n x i e t y I n v e n t o r y . 1 0 0 I b i d . , p. 10. 1 0 1 I b i d . , p. 11. 54 102 L e v i t t endorses the S t a t e - T r a i t A n x i e t y I n v e n t o r y as the most c a r e f u l l y d e v e l o p e d i n s t r u m e n t from both the t h e o r e t i c a l and m e t h o d o l o g i c a l s t a n d p o i n t s . The t e s t c o n s t r u c t i o n p r o c e d u r e s were h i g h l y s o p h i s t i c a t e d . " The v a l i d a t i n g d a t a on the S t a t e - T r a i t A n x i e t y I n v e n t o r y are c l e a r l y i n a c c o r d w i t h the t h e o r e t i c a l c o n c e p t o f a n x i e t y . L e v i t t s u g g e s t e d t h a t the measure o f t r a i t a n x i e t y s h o u l d be s t a b l e and c o n s i s t e n t and a measure o f s t a t e a n x i e t y s h o u l d be s e n s i t i v e t o s t r e s s s i t u a t i o n s . T r a i t s c o r e s ought to be c o r r e l a t e d w i t h an i n c r e a s e i n s t a t e s c o r e s under 103 s t r e s s f o r a g i v e n group o f r e s p o n d e n t s . A l t h o u g h the S t a t e - T r a i t A n x i e t y I n v e n t o r y was o r i g i n a l l y c o n s t r u c t e d as a r e s e a r c h i n s t r u m e n t f o r i n v e s t i g a t i n g t h e a n x i e t y phenomena i n normal a d u l t s , i t has a l s o proved u s e f u l i n the measurement o f s t a t e and 104 t r a i t a n x i e t y i n s u r g i c a l p a t i e n t s . The 40 i t e m S t a t e - T r a i t A n x i e t y I n v e n t o r y i s b r i e f and easy to a d m i n i s t e r to p a t i e n t s , whose a t t e n t i o n span, due t o the trauma o f b u r n s , i s s h o r t (see Appendix B). 2. The M e d i c a t i o n Record As d i s c u s s e d i n C h a p t e r 2, t h e r e i s a r e l a t i o n s h i p between p a i n and a n x i e t y . P a i n i s worsened by a n x i e t y and anxious e x p e c t a t i o n o f p a i n i s 105 the s a l i e n t f a c t o r i n c a u s i n g i t s p r o g r e s s i v e i n c r e a s e . 102 Eugene E. L e v i t t , The P s y c h o l o g y o f A n x i e t y , (New York: The B o b b s - M e r r i l l Co., I n c . , 1967), p. 71. 1 0 3 I b i d . , p. 72. 104 S p i e l b e r g e r and S a r a s o n , S t r e s s and A n x i e t y , p. 139. 105 N. J . Andreasen and R u s s e l l Noyes, e t a l , "Management o f Emotional R e a c t i o n s i n S e r i o u s l y Burned A d u l t s , " New England J o u r n a l o f M e d i c i n e 286, (January 13, 1972):66. 55 P e r c e p t i o n s o f p a i n v a r y g r e a t l y from pe r s o n t o p e r s o n . A n x i e t y i s c o n s i d e r e d a s i g n i f i c a n t f a c t o r i n v i r t u a l l y a l l d i s c u s s i o n s o f the p a i n 106 e x p e r i e n c e . I t i s , t h e r e f o r e , l o g i c a l t o assume t h a t a p a t i e n t ' s r e q u e s t s f o r a n a l g e s i c m e d i c a t i o n r e f l e c t not o n l y h i s l e v e l o f p a i n e x p e r i e n c e but a l s o h i s l e v e l o f s t a t e a n x i e t y . I t f o l l o w s t h a t h i s r e q u e s t s f o r s e d a t i v e and s l e e p i n g m e d i c a t i o n a l s o r e f l e c t h i s l e v e l o f a n x i e t y . As a method o f dat a c o l l e c t i o n , a r e c o r d o f the f r e q u e n c y and time a n a l g e s i c ^ s e d a t i v e and s l e e p i n g m e d i c a t i o n s were r e q u e s t e d by, o r r o u t i n e l y g i v e n t o , each p a t i e n t was kept by the s t a f f n u rses o v e r the data c o l l e c t i o n p e r i o d . The ty p e and s t r e n g t h o f m e d i c a t i o n was noted from the nurses' n o t e s . (See Appendix F ) . No attempt was made t o r e f i n e the r e l i a b i l i t y o f the m e d i c a t i o n r e c o r d . 3. S l e e p Record I t has been demonstrated t h a t s l e e p p a t t e r n s a r e s e n s i t i v e i n d i c a t o r s o f both s t a t e and t r a i t a n x i e t y . Snyder s t a t e s t h a t t he e f f e c t s o f a b i d i n g l e v e l s o f s t r e s s o r a n x i e t y on s l e e p p r o f i l e s a r e p a r t i c u l a r l y i n t e r e s t i n g t o p s y c h o p h y s i o l o g i s t s . 1 ^ 7 T h e r e f o r e , a r e c o r d was kept by the s t a f f n u rses o f the d u r a t i o n and hours o f s l e e p and w a k e f u l n e s s d u r i n g a 12 hour time p e r i o d , 1900 hours t o Mary Ann B r u e g e l , " R e l a t i o n s h i p o f P r e - O p e r a t i v e A n x i e t y t o P e r c e p t i o n o f P o s t - O p e r a t i v e P a i n , " N u r s i n g Research 20, ( J a n u a r y - F e b r u a r y 1971): 26. F r e d e r i c k Snyder and Jimmy S c o t t , "The P s y c h o p h y s i o l o g y o f S l e e p , " Handbook o f P s y c h o p h y s i o l o g y , ed. Norman G r e e n f i e l d and R i c h a r d S t e i n b a c h , (New York: H o l t , R h i n e h a r t and Winston Inc.,1972), p.680. 0700 hours (See Appendix E ) . No attempt was made to determine the r e l i a b i l i t y o f t h e s l e e p r e c o r d , a l t h o u g h an i n t e r e s t i n g comparison was a v a i l a b l e between the p a t i e n t ' s assessment o f h i s s l e e p and the n u r s e ' s r e c o r d i n g o f the hours o f s l e e p o b t a i n e d . 4. The P a t i e n t ' s P e r s o n a l D a i l y D i a r y D u r i n g the d a t a c o l l e c t i o n p e r i o d , the p a t i e n t was asked t o keep a p e r s o n a l d a i l y d i a r y o f h i s t h o u g h t s , f e e l i n g s and emotions. He r a t e d h i s g e n e r a l o v e r a l l f e e l i n g s on a L i k e r t - t y p e s c a l e from 1 t o 5. He then c o n s i d e r e d how he f e l t t h a t day about t r e a t m e n t s , p a i n a n t i c i p a t i o n and e x p e r i e n c e , a n x i e t y and c o n c e r n f o r s e l f , f a m i l y and f u t u r e employment (See Appendix H). The g o a l s o f the d i a r y were: a) To accumulate a d a i l y a c c o u n t o f the p a t i e n t ' s r e a c t i o n s t o burn t r e a t m e n t , i n c l u d i n g h i s p e r c e p t i o n o f h i s p a i n , s l e e p p a t t e r n s , need f o r m e d i c a t i o n and f e e l i n g s o f a n x i e t y r e g a r d i n g h i s c a r e and f u t u r e . b) To accumulate ongoing r e c o r d s o f t h e p a t i e n t ' s c o n c e r n s as e n t e r e d i n the d i a r y . c) To determine i f t h e r e i s an e v o l v i n g p a t t e r n o f a n x i e t y d u r i n g the c o u r s e o f h o s p i t a l i z a t i o n . The i d e a o f a d i a r y was s u g g e s t e d by a former p a t i e n t d u r i n g an i n t e r v i e w . T h i s p a t i e n t wished t h a t he had been a b l e t o keep a w r i t t e n r e c o r d o f h i s f e a r s and a n x i e t i e s d u r i n g h i s h o s p i t a l i z a t i o n . To have been a b l e t o e x p r e s s t h e s e emotions on paper would have been h e l p f u l t o him. Perhaps the o p p o r t u n i t y t o v e n t i l a t e f r u s t r a t i o n s i n w r i t i n g a t t h e end o f the day may be t h e r a p e u t i c and reduce s t a t e a n x i e t y . 57 The d i a r y was kept o v e r a p e r i o d o f d a t a c o l l e c t i o n t h a t i s , not l e s s than t h r e e weeks o r more than one month. The p a t i e n t was i n s t r u c t e d t o w r i t e i n h i s comments and r a t e each answer t o the q u e s t i o n on a L i k e r t - t y p e s c a l e . I f t h e p a t i e n t was unable t o w r i t e due to burned hands, a, r e l a t i v e was d e l e g a t e d t h i s t a s k . The p a t i e n t was g i v e n feedback by the i n v e s t i g a t o r a t the end o f the d a t a c o l l e c t i o n p e r i o d as t o the t r e n d s and f l u c t u a t i o n s i n h i s d a i l y emotions. R e l a t i v e t o the r e s e a r c h p l a n , the d i a r y s u p p l i e d the p a t i e n t ' s p e r s o n a l p e r c e p t i o n s o f the elements o f the v a r i a b l e under study f o r comparison w i t h the e x t e r n a l measuring d e v i c e s , namely the S t a t e - T r a i t A n x i e t y I n v e n t o r y , the s l e e p and m e d i c a t i o n r e c o r d s and the s t a f f ' s p e r c e p t i o n s o f the p a t i e n t ' s a n x i e t y l e v e l . 5. Nurses' Assessment o f A n x i e t y The nurse c a r i n g f o r the p a t i e n t t h a t day was asked to a s s e s s and r a t e her p a t i e n t ' s l e v e l o f s t a t e and t r a i t a n x i e t y on a L i k e r t - t y p e s c a l e . T h i s assessment was done a t the b e g i n n i n g and a t the end o f the data c o l l e c t i o n p e r i o d . (See Appendix G). The purpose o f t h i s d a t a c o l l e c t i n g i n s t r u m e n t was t o compare the n u rse's assessment o f h e r p a t i e n t ' s l e v e l o f a n x i e t y w i t h the S t a t e - T r a i t A n x i e t y I n v e n t o r y as w e l l as the p a t i e n t ' s s e l f - p e r c e p t i o n o f h i s a n x i e t y from h i s d a i l y d i a r y . 6. E v a l u a t i o n o f the I n s t r u c t i o n a l Program. The i n f o r m a t i o n a l and s u p p o r t components o f the i n s t r u c t i o n a l program were e v a l u a t e d by means o f a q u e s t i o n and answer format. The i n v e s t i g a t o r asked the p a t i e n t q u e s t i o n s p e r t a i n i n g t o the s e c t i o n o f the t a p e - s l i d e program he had been shown. I f the p a t i e n t ' s answer s a t i s f i e d the i n v e s t i g a t o r and i t was f e l t t h a t he u n d e r s t o o d the i n f o r m a t i o n , the "yes" column o f the format was checked. I f the p a t i e n t ' s r e p l y d i d . n o t s a t i s f y the i n v e s t i g a t o r , the "no" column was checked and f u r t h e r e x p l a n a t i o n o r c l a r i f i c a t i o n was g i v e n . The p a t i e n t was then asked t o r a t e the h e l p f u l n e s s o f the t a p e - s l i d e program and the d i s c u s s i o n f o l l o w i n g the program on a L i k e r t - t y p e s c a l e . (See Appendix D). Method o f Data A n a l y s i s The methodology was s e t up as a comparison. A p p r o p r i a t e s t a t i s t i c a l measures f o r comparison were u t i l i z e d t o t e s t the n u l l h y p o t heses. The S t a t e - T r a i t A n x i e t y I n v e n t o r y was s c o r e d as d e s c r i b e d i n the , 1 0 8 accompanying manual. The range o f p o s s i b l e s c o r e s f o r Form X o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y v a r i e s from a minimum s c o r e o f 20 to a maximum s c o r e o f 80 on both s t a t e and t r a i t s u b s c a l e s . A p a i r e d comparison between the means o f the " s t a t e " s c o r e s may be d e t ermined by a o n e - t a i l e d p a i r e d t t e s t . The n u l l h y p o t h e s i s , t h a t t h e r e i s no measurable r e d u c t i o n o f s t a t e a n x i e t y o v e r t i m e , was t e s t e d a t the .05 l e v e l o f s i g n i f i c a n c e . S p i e l b e r g e r , Manual f o r t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y , pp.4-5. 59 A comparison was made between the p a t i e n t ' s o p i n i o n o f h i s q u a l i t y o f s l e e p as e x p r e s s e d i n d a i l y d i a r y and the amount o f s l e e p r e c o r d e d on the s l e e p r e c o r d . A comparison o f the means o f t h e s e two v a r i a b l e s was d e t e r m i n e d . A comparison was made between t h e p a t i e n t ' s o p i n i o n o f h i s need f o r a n a l g e s i c s e d a t i v e m e d i c a t i o n as e x p r e s s e d i n h i s d a i l y d i a r y and t h e amount o f m e d i c a t i o n r e q u e s t e d , as r e c o r d e d on the m e d i c a t i o n r e c o r d . A comparison o f the means o f t h e s e v a r i a b l e s was d e t e r m i n e d . A comparison was made between the p a t i e n t ' s o p i n i o n o f h i s degree o f a n x i o u s n e s s as e x p r e s s e d i n t h e d a i l y d i a r y and the l e v e l o f a n x i e t y measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r y . A comparison o f the means o f t h e s e two v a r i a b l e s was d e t e r m i n e d . A comparison was made between the s t a f f n u r s e ' s r a t i n g o f the p a t i e n t ' s t r a i t and s t a t e a n x i e t y on a L i k e r t - t y p e s c a l e on a d m i s s i o n t o the burn u n i t and the r a t i n g o f the p a t i e n t ' s s t a t e and t r a i t a n x i e t y by the S t a t e - T r a i t A n x i e t y I n v e n t o r y . A comparison was made between the s t a f f n u r s e ' s r a t i n g o f the p a t i e n t ' s t r a i t and s t a t e a n x i e t y on a L i k e r t - t y p e s c a l e a t the end o f the d a t a c o l l e c t i o n p e r i o d and t h e r a t i n g o f the p a t i e n t ' s s t a t e and t r a i t a n x i e t y by t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y . O v e r a l l t r e n d s among a l l p a t i e n t s were i n s p e c t e d f o r change. E v a l u a t i o n o f t h e c o n t e n t v a l i d i t y o f the i n f o r m a t i o n a l and s u p p o r t component o f the i n s t r u c t i o n a l program was made from p a t i e n t s ' comments about the program. O v e r a l l a n a l y s i s o f t h e comments i n the p a t i e n t s ' d i a r i e s were summarized. No s t a t i s t i c a l measures were a p p l i e d t o the e v a l u a t i o n o f the i n s t r u c t i o n a l program o r the a n a l y s i s o f the d i a r y comments. These, however, were u t i l i z e d i n an i n d i v i d u a l c ase s t u d y r e p o r t o r g a n i z e d around the c o n c e r n s and r e a c t i o n s o f each p a t i e n t . In summary, t h e method o f da t a a n a l y s i s was s e t up as a comparison The n u l l hypotheses were t e s t e d w i t h a p p r o p r i a t e s t a t i s t i c a l measures f o r comparison. Other d a t a were i n s p e c t e d f o r o b s e r v a b l e t r e n d s . C h a p t e r 4 THE FINDINGS I n t r o d u c t i o n The f i n d i n g s o f t h i s s t u d y w i l l be p r e s e n t e d , f i r s t l y ^ i n t h e form o f i n d i v i d u a l case s t u d i e s d e l i n e a t i n g an a n a l y s i s o f the d a t a as o b j e c t i v e l y g a t h e r e d by the d a t a c o l l e c t i n g i n s t r u m e n t s . S e c o n d l y , a s u b j e c t i v e e v a l u a t i o n o f the p l a n n e d n u r s i n g i n t e r v e n t i o n s , as d e s c r i b e d through p a t i e n t comments,wil1 be p r e s e n t e d . T h i r d l y , t he s t a t i s t i c a l s i g n i f i c a n c e o f the f i n d i n g s w i l l be o u t l i n e d i n r e l a t i o n t o the hypotheses o f the s t u d y . F o u r t h l y , a r e p o r t and d i s c u s s i o n o f the f i n d i n g s a d d r e s s i n g t he b e h a v i o r a l phenomena e x h i b i t e d by the p a t i e n t s w i l l f o l l o w . S i n c e t he S t a t e - T r a i t A n x i e t y I n v e n t o r y Manual d i d not i n t e r p r e t the s c o r e s o f the I n v e n t o r y , the scores' were i n t e r p r e t e d a r b i t r a r i l y by the i n v e s t i g a t o r . The i n t e r p r e t a t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y f o l l o w s : TABLE 1 INTERPRETATION OF THE STAI SCORES STAI S c o r e s I n t e r p r e t a t i o n 80 - 70 h i g h l y a n x i o u s 55 - 69 h i g h - m o d e r a t e l y a n x i o u s 45 - 54 m o d e r a t e l y a n x i o u s 40 - 44 m o d e r a t e - f a i r l y a n x i o u s 35 - 39 f a i r l y a n x i o u s 20 - 34 low a n x i e t y / n o n - a n x i o u s 62 Regarding t he s l e e p r e c o r d , t he i n v e s t i g a t o r a r b i t r a r i l y assumed t h a t 6 hours o r more was a "good s l e e p " and l e s s than 6 hours was a "poor s l e e p . " S l e e p i n t e r r u p t i o n due to n u r s i n g t a s k s was noted but not taken i n t o a c c o unt when j u d g i n g t he q u a l i t y o f s l e e p . Burn c a r e r e q u i r e s t h a t t r e a t m e n t s be a d m i n i s t e r e d t h r o u g h o u t t he n i g h t . Each d a i l y d i a r y was a s s i g n e d a t o t a l s c o r e from t he numbers on the L i k e r t s c a l e a f t e r each statement i n the d i a r y . The minimum s c o r e was 11, i n d i c a t i n g a low a n x i e t y l e v e l , and the maximum s c o r e was 55, i n d i c a t i n g a h i g h a n x i e t y l e v e l . E v a l u a t i o n o f the Planned N u r s i n g I n t e r v e n t i o n s  from Data C o l l e c t i n g Instruments P a t i e n t One T h i s 20 y e a r o l d male was burned to 15% o f h i s body. Second and t h i r d degree burns c o v e r e d h i s hands, forearms and r i g h t f l a n k . Data was c o l l e c t e d o v e r a 21 day p e r i o d , from t he s i x t h day a f t e r a d m i s s i o n t o the day o f d i s c h a r g e . The i n v e s t i g a t o r v i s i t e d t h i s p a t i e n t on DAYS 1, 3, 7, 10, 12, 14, 17 and 21. The Burn Treatment A d m i n i s t e r e d DAY 1 - S a l i n e compresses i n the morning. S k i n g r a f t i n g i n t h e a f t e r n o o n t o the r i g h t hand, e v e n i n g arm bath to t h e l e f t hand DAYS 2-6 - s k i n g r a f t s r o l l e d e v e r y 2 h o u r s , l a t e r , e v e r y 4 hours morning tub bath f o l l o w e d by c l e a n s i n g o f the wounds and a p p l i c a t i o n o f an a n t i b i o t i c cream DAYS 7-12 - s a l i n e compresses t o t h e back e v e r y 4 hours morning tub baths DAYS 13-20 - P o r c i n e d r e s s i n g s a p p l i e d to t h e r i g h t s i d e o f th e body. DAY 21 - p a t i e n t to be d i s c h a r g e d from h o s p i t a l t h e next -. day. A n a l y s i s o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r i e s The raw s c o r e s o f t h e " s t a t e " p o r t i o n o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y , h e r e f o r t h r e f e r r e d to as t h e STAI, d i d not change d r a m a t i c a l l y over t h i s p a t i e n t 1 s p e r i o d o f r e c o v e r y . A c o n s i s t e n t m i d d l e s c o r e , i n d i c a t i n g a moderate a n x i e t y l e v e l , was m a i n t a i n e d . TABLE 1-1 SCORES OF THE STAI DAY STAI S t a t e P o r t i o n T r a i t P o r t i o n 1 1 46 50 7 2 50 44 10 3 51 47 14 4 51 41 17 5 43 43 21 6 48 40 S t a t e a n x i e t y i n c r e a s e d from DAY 7 t o DAY 12 when the p a t i e n t was undergoing compress t r e a t m e n t to h i s back. However, the ' s t a t e ' s c o r e d i p p e d t o a low o f 43 on DAY 17 when he was h a v i n g t u b b a t h s . On the day o f d i s c h a r g e , t he ' s t a t e ' s c o r e r o s e to 48. The p a t i e n t a d m i t t e d t o the nurses and i n v e s t i g a t o r t h a t he was a n x i o u s about l e a v i n g the s e c u r i t y o f the burn u n i t . T here was l i t t l e change o v e r time i n t h e t r a i t s c o r e s o f the STAI. The s c o r e s were h i g h e s t on DAY 1 and 10. The p a t i e n t appeared ve r y a p p r e h e n s i v e about t h e a p p l i c a t i o n o f s k i n g r a f t s . T h i s a p p r e h e n s i o n c o u l d have r e f l e c t e d on h i s answers t o " t r a i t " q u e s t i o n s o f t h e STAI on 64 DAY 1. I t i s noted t h a t , on DAY 10, compresses t o h i s back were i n p r o g r e s s . In summary, v i s u a l a n a l y s i s o f the raw s c o r e s o f t h e STAI r e v e a l l i t t l e d r a m a t i c change o v e r time. A r i s e i n the s t a t e and t r a i t s c o r e s toward h e i g h t e n e d a n x i e t y c o i n c i d e d w i t h p a i n f u l t r e a t m e n t . There was no remarkable change i n t r a i t a n x i e t y o v e r time. A n a l y s i s o f the S l e e p Record Over the 21 day d a t a c o l l e c t i o n p e r i o d , t h e p a t i e n t o n l y had 11 n i g h t s o f "good s l e e p . " Three n i g h t s o f c o n s e c u t i v e s l e e p l o s s o c c u r r e d d u r i n g DAYS 3, 4, & 5 when s k i n g r a f t s were b e i n g r o l l e d e v e r y 2 hours and d u r i n g DAYS 9, 10 & 11 when compresses were be i n g a p p l i e d to h i s back. I t was noted t h a t both " s t a t e " and " t r a i t " s c o r e s o f the STAI were a t t h e i r h i g h e s t l e v e l on DAY 10. A n a l y s i s o f the M e d i c a t i o n Record From DAY 1 t o DAY 7, a n a l g e s i c m e d i c a t i o n s were r e q u e s t e d f r e q u e n t l y by t he p a t i e n t . S e d a t i v e s and s l e e p i n g p i l l s were g i v e n from DAY 1 t o DAY 5. The p a t i e n t began r e f u s i n g s l e e p i n g p i l l s a f t e r DAY 6. I t was i n t e r e s t i n g t o note t h a t no a n a l g e s i c s were r e q u e s t e d on DAYS 10 &.11 when compresses were b e i n g a p p l i e d to h i s back. Only one a n a l g e s i c was g i v e n by the nurse on DAYS 9 & 10. The p a t i e n t r e q u e s t e d o n l y 3 a n a l g e s i c s o v e r the 6 day compress p e r i o d . A f t e r DAY 9, o n l y 2 a n a l g e s i c s were r e q u e s t e d by the p a t i e n t . 65 A n a l y s i s o f the D i a r y S c o r e s I t appears t h a t t h e d i a r y s c o r e s peaked on DAY 4 and DAY 6, then r o s e a g a i n on DAY 10 and DAY 11. A c c o r d i n g t o the n u r s e s ' notes on DAY 4, t h e p a t i e n t was v e r y shakey and nervous about h i s tub bath. A l t h o u g h he t o l e r a t e d t h e debridement o f h i s wounds w e l l , he r e q u e s t e d a n a l g e s i c s f r e q u e n t l y . The nurses notes s t a t e d t h a t , "the p a t i e n t was w r i t i n g i n h i s d i a r y , b r e a t h i n g d e e p l y and w h i s p e r i n g . He appeared angry but was not e x p r e s s i n g h i s anger i n words." He f e l t a l l pent-up, c o u l d n ' t l e t out h i s f e e l i n g s , was f e e l i n g v e r y d e p r e s s e d and would l o v e to c r y but j u s t c o u l d n ' t . The p a t i e n t wrote i n h i s d i a r y t h a t t h e p l a s t i c d r e s s i n g from h i s donor s i t e had been removed and i t was now v e r y p a i n f u l . The a n a l g e s i c s d i d h e l p and the p a i n made him f e e l as i f he was " g o i n g i n s a n e . " The d r a i n a g e from t h e exposed donor s i t e was d r i p p i n g between h i s l e g s ; h i s back was s t i c k i n g t o t h e bed; he was a n x i o u s about h i s tub b a t h ; he had a new nurse and was w o r r i e d about her competence a t d r e s s i n g changes. Moreover, he was w o r r i e d about h i s j o b and what would be h i s way o f l i f e . A l l t h e s e r e a s o n s , p l u s the d r e a d f u l p a i n , r a i s e d h i s a n x i e t y l e v e l r e m a r k a b l y on DAY 4. On DAY 6, he was u n c o m f o r t a b l e w i t h p a i n , a g a i n ; f e l t v e r y t i r e d due t o n i g h t l y d r e s s i n g changes and subsequent l a c k o f s l e e p , d e p r e s s e d , l o n e l y , bored and thought t h a t time was "so slow i n p a s s i n g . " On DAY 10 and DAY 11, the d i a r y s c o r e s r o s e , i n d i c a t i n g h e i g h t e n e d a n x i e t y . Compresses were b e i n g a p p l i e d t o h i s back a t t h i s t i m e . He l a c k e d s l e e p f o r t h r e e c o n s e c u t i v e n i g h t s . However, t h e n u r s e s ' notes r e p o r t e d him as b e i n g c h e e r f u l , happy, t a l k a t i v e , and i n good s p i r i t s . In h i s d i a r i e s , he complained o f b e i n g i t c h y , i r r i t a b l e , i n p a i n , bored and d e p r e s s e d . A l t h o u g h he f e l t " a w f u l , " he wrote t h a t he e n j o y e d t a l k i n g w i t h the i n v e s t i g a t o r and t h a t the v i s i t " p i c k e d up my s p i r i t s . " I t appears t h a t t he c o m b i n a t i o n o f debridement o f t h e burn wound i n t h e t u b bath and t h e a p p l i c a t i o n o f s a l i n e compresses t o h i s back e v e r y f o u r hours r e s u l t e d i n h e i g h t e n e d a n x i e t y . T h i s was d e p i c t e d by the s c o r e s o f the STAI, d i a r i e s , s l e e p r e c o r d and the e x p r e s s i o n o f a n x i e t y i n the d i a r y comments. T h i s 35 y e a r o l d male was burned t o 12% o f h i s body. Second and t h i r d degree burns c o v e r e d both c a l v e s c i r c u m f e r e n t i a l l y . Data was c o l l e c t e d o v e r a 31 day p e r i o d , from t he f o u r t h day a f t e r a d m i s s i o n t o the burn u n i t to the day b e f o r e d i s c h a r g e . The i n v e s t i g a t o r v i s i t e d the p a t i e n t on DAYS 1, 3, 7, 14, 17, 24, 29 and 31. The Burn Treatment A d m i n i s t e r e d DAYS 1 - 3 - Burn baths f o l l o w e d by P o l y m i x i n compresses e v e r y P a t i e n t Two 4 hours DAY 3 - Su r g e r y - debridement o f both l e g s . P o l y m i x i n compresses resumed p o s t - o p e r a t i v e l y DAYS 3 - 5 - Compresses changed e v e r y 4 hours DAYS 6 - 7 - S a l i n e compresses DAY 7 - S u r g e r y - debridement o f wounds and i n s e r t i o n o f K-wires ( s u r g i c a l p i n s ) . S a l i n e compresses resumed p o s t - o p e r a t i v e l y . DAY 8 - Legs suspended i n t r a c t i o n . S k i n g r a f t s a p p l i e d to l e g s . DAYS 8 - 1 5 - G r a f t s r o l l e d e v e r y 2 hours DAY 15 - D a i l y burn baths resumed. 67 DAY 17 - K-wires removed. DAYS 1 7 - 1 8 - S a l i n e compresses a p p l i e d to open a r e a s between g r a f t s DAY 18 - S k i n g r a f t s a p p l i e d t o open a r e a s DAYS 1 8 - 2 3 - S k i n g r a f t s r o l l e d e v e r y 2 hours DAY 25 - D a i l y t ub baths resumed. P a t i e n t m o b i l i z e d DAY 27 - F i r s t day o f w a l k i n g DAY 31 - End o f d a t a c o l l e c t i o n . Day b e f o r e d i s c h a r g e . A n a l y s i s o f the State-- T r a i t I n v e n t o r i e s The r e s u l t s o f the " s t a t e " p o r t i o n o f t h e STAI changed s i g n i f i c a n t l y o v e r t he p a t i e n t ' s p e r i o d o f r e c o v e r y . TABLE 1-2 SCORES OF THE STAI DAY STAI S t a t e P o r t i o n T r a i t P o r t i o n 1 1 30 36 7 2 36 36 14 3 39 30 17 4 22 38 24 5 38 37 31 6 32 39 I t appears t h a t s t a t e a n x i e t y r o s e from DAY 1 to DAY 14. The p a t i e n t was undergoing compress t r e a t m e n t to h i s l e g s from DAY 1 t o DAY 8. A f t e r h i s s k i n g r a f t s were a p p l i e d and h i s l e g s suspended i n t r a c t i o n on DAY 8, t h e p a t i e n t c o m p l a i n e d o f s e v e r e heel and knee p a i n . T h i s p a i n was p r e v a l e n t from DAY 11 t o DAY 14. The " s t a t e " s c o r e o f the STAI di p p e d a low o f 22 on DAY 17. On t h i s day, t h e K-wires were about to be removed, t h e s k i n g r a f t s had t a k e n w e l l and t h e p a t i e n t was s l e e p i n g l o n g p e r i o d s d u r i n g the n i g h t . The s c o r e o f the STAI would i n d i c a t e t h a t t h e p a t i e n t was a t a v e r y low l e v e l o f a n x i e t y . On DAY 24, the " s t a t e " s c o r e r o s e to 38. I t was noted t h a t m o b i l i z a t i o n was about t o b e g i n . The p a t i e n t l o o k e d f o r w a r d w i t h a n t i c i p a t i o n t o w a l k i n g a g a i n but a l s o w i t h a p p r e h e n s i o n . F u r t h e r m o r e , he e x p r e s s e d anger about t h e poor c a r e he had r e c e i v e d a t a n o t h e r h o s p i t a l immediately a f t e r h i s a c c i d e n t . The p a t i e n t was c o n s i d e r i n g a l a w s u i t . He a l s o s t a t e d t h a t he had been s l e e p i n g p o o r l y l a t e l y due to t h e awkward p o s i t i o n he had t o m a i n t a i n . Moreover, s l e e p i n g d u r i n g t h e day h i n d e r e d h i s n o c t u r n a l s l e e p . The " s t a t e " s c o r e o f the STAI was 32 on t h e day b e f o r e d i s c h a r g e . The p a t i e n t was c h e e r f u l , i n good s p i r i t s but a p p r e h e n s i v e about h i s imminent d i s c h a r g e . He appeared v e r y r e s t l e s s , e x c i t e d and f i d g i t y . He s t a t e d t h a t he c o u l d n ' t keep s t i l l and was "very h i g h . " There was l i t t l e change o v e r time i n the " t r a i t " s c o r e s o f t h e STAI. The s c o r e s were the h i g h e s t on DAYS 17, 24 & 31. I t i s i n t e r e s t i n g t o note h i s l o w e s t " s t a t e " s c o r e o c c u r r e d on DAY 17. I t was noted t h a t as t h e " s t a t e " s c o r e s f e l l , t h e " t r a i t " s c o r e s r o s e between DAY 14 and DAY 17. In summary, v i s u a l a n a l y s i s o f the " s t a t e " s c o r e s o f t h e STAI r e v e a l e d a s i g n i f i c a n t f l u c t u a t i o n i n a n x i e t y i n r e s p o n s e to the e f f e c t s o f 69 t r e a t m e n t s t r e s s . There appeared to be no remarkable change i n t h e " t r a i t " s c o r e s o f t h e STAI o v e r time. A n a l y s i s o f the Sl e e p Record Over t h e 31 days o f the d a t a c o l l e c t i o n p e r i o d , t h i s p a t i e n t had 12 n i g h t s o f "good s l e e p . " Three n i g h t s o f c o n s e c u t i v e s l e e p l o s s o c c u r r e d t h r e e t i m e s . From DAY 18 t o DAY 24, the p a t i e n t had seven n i g h t s o f c o n s e c u t i v e s l e e p l o s s . S l e e p l e s s n i g h t s o c c u r r e d when t h e burn wounds were be i n g compressed, when t h e p a t i e n t s u f f e r e d p a i n f u l h e e l s and knees w h i l e i n K-wire t r a c t i o n and when s k i n g r a f t s were b e i n g r o l l e d f r e q u e n t l y . " S t a t e " and " t r a i t " s c o r e s o f t h e STAI d i d not r i s e s i g n i f i c a n t l y d u r i n g t h e s l e e p l e s s p e r i o d from DAY 1 t o DAY 8. However, the s c o r e o f the d a i l y d i a r y peaked d r a m a t i c a l l y on DAY 4, i n d i c a t i n g a h i g h a n x i e t y s t a t e . On t h i s day, i t i s noted t h a t t he compresses were b e i n g changed ev e r y 4 hour s , t h e p a t i e n t had a s l e e p l e s s n i g h t and a n a l g e s i c s and s e d a t i v e s were b e i n g g i v e n f r e q u e n t l y . A n a l y s i s o f the M e d i c a t i o n Record S e d a t i v e s were a d m i n i s t e r e d to the p a t i e n t f o u r times a day from DAY 3 to DAY 16, and t w i c e a day from DAY 17 to DAY 31. S l e e p i n g p i l l s were g i v e n e v e r y n i g h t o v e r t he d a t a c o l l e c t i o n p e r i o d . On DAYS 4, 5 & 10, t h e p a t i e n t r e q u e s t e d a s l e e p i n g p i l l . I t was noted t h a t a n a l g e s i c s were g i v e n q u i t e f r e q u e n t l y from DAY 2 to DAY 7, d u r i n g t h e compress t r e a t m e n t p e r i o d . From DAY 8 t o DAY 13, the p a t i e n t r e q u e s t e d a n a l g e s i c s f r e q u e n t l y . D u r i n g t h e s e d a y s , h i s l e g s were suspended i n t r a c t i o n , h i s s k i n g r a f t s were being r o l l e d f r e q u e n t l y and h i s h e e l s and knees were ver y p a i n f u l . On DAY 18, he began f r e q u e n t r e q u e s t s f o r a n a l g e s i c s f o r t h r e e days. A t t h i s t i m e , h i s K-wires had been removed one day b e f o r e . Compresses t o open a r e a s on h i s l e g s , f o l l o w e d by s k i n g r a f t i n g and f r e q u e n t r o l l i n g o f the g r a f t s , o c c u r r e d on DAY 18. No c o n s e c u t i v e p e r i o d o f m e d i c a t i o n r e q u e s t was noted f o r the remainder o f the data c o l l e c t i o n p e r i o d . A n a l y s i s o f the D i a r y S c o r e s The d i a r y s c o r e s "peaked" on DAY 4 and DAY 7, then r o s e a g a i n on DAY 16 and DAY 30. I t was noted t h a t on DAY 4, 5, & 6, t h e p a t i e n t was r e c e i v i n g compress t r e a t m e n t to h i s burn wounds p o s t - o p e r a t i v e l y . On DAY 4, the n u r s e s ' notes r e p o r t e d the p a t i e n t as b e i n g " e x t r e m e l y a n x i o u s , h y p e r v e n t i l a t i n g and a s k i n g f o r r e a s s u r a n c e . " The p a t i e n t had l i t t l e s l e e p t h e p r e v i o u s n i g h t . His d i a r y s c o r e peaked on DAY 4 to i t s h i g h e s t p o i n t o v e r the r e c o v e r y p e r i o d . No comments were w r i t t e n i n t h e d i a r y . During a v i s i t w i t h the i n v e s t i g a t o r on DAY 3, t h e p a t i e n t e x p r e s s e d h i s a n x i e t y about b e i n g " c a r v e d up" and " s k i n n e d " i n t h e o p e r a t i n g room. L a t e r t h a t day he e x p r e s s e d h i s f e a r o f the p a i n and the a n t i c i p a t i o n o f t h e s u r g i c a l p i n n i n g . On DAY 7, the s c o r e o f h i s d i a r y peaked a g a i n . A l t h o u g h h i s " t r a i t " s c o r e o f the STAI remained the same, h i s " s t a t e " s c o r e r o s e from 30 on DAY 1 t o 36 on DAY 7. S i n c e the p a t i e n t was s c h e d u l e d f o r h i s second s u r g e r y t h a t a f t e r n o o n , h i s compress t r e a t m e n t s were s t i l l i n p r o g r e s s . The n u r s e s ' notes r e p o r t e d the p a t i e n t as b e i n g v e r y a n x i o u s and c o m p l a i n i n g o f t h i r s t . No comments were w r i t t e n i n the d i a r y . The i n v e s t i g a t o r v i s i t e d t h e p a t i e n t p r e - o p e r a t i v e l y on DAY 7. The p a t i e n t 71 s t a t e d t h a t he was i n s e v e r e p a i n and was t r y i n g t o use a mental r e l a x a t i o n t e c h n i q u e t o d i v e r t h i s a t t e n t i o n from the p a i n . However, he a n t i c i p a t e d the s u r g e r y e a g e r l y , s t a t i n g t h a t t h i s was a t u r n i n g p o i n t i n h i s r e c o v e r y . With t h e s k i n g r a f t s on h i s l e g s , he thought t h a t he would f e e l b e t t e r , see more day t o day improvement and f e e l l e s s p a i n . Today was t o be the l a s t day o f the " r e a l p a i n " e x p e r i e n c e . The d i a r y s c o r e r o s e to 31 on DAY 16. I t was noted t h a t the p a t i e n t was i nformed t h a t h i s K-wires would be removed on the f o l l o w i n g day. He a d m i t t e d t h a t he was w o r r i e d about t h e removal o f the K-wires and the a n t i c i p a t i o n o f p a i n on w a l k i n g . D i a r y e n t r y was missed from DAY 18 t o DAY 26 w i t h the e x c e p t i o n o f DAY 24 when the i n v e s t i g a t o r v i s i t e d the p a t i e n t . He f e l t m i s e r a b l e due to c o n s t i p a t i o n and t h e r e f o r e had o m i t t e d h i s d i a r i e s . On DAY 30, the d i a r y s c o r e r o s e from DAY 19 to DAY 27. The n u r s e s ' notes r e p o r t e d t h a t t h e p a t i e n t appeared a p p r e h e n s i v e about h i s d i s c h a r g e . On DAY 29, when the i n v e s t i g a t o r asked the p a t i e n t i f he was w o r r i e d about going home, he answered n e g a t i v e l y . However, on DAY 31, t h e day b e f o r e d i s c h a r g e , the p a t i e n t a d m i t t e d t h a t he was v e r y e x c i t e d about g o i n g home. He was r e s t l e s s and f i d g i t y . In summary, t h e s c o r e s o f t h e d i a r i e s f l u c t u a t e d i n r e s p o n s e t o t h e e f f e c t s o f t r e a t m e n t s t r e s s . P a t i e n t T h r e e T h i s 30 y e a r o l d male was burned to 26% o f h i s body. Second and t h i r d degree burns c o v e r e d both hands, l e f t f o r e a r m , back, neck and f a c e . Data was c o l l e c t e d from t h i s p a t i e n t o v e r a 25 day p e r i o d , from t h e e l e v e n t h day a f t e r a d m i s s i o n t o the day b e f o r e d i s c h a r g e . The i n v e s t i g a t o r v i s i t e d t h e p a t i e n t on DAYS 1, 4, 8, 11, 15, 18, 22 and 25. The Burn Treatment A d m i n i s t e r e d DAYS 1 - 1 0 - D a i l y burn baths Eye and e a r c a r e e v e r y 4 hours DAYS 3 - 9 - As above p l u s -Eveni n g arm baths DAYS 5 - 1 1 - As above p l u s -S a l i n e compresses t o neck and both arms e v e r y 4 hours DAY 10 - S u r g e r y - debridement - S k i n f o r g r a f t s taken - Compresses resumed post-op t o r i g h t f o r e a r m , l e f t arm and neck DAY 11 - S k i n g r a f t s t o above a r e a s DAYS 1 1 - 2 5 - G r a f t s r o l l e d e v e r y 2 hours DAYS 1 8 - 1 9 - Compresses t o l e f t e a r e v e r y 4 hours DAY 19 - S k i n g r a f t s t o e a r - G r a f t s r o l l e d e v e r y 2 hours DAY 20 - Severe e a r a c h e DAYS 2 2 - 2 5 - Tub baths resumed DAY 25 - Day b e f o r e d i s c h a r g e . A n a l y s i s o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r i e s The s c o r e s o f t h e " s t a t e " p o r t i o n o f t h e STAI d i d not change s i g n i f i c a n t l y o v e r t he p a t i e n t ' s p e r i o d o f r e c o v e r y . A c o n s i s t e n t low a n x i e t y l e v e l was m a i n t a i n e d . 73 TABLE 1-3 SCORES OF THE STAI DAY STAI S t a t e P o r t i o n T r a i t P o r t i o n 1 1 30 24 4 2 22 22 8 3 22 22 15 4 21 22 18 5 20 21 25 6 2 1 2 5 A l t h o u g h t h e " s t a t e " s c o r e was h i g h e s t on DAY 1, i t d i d not;change when t h e compress t r e a t m e n t p e r i o d was i n i t i a t e d . T here was no s i g n i f i c a n t change o v e r time i n the " t r a i t " s c o r e s o f the STAI. A "non-anxious" p e r s o n a l i t y t r a i t was m a i n t a i n e d . In summary, v i s u a l , a n a l y s i s o f the STAI s c o r e s r e v e a l no s i g n i f i c a n t change, o v e r a l l . I t was noted by t h e i n v e s t i g a t o r t h a t , g e n e r a l l y , t h e r e was l i t t l e e f f e c t o f t r e a t m e n t s t r e s s on t h i s p a t i e n t . A n a l y s i s o f t h e S l e e p Record Over the 25 days o f the d a t a c o l l e c t i o n p e r i o d , t he p a t i e n t had twenty n i g h t s o f "good s l e e p . " T h e r e were no c o n s e c u t i v e n i g h t s o f s l e e p l o s s . One n i g h t o f s l e e p l o s s o c c u r r e d on DAY 11 when the p a t i e n t was i n s e v e r e p a i n p o s t - o p e r a t i v e l y . However, i t i s i n t e r e s t i n g t o note t h a t t h i s p a t i e n t s t i l l m a i n t a i n e d a "good s l e e p " p a t t e r n from DAY 5 to DAY 10 when compress t r e a t m e n t was b e i n g a d m i n i s t e r e d . T h i s i s c o n t r a r y t o t h e o t h e r p a t i e n t s i n t h i s s t u d y who e x h i b i t e d c o n s e c u t i v e s l e e p l e s s n e s s d u r i n g t h e compress t r e a t m e n t p e r i o d . A n a l y s i s o f the M e d i c a t i o n Record A n a l g e s i c m e d i c a t i o n s were g i v e n t o the p a t i e n t f r e q u e n t l y from DAY 5 to DAY 11, d u r i n g t h e compress t r e a t m e n t p e r i o d . A n a l g e s i c s were not r e q u e s t e d by the p a t i e n t u n t i l he s t a r t e d to c o m p l a i n o f a s e v e r e e a r a c h e on DAY 21. S e d a t i v e s were g i v e n t o the p a t i e n t t h r e e times a day from DAY 11 t o DAY 21. S l e e p i n g p i l l s were g i v e n t o t h e p a t i e n t r o u t i n e l y o v e r t h e d a t a c o l l e c t i o n p e r i o d . The p a t i e n t r e q u e s t e d a s l e e p i n g p i l l o n l y on DAY 18 and DAY 19 when he was s u f f e r i n g from an e a r a c h e . A n a l y s i s o f t h e D i a r y S c o r e s The d i a r y s c o r e s r o s e on DAY 2 and DAY 10. On DAY 2, t h e p a t i e n t wrote i n h i s d i a r y t h a t he was s u f f e r i n g s e v e r e p a i n i n t h e open a r e a under h i s l e f t arm. On DAY)10, t h e p a t i e n t was s u f f e r i n g s e v e r e p a i n p o s t - o p e r a t i v e l y . A f t e r s u r g i c a l debridement o f h i s wounds, compresses were f r e q u e n t l y a p p l i e d to h i s arms and neck. On DAY 15, the d i a r y s c o r e s r o s e a g a i n , but not s i g n i f i c a n t l y . The p a t i e n t was asked t o p a r t i c i p a t e i n a s e l f - c a r e program and was t o l d he s h o u l d be morevin'dependent. He was u p s e t about a l i s t o f "independent a c t i v i t i e s " t a p ed t o t h e w a l l above h i s bed as w e l l as the manner i n which the s e l f - c a r e program was e x p l a i n e d to him. From DAY 16 to the day o f d i s c h a r g e , the d i a r y s c o r e s remained a t a v e r y low l e v e l . There appears t o be no i n d i c a t i o n o f i n c r e a s e d a n x i e t y when d i s c h a r g e from the h o s p i t a l was imminent. In summary, the d i a r y s c o r e s d i d not f l u c t u a t e remarkably i n r e s p o n s e t o t h e e f f e c t s o f t r e a t m e n t s t r e s s . T h i s p a t i e n t coped c o n s i d e r a b l y w e l l 75 w i t h h i s t r e a t m e n t s and h i s p a i n e x p e r i e n c e . Low " t r a i t " s c o r e s , low " s t a t e " s c o r e s and low d i a r y s c o r e s were c o n s i s t e n t o v e r the e n t i r e d a t a c o l l e c t i o n p e r i o d . P a t i e n t Four T h i s 27 y e a r o l d male was burned t o 4% o f h i s body. Second and t h i r d degree burns c o v e r e d h i s r i g h t hand and fo r e a r m . Data was c o l l e c t e d from t h i s p a t i e n t o v e r a 24 day p e r i o d , from the f i r s t day a f t e r a d m i s s i o n to the burn u n i t to t h e day b e f o r e d i s c h a r g e . The i n v e s t i g a t o r v i s i t e d t h e p a t i e n t on DAYS 1, 3, 7, 10,14, 17, 21 and 24. The Burn Treatment A d m i n i s t e r e d DAY 1 - 4 - D a i l y tub bath - E v e n i n g arm bath DAY 4 - S u r g e r y - debridement, i n s e r t i o n o f K-wires, - S k i n f o r g r a f t i n g taken from donor a r e a - S a l i n e compresses p o s t - o p DAYS 4 - 6 - Compresses e v e r y 4 hours DAY 6 - Kr w i r e t o t r a c t i o n - S k i n g r a f t s a p p l i e d DAYS 6 - 14 - - G r a f t s r o l l e d f r e q u e n t l y DAY 14 - D a i l y t u b baths resumed - Even i n g arm baths DAY 15 - K-wire removed DAY 16 - N e c r o t i c s k i n g r a f t d e b r i d e d S a l i n e compresses a p p l i e d DAY 17 - Compresses d u r i n g morning S k i n g r a f t s a p p l i e d i n a f t e r n o o n DAYS 1 7 - 2 2 - G r a f t s r o l l e d f r e q u e n t l y DAY 22 - D a i l y tub baths resumed - E v e n i n g arm baths P a t i e n t moved t o "p o r c h " DAY 24 - Day b e f o r e d i s c h a r g e 76 A n a l y s i s o f the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s The s c o r e s o f t h e " s t a t e " p o r t i o n o f t h e STAI changed d r a m a t i c a l l y o v e r the p a t i e n t ' s p e r i o d o f r e c o v e r y . TABLE 1-4 SCORES OF THE STAI DAY STAI S t a t e P o r t i o n T r a i t P o r t i o n 1 1 71 37 7 2 41 39 10 3 26 31 14 4 28 36 21 5 29 35 24 6 22 37 An e x t r e m e l y h i g h a n x i e t y l e v e l was noted on DAY 1. At t h i s t i m e , the p a t i e n t was r e c e i v i n g arm baths accompanied by debridement o f t h e burns. On DAY 7, s k i n g r a f t s , which had been a p p l i e d the day b e f o r e , were b e i n g r o l l e d f r e q u e n t l y . By the time the t h i r d STAI was a d m i n i s t e r e d , t h i s p a t i e n t ' s s t a t e a n x i e t y was a t a low l e v e l . T h i s l e v e l was m a i n t a i n e d d u r i n g t h e remainder o f t h e d a t a c o l l e c t i o n p e r i o d . There was no remarkable change o v e r time i n t h e " t r a i t " s c o r e s o f t h e STAI. T r a i t a n x i e t y was m a i n t a i n e d a t a " f a i r l y a n x i o u s " l e v e l d u r i n g the p a t i e n t ' s r e c o v e r y p e r i o d . A n a l y s i s o f the S l e e p Record Over the 24 day d a t a c o l l e c t i o n p e r i o d , the p a t i e n t o n l y had 11 n i g h t s o f "good s l e e p . " Three n i g h t s o f c o n s e c u t i v e s l e e p l o s s o c c u r r e d t h r e e t i m e s d u r i n g t h e d a t a c o l l e c t i o n p e r i o d . These were a f t e r 77 a d m i s s i o n t o the burn u n i t (DAYS 1, 2 & 3 ) , d u r i n g compress t r e a t m e n t (DAYS 5, 6 & 7 ) , and a f t e r t he second s k i n g r a f t i n g s e s s i o n (on DAY 17) when g r a f t s were b e i n g r o l l e d f r e q u e n t l y . I t was noted t h a t t he " s t a t e " s c o r e s o f the STAI i n d i c a t e d h e i g h t e n e d a n x i e t y d u r i n g t h e s e p e r i o d s . The s c o r e s o f the d i a r i e s a l s o r e v e a l e d a r i s e i n a n x i e t y l e v e l d u r i n g t h e s e s l e e p l e s s p e r i o d s . A n a l y s i s o f the M e d i c a t i o n Record A n a l g e s i c m e d i c a t i o n s were r e q u e s t e d f r e q u e n t l y by the p a t i e n t d u r i n g compress t r e a t m e n t on DAY 5 and DAY 6. A f t e r DAY 9, no a n a l g e s i c s were r e q u e s t e d f o r the remainder o f the data c o l l e c t i o n p e r i o d . S l e e p i n g p i l l s were g i v e n t o the p a t i e n t r o u t i n e l y from DAY 5 t o DAY 24. The o n l y time t h a t t he p a t i e n t r e q u e s t e d a s l e e p i n g p i l l was on DAY 9, when h i s s k i n g r a f t s were b e i n g r o l l e d e v e r y 2 hours. A t no time were s e d a t i v e s g i v e n t o t h e p a t i e n t . A n a l y s i s o f the D i a r y S c o r e s A d i a r y s c o r e o f 33 on DAY 1 i n d i c a t e d a h i g h a n x i e t y l e v e l . The i n v e s t i g a t o r o b s e r v e d t h a t the p a t i e n t appeared v e r y t e n s e and a n x i o u s , t i r e d from l a c k o f s l e e p t h e n i g h t p r e v i o u s and w o r r i e d about t h e . f u t u r e f u n c t i o n i n g and appearance o f h i s hand. On DAY 2, the d i a r y s c o r e was 24. In the d i a r y comments, he i n d i c a t e d t h a t he had s l e p t b e t t e r d u r i n g t he n i g h t ; he was g e n e r a l l y f e e l i n g b e t t e r and t a l k i n g t o the n u r s e s . Moreover, he had g a i n e d a sense o f s e c u r i t y about h i s j o b a f t e r s p e a k i n g t o h i s employer on t h e t e l e p h o n e . A l t h o u g h t he d i a r y s c o r e r o s e to 33, a g a i n , on DAY 3, t h e p a t i e n t appeared w e l l r e s t e d , more c h e e r f u l and eager t o t a l k to the i n v e s t i g a t o r . He commented r e p e a t e d l y , both v e r b a l l y and i n h i s d i a r y , t h a t he was w o r r i e d about h i s s u r g e r y on DAY 4. The p a r t s o f the t a p e - s l i d e program on " S k i n G r a f t i n g " and " S p l i n t i n g " were shown t o the p a t i e n t . He appeared ve r y i n t e r e s t e d . F u r t h e r m o r e , the d i s c u s s i o n f o l l o w i n g was f r u i t f u l . He s t a t e d t h a t the t e a c h i n g and emotional s u p p o r t , g i v e n to him a t t h i s c r u c i a l t i m e , p a r t i a l l y r e l i e v e d h i s a n x i e t y about t h e s u r g e r y . The d i a r y s c o r e s r o s e u n t i l DAY 5 when the h i g h e s t s c o r e o v e r the e n t i r e d a t a c o l l e c t i o n p e r i o d was r e a c h e d . At t h i s t i m e , the p a t i e n t was u n d ergoing compress t r e a t m e n t p o s t - o p e r a t i v e l y . The o n l y comment i n h i s d i a r y was t h a t h i s wounds were now much more p a i n f u l . S k i n g r a f t s were a p p l i e d to h i s hand on DAY 6. E v i d e n t l y he had completed the d i a r y b e f o r e the g r a f t i n g p r o c e d u r e . He/commented t h a t the compress changes were v e r y p a i n f u l . He l a c k e d s l e e p from the i n t e r r u p t i o n s d u r i n g t h e n i g h t as w e l l as from the u n b e a r a b l e p a i n . ( By DAY 7, the d i a r y s c o r e s c o n t i n u e d to d e c l i n e . The g r a f t s were b e i n g r o l l e d e v e r y 2 hours. He wrote t h a t the p a i n was a t h r o b b i n g ache but b e a r a b l e . His main c o n c e r n s were the appearance o f t h e s k i n g r a f t s and the method t h a t the d o c t o r would use t o remove the K-wire. Moreover, r e q u e s t s f o r a n a l g e s i c s had c e a s e d . The " s t a t e " s c o r e o f t h e STAI was down t o 41, q u i t e a d e c r e a s e from a h i g h o f 71 on DAY 1. The d i a r y s c o r e s i n d i c a t e d a low a n x i e t y u n t i l DAY 15. At t h i s t i m e , the K-wire from t h e p a t i e n t ' s hand was t o be removed. Fu r t h e r m o r e , he was informed t h a t some g r a f t e d a r e a s on h i s hand had "not t a k e n . " S i n c e he was l o o k i n g forward t o d i s c h a r g e by the end o f t h e week, t h i s i n f o r m a t i o n 79 was ver y d i s a p p o i n t i n g . On DAY 16, the n e c r o t i c g r a f t s were d e b r i d e d . S a l i n e compresses t o t h e s e a r e a s were resumed. D i a r y s c o r e s c o n t i n u e d t o r i s e . On DAY 17, the a r e a s on h i s hand were r e - g r a f t e d . He wrote t h a t he was v e r y d e p r e s s e d . T h i s c o m p l i c a t i o n would mean a d e l a y i n h i s d i s c h a r g e from t h e h o s p i t a l . He l a c k e d t h r e e c o n s e c u t i v e n i g h t s o f s l e e p because the g r a f t s were b e i n g r o l l e d f r e q u e n t l y . By DAY 18, the d i a r y s c o r e s were b e g i n n i n g t o s t e a d i l y d e c l i n e . However, on DAY 22, the s c o r e r o s e s l i g h t l y . I t was noted i n the d i a r y t h a t t he p a t i e n t was t o l d t h a t he would be d i s c h a r g e d from h o s p i t a l i n t h r e e days. A l t h o u g h he was eager to l e a v e t he h o s p i t a l , t h e p a t i e n t d i d expr e s s c o n c e r n about t h e a b i l i t y o f t h e knuckle s k i n g r a f t t o s t r e t c h and t he f u n c t i o n i n g o f h i s hand. On DAY 24, the day b e f o r e d i s c h a r g e , the p a t i e n t d e n i e d any co n c e r n s o r a n x i e t y . He appeared c h e e r f u l and r e l a x e d . In summary, the s c o r e s o f both t he STAI and d i a r y changed s i g n i f i c a n t l y i n re s p o n s e to the e f f e c t s o f t r e a t m e n t s t r e s s . At t h e b e g i n n i n g o f t h e data c o l l e c t i o n p e r i o d , t h i s p a t i e n t was h i g h l y a n x i o u s . However, as r e c o v e r y p r o g r e s s e d , he m a i n t a i n e d a moderate a n x i e t y l e v e l . P a t i e n t F i v e T h i s 60 y e a r o l d l a d y was burned to 10% o f her body. Second and t h i r d degree burns c o v e r e d both a n t e r i o r a s p e c t s o f her t h i g h s and perineum. Data was c o l l e c t e d o v e r a 26 day p e r i o d , from t h e t h i r d day a f t e r a d m i s s i o n t o a few days b e f o r e d i s c h a r g e . The i n v e s t i g a t o r v i s i t e d t h e p a t i e n t on DAYS 1, 6, 8, 12, 14, 19, 22 and 26. The Burn Treatment A d m i n i s t e r e d DAYS 1 - 6 - Tub baths f o l l o w e d by c l e a n s i n g o f the burn wound and a p p l i c a t i o n o f an a n t i b i o t i c cream DAYS 6 - 1 5 S a l i n e compresses t o t h e t h i g h s e v e r y f o u r hours Tub baths i n t h e morning DAY 15 Surgery - debridement o f the burn wounds f o l l o w e d by a p p l i c a t i o n o f s a l i n e compresses DAYS 1 6 - 2 0 S k i n g r a f t i n g f o l l o w e d by f r e q u e n t r o l l i n g o f the g r a f t s DAYS 2 1 - 2 5 Tub baths resumed DAYS 2 3 - 2 4 S a l i n e compresses to a small open a r e a a f t e r n e c r o t i c g r a f t removed. DAYS 25 - 26 S k i n g r a f t s t o small a r e a r e - a p p l i e d f o l l o w e d by f r e q u e n t r o l l i n g . A n a l y s i s o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r i e s The s c o r e s o f the " s t a t e " p o r t i o n o f t h e STAI changed s i g n i f i c a n t l y o v e r the d a t a c o l l e c t i o n p e r i o d . TABLE 1-5 SCORES OF THE STAI DAY STAI S t a t e P o r t i o n T r a i t P o r t i o n 1 1 52 28 6 2 37 23 8 3 44 29 14 4 50 28 22 5 34 28 26 6 36 28 On DAY 1, t h e " s t a t e " s c o r e o f the STAI was a t i t s h i g h e s t l e v e l . The p a t i e n t was h i g h l y a n x i o u s and nervous on a d m i s s i o n to the burn u n i t . 81 The s a l i n e compress t r e a t m e n t was i n i t i a t e d on DAY 6, a f t e r a d m i n i s t r a t i o n o f t he STAI. On DAY 8, the p a t i e n t ' s a n x i e t y l e v e l had r i s e n d u r i n g compress t r e a t m e n t . A g a i n , on DAY 14, the " s t a t e " p o r t i o n o f t h e STAI i n d i c a t e d h e i g h t e n e d a n x i e t y . A t t h i s t i m e , t h e p a t i e n t was i n f o r m e d t h a t she would be g o i n g t o the o p e r a t i n g room e a r l y t he next day. As r e c o v e r y p r o g r e s s e d , t he s c o r e s o f the STAI m a i n t a i n e d a low a n x i e t y l e v e l . There was no s i g n i f i c a n t change i n t h e " t r a i t " s c o r e s o f t h e STAI o v e r the d a t a c o l l e c t i o n p e r i o d . T r a i t a n x i e t y was c o n s i s t e n t l y m a i n t a i n e d a t a low l e v e l . A n a l y s i s o f t h e Sl e e p Record Over a p e r i o d o f 25 days, t h e p a t i e n t had twelve n i g h t s o f "good s l e e p . " I t was noted by t h e s t a f f nurses t h a t she s l e p t a g r e a t deal d u r i n g t h e day from DAY 1 to DAY 8. The p a t i e n t c o m p l a i n e d o f b e i n g unable t o s l e e p a t n i g h t due t o the ext r a n e o u s sounds i n her ward room. There were no n i g h t s o f c o n s e c u t i v e s l e e p l o s s d u r i n g t he f i r s t compress t r e a t m e n t p e r i o d . However, from DAY 21 t o DAY 26, t h i s p a t i e n t had s i x c o n s e c u t i v e n i g h t s o f s l e e p l e s s n e s s . I t was d u r i n g t h i s p e r i o d t h a t s a l i n e compresses were resumed a f t e r a small g r a f t d i d not 'take.' A n a l y s i s o f t h e M e d i c a t i o n Record S e d a t i v e s were g i v e n r o u t i n e l y , t h r e e times a day t o t h i s p a t i e n t o v e r t h e e n t i r e data c o l l e c t i o n p e r i o d . Requests f o r a n a l g e s i c s were no t e d d u r i n g t h e f i r s t week o f r e c o v e r y . A n a l g e s i c s were r o u t i n e l y g i v e n when compress t r e a t m e n t was i n i t i a t e d on DAY 6. By DAY 13, a l t h o u g h compress tr e a t m e n t was s t i l l i n p r o g r e s s , t he p a t i e n t began to r e f u s e a n a l g e s i c m e d i c a t i o n . When compress t r e a t m e n t was resumed on DAY 23, t h e p a t i e n t was 82 r o u t i n e l y g i v e n a n a l g e s i c s b e f o r e t r e a t m e n t . S l e e p i n g p i l l s were g i v e n on DAYS 1 and 2. They were d i s c o n t i n u e d , when t h e p a t i e n t appeared t o be drowsy and s l e e p i n g throughout t he day. S l e e p i n g m e d i c a t i o n s were resumed on DAY 17 and gi v e n r o u t i n e l y f o r the remainder o f the data c o l l e c t i o n p e r i o d . A n a l y s i s o f the D i a r y S c o r e s D i a r y s c o r e s were c o n s i s t e n t l y m a i n t a i n e d a t a low a n x i e t y l e v e l from DAY 1 t o DAY 14. Then, the s c o r e s peaked d r a m a t i c a l l y on DAY 15, the day o f s u r g e r y . They remained high u n t i l DAY 17 when t h e y g r a d u a l l y f e l l . By DAY 20, the d i a r y s c o r e s were m a i n t a i n e d near t he l e v e l o f the p r e - s u r g e r y s c o r e s . The d i a r y s c o r e r o s e on DAY 26 as t h e day o f d i s c h a r g e grew c l o s e r . Two d i a r i e s were not completed, on DAY 12 and DAY 13. At t h i s t i m e , t h e p a t i e n t was ver y d e p r e s s e d when n o t i f i e d t h a t her t h i r d degree burns would have t o be g r a f t e d . In summary, the s c o r e s o f t h e d i a r i e s i n d i c a t e d a low a n x i e t y l e v e l . However, i t was noted by the i n v e s t i g a t o r t h a t t h i s p a t i e n t was l a u g h i n g about her s i t u a t i o n when she was r e a l l y w o r r i e d , s t a t i n g t h a t n o t h i n g was b o t h e r i n g her y e t enumerating t h i n g s which were. She o v e r - r e a c t e d t o a small a r e a o f s k i n g r a f t r e j e c t i o n i n comparison to o t h e r p a t i e n t s ' r e s p o n s e t o s i m i l a r o r much more e x t e n s i v e c i r c u m s t a n c e s . E v a l u a t i o n o f the Planned N u r s i n g I n t e r v e n t i o n s  from P a t i e n t Comments I t was a p p a r e n t t h a t p a r t i c i p a t i o n i n t h i s study was b e n e f i c i a l f o r th e s e p a t i e n t s f r o m • t h e i r comments. They e x p r e s s e d a g r e a t need t o v e n t i l a t e f r u s t r a t i o n , emotions and co n c e r n s r e g a r d i n g t h e i r b u r n , t r e a t m e n t , s k i n g r a f t i n g and n u r s e - p a t i e n t r e l a t i o n s h i p . The f a c t t h a t t h e i n v e s t i g a t o r was an unbiased p e r s o n , not i n v o l v e d i n t h e i r p h y s i c a l c a r e , a l l o w e d them t o v e n t i l a t e and d i s p e l t h e i r c o n c e r n s . A l l t h e p a t i e n t s s t a t e d t h a t t h e t a p e - s l i d e program and the d i s c u s s i o n f o l l o w i n g were v e r y h e l p f u l . They appeared very i n t e r e s t e d i n the i n s t r u c t i o n a l program. The a u d i o - v i s u a l a i d s t i m u l a t e d q u e s t i o n s and e x p r e s s i o n o f c o n c e r n s . Only one p a t i e n t r e f u s e d v i e w i n g o f the p a r t o f the program on s k i n g r a f t i n g . She f e a r e d t h a t the photographs might " s c a r e " her. The f i r s t p a t i e n t commented q u i t e f r e q u e n t l y about the h e l p f u l n e s s o f the d i s c u s s i o n s w i t h the i n v e s t i g a t o r . He s a i d t h a t he l o o k e d f o r w a r d to the v i s i t s because he " f e l t so good a f t e r w a r d s . " E x p r e s s i n g h i s f r u s t r a t i o n s and anger to someone who was w i l l i n g t o l i s t e n , who a c c e p t e d h i s emotions and who was non-judgmental r e l i e v e d h i s t e n s i o n . The n u r s e s s t a t e d t h a t t h e p a t i e n t ' s d i s p o s i t i o n and a t t i t u d e toward h i s h o s p i t a l i z a t i o n and the n u r s i n g s t a f f changed p o s i t i v e l y s i n c e t h e s e v i s i t s were i n i t i a t e d . The s t a f f s t a t e d t h a t he c o n c e n t r a t e d hard on h i s d i a r y r e s p o n s e s . The p a t i e n t commented t h a t w r i t i n g down h i s f e e l i n g s i n the d i a r y was v e r y h e l p f u l i n r e l i e v i n g d a i l y a n x i e t i e s and t e n s i o n . The second p a t i e n t a l s o commented q u i t e f r e q u e n t l y about t h e h e l p f u l n e s s o f the d i s c u s s i o n s w i t h the i n v e s t i g a t o r . The o p p o r t u n i t y to v e n t i l a t e h i s t h o u g h t s was good f o r him p h y s i c a l l y and e m o t i o n a l l y . He f e l t t h a t i t i s h e l p f u l f o r p a t i e n t s t o t a l k about day t o day f r u s t r a t i o n s , t o e x p r e s s pent-up f e e l i n g s and c o n c e r n s , and t o hear each p r o c e d u r e and phase o f r e c o v e r y e x p l a i n e d b e f o r e h a n d . He thought t h a t t h e t a p e - s l i d e program Was "superb." I t was h e l p f u l 84 to see what was g o i n g t o happen b e f o r e i t took p l a c e . The s e c t i o n o f t h e program on s k i n g r a f t i n g and the d i s c u s s i o n f o l l o w i n g d e c r e a s e d h i s a n x i e t y g r e a t l y as i n d i c a t e d by the d i a r y and S t a t e - T r a i t A n x i e t y I n v e n t o r y s c o r e s . T h i s p a t i e n t a l s o s t a t e d t h a t he l o o k e d f o r w a r d t o t h e v i s i t s . I t was noted t h a t , a t t i m e s , the p a t i e n t appeared drowsy when t h e i n v e s t i g a t o r e n t e r e d t he room. D u r i n g t he v i s i t , he perked up and became v e r y t a l k a t i v e . T h i s p a t i e n t ' s s t a t e a n x i e t y and emotional d i s p o s i t i o n f l u c t u a t e d i n r e l a t i o n t o t h e typ e o f t r e a t m e n t he was r e c e i v i n g . A l t h o u g h the p o s i t i v e e f f e c t s o f t h e n u r s i n g i n t e r v e n t i o n s were e x p r e s s e d by t h e p a t i e n t , t h e s e i n t e r v e n t i o n s d i d not have a g r e a t c o n t r i b u t i o n i n i r e d u c i n g s t a t e a n x i e t y due to the e f f e c t s o f t r e a t m e n t s t r e s s . The t h i r d p a t i e n t was a ver y a r t i c u l a t e and i n f o r m a t i v e man. He always seemed t o be i n c o n t r o l o f h i m s e l f and h i s r e c o v e r y e x p e r i e n c e . The i n v e s t i g a t o r ' s v i s i t s w i t h t h e p a t i e n t were m o s t l y i n f o r m a t i o n -g i v i n g s e s s i o n s on h i s p a r t . His use o f medical t e r m i n o l o g y was amazing. He o b v i o u s l y knew a g r e a t d e a l about t h e purposes o f h i s t r e a t m e n t . He f e l t t h a t i t was h e l p f u l to d i s c u s s and a n a l y z e h i s f e e l i n g s d u r i n g v i s i t s w i t h t he i n v e s t i g a t o r . He s t a t e d , " i f I d i d n ' t get my b o t t l e d f e e l i n g s o u t , I'd get the meemies." V e n t i l a t i o n o f day t o day f r u s t r a t i o n s and a n a l y s i s o f h i s thoughts to a per s o n w i t h t h e time t o l i s t e n , was ver y i m p o r t a n t t o him. For example, on two o c c a s i o n s t h e i n v e s t i g a t o r found t he p a t i e n t l y i n g i n bed i n a d e p r e s s e d mood, s h a k i n g h i s r i g h t f o o t . T h i s a c t i o n was h i s normal way o f r e l a x i n g and d e c r e a s i n g t e n s i o n . At t h e end o f t h e v i s i t , i t was noted by t h e i n v e s t i g a t o r t h a t 85 the p a t i e n t was s m i l i n g , j o k i n g and s i t t i n g up i n bed. He had stopp e d s h a k i n g h i s f o o t . D u r i n g t h e l a s t v i s i t , on the day b e f o r e d i s c h a r g e , he s a i d t h a t p a t i e n t s need a "sounding board" t o get f r u s t r a t i o n s out o f t h e i r "system." The f o u r t h p a t i e n t s t a t e d t h a t he l o o k e d forward to the v i s i t s . O f t e n , he appeared bored and d e p r e s s e d o r angry when t h e i n v e s t i g a t o r e n t e r e d the room. By t h e end o f the v i s i t , t h e p a t i e n t was s m i l i n g , l a u g h i n g a t h i s c i r c u m s t a n c e s and f e l l a s l e e p a f t e r the v i s i t . T h i s p a t i e n t b e n e f i t t e d from p a r t i c i p a t i o n i n the r e s e a r c h study i n the f o l l o w i n g ways. He was g e n e r a l l y s a d , d i s c o u r a g e d and o f t e n e x p r e s s e d anger a t the o n s e t o f t h e v i s i t . A f t e r t he v i s i t , h i s mood was g e n e r a l l y e l e v a t e d t o s m i l e s , l a u g h t e r and e x p r e s s i o n o f g r a t i t u d e f o r an o p p o r t u n i t y t o s h a r e h i s f e e l i n g s r e g a r d i n g h i s burn c a r e . The f i f t h p a t i e n t o f t e n s t a t e d t h a t t he v i s i t s from t h e i n v e s t i g a t o r would c h e e r her up and h e l p boost her morale. F u r t h e r m o r e , the v i s i t was the c h e e r i e s t p a r t o f her day. She f e l t t h a t P a r t I o f t h e t a p e - s l i d e program was "superb" and v e r y h e l p f u l . She o n l y wished t h a t she had seen i t as soon as she was a d m i t t e d . In summary, t h e i n f o r m a t i o n a l and s u p p o r t i v e components o f t h e planned n u r s i n g i n t e r v e n t i o n s seemed to reduce emotional s t r e s s . The p a t i e n t s c l e a r l y i n d i c a t e d a need t o v e n t i l a t e t h e i r f r u s t r a t i o n s as a r e s u l t o f the e f f e c t s o f t r e a t m e n t s t r e s s . The p o s i t i v e e f f e c t s o f t h e planned n u r s i n g i n t e r v e n t i o n s were a l s o r e i n f o r c e d by s t a f f comments. 86 S t a t i s t i c a l A n a l y s i s o f t h e F i n d i n g s The a n a l y s i s o f t h e d a t a c e n t e r e d around t e s t i n g t h e seven n u l l h y p o t h eses. To t e s t h y p o t h e s i s one, u s i n g t he s c o r e ' s o f t h e " t r a i t " p o r t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y , a p a i r e d t t e s t was a p p l i e d to the f i r s t t h r e e s c o r e s o f a l l t he p a t i e n t s and the l a s t t h r e e s c o r e s o f a l l t h e p a t i e n t s . To t e s t h y p o t h e s i s two, a p r o d u c t moment c o r r e l a t i o n c o e f f i c i e n t was used to c o r r e l a t e the p a t i e n t s ' s c o r e s on the " s t a t e " p o r t i o n o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y w i t h t h e s c o r e s o b t a i n e d on t h e d i a r i e s . The two t a i l e d t e s t was used and a s i g n i f i c a n c e l e v e l o f .05 was c o n s i d e r e d a c c e p t a b l e t o r e j e c t t he n u l l h y p o t h e s i s . To t e s t hypotheses t h r e e and f o u r , .:. p r o d u c t moment c o r r e l a t i o n c o e f f i c i e n t s were u t i l i z e d to de t e r m i n e the s t r e n g t h o f the c o r r e l a t i o n o f the v a r i a b l e s named i n t h e s e hypotheses. H y p o t h e s i s f i v e was a p p a r e n t by i n s p e c t i o n . To t e s t hypotheses s i x and seven, p r o d u c t moment c o r r e l a t i o n c o e f f i c i e n t s were used t o c o r r e l a t e the p a t i e n t s ' s c o r e s on the S t a t e - T r a i t A n x i e t y I n v e n t o r y w i t h t he n u r s e s ' assessment o f p a t i e n t a n x i e t y on the L i k e r t - t y p e s c a l e . A s i g n i f i c a n c e l e v e l o f .05 was c o n s i d e r e d a c c e p t a b l e to r e j e c t t h e n u l l h y p o theses. The s t a t i s t i c a l a n a l y s i s o f t h e data i s p r e s e n t e d i n r e l a t i o n t o each h y p o t h e s i s . H y p o t h e s i s One The f i r s t n u l l h y p o t h e s i s t e s t e d was t h a t , There i s no measurable change i n t r a i t a n x i e t y o v e r u n i t time i n a sample o f burn p a t i e n t s r e c e i v i n g exposure to an i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t d u r i n g the c o u r s e o f t r e a t m e n t s as measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s . 87 T r a i t a n x i e t y was measured by t h e " t r a i t " p o r t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y , a d m i n i s t e r e d s i x times to each p a t i e n t . T a b l e ,2 l i s t s t h e raw s c o r e s . TABLE 2 TOTAL SCORES OF THE "TRAIT" PORTION STATE-TRAIT ANXIETY INVENTORY OF THE STAI P a t i e n t 1 P a t i e n t 2 P a t i e n t 3 P a t i e n t 4 P a t i e n t 5 1 50 36 24 37 28 2 44 36 22 39 23 3 47 30 22 31 29 4 41 38 22 36 28 5 43 37 21 35 28 6 40 39 25 37 28 A p a i r e d t t e s t was a p p l i e d to the f i r s t t h r e e s c o r e s o f a l l the p a t i e n t s and the l a s t t h r e e s c o r e s o f a l l t h e p a t i e n t s . At f o u r t e e n d e g r e s s o f freedom, the t v a l u e was 0.000 w i t h a T p r o b a b i l i t y o f 1.000. A t t h e .05 l e v e l o f s i g n i f i c a n c e , t h e c r i t i c a l v a l u e was 2.145. S i n c e t h e d i f f e r e n c e between the means i s not s i g n i f i c a n t , t h e n u l l h y p o t h e s i s was not r e j e c t e d . There was no change i n t r a i t a n x i e t y o v e r u n i t t i m e . T h e r e f o r e , no change i n t r a i t a n x i e t y , o r a n x i e t y - p r o n e n e s s , o c c u r r e d i n a sample o f burn p a t i e n t s o v e r u n i t time. H y p o t h e s i s Two The second n u l l h y p o t h e s i s t e s t e d was t h a t , There i s no measurable r e d u c t i o n o f s t a t e a n x i e t y o v e r u n i t time i n a sample o f burn p a t i e n t s r e c e i v i n g exposure t o an i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t d u r i n g t h e c o u r s e o f t r e a t m e n t s 88 as measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s and as i n d i c a t e d by the p a t i e n t s ' p e r s o n a l d i a r i e s . S t a t e a n x i e t y was measured by the " s t a t e " p o r t i o n o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y , a d m i n i s t e r e d s i x times t o each p a t i e n t . The c o r r e s p o n d i n g d i a r y s c o r e s were t a b u l a t e d f o r each p a t i e n t . T a b l e 3 l i s t s t he raw s c o r e s . TABLE 3 TOTAL SCORES OF THE "STATE" PORTION OF THE STATE-TRAIT ANXIETY INVENTORY AND TOTAL SCORES OF THE DIARY STAI P a t i e n t 1 STAI d i a r y P a t i e n t 2 STAI d i a r y P a t i e n t 3 STAI d i a r y P a t i e n t 4 STAI d i a r y P a t i e n t 5 STAI d i a r y 1 46 31 30 31 30 25 71 33 52 28 2 50 30 36 39 22 21 41 31 37 27 3 51 39 39 25 22 16 26 19 44 27 4 51 33 22 26 21 18 28 18 50 28 5 43 34 38 30 20 13 29 20 28 30 6 48 32 32 27 21 13 22 14 36 22 A product-moment c o r r e l a t i o n c o e f f i c i e n t was used to c o r r e l a t e the s c o r e s o b t a i n e d by a l l t h e p a t i e n t s on t h e " s t a t e " p o r t i o n o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y w i t h t h e s c o r e s o b t a i n e d by a l l t h e p a t i e n t s on the c o r r e s p o n d i n g d i a r i e s . At t w e n t y - n i n e degrees o f freedom, the f i n d i n g was r .72 which i s a s i g n i f i c a n t c o r r e l a t i o n a t the .05 l e v e l o f s i g n i f i c a n c e f o r a two t a i l e d t e s t . At t w e n t y - n i n e d e g r e e s ' o f freedom, t h e f i n d i n g , r . 7 2 , was a l s o s i g n i f i c a n t a t the .01 l e v e l when compared t o t h e c r i t i c a l v a l u e s o f r a t t h i s l e v e l . T h e r e f o r e , t h e n u l l h y p o t h e s i s was r e j e c t e d a t t h e .01 l e v e l o f s i g n i f i c a n c e . F u r t h e r m o r e , t h e f i r s t t h r e e s c o r e s o f the S t a t e - T r a i t A n x i e t y 89 I n v e n t o r y and the l a s t t h r e e s c o r e s o f t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y were t e s t e d w i t h a p a i r e d t t e s t . A t f o u r t e e n degrees o f freedom, t he t v a l u e was 2.556 w i t h a T p r o b a b i l i t y o f 0.0229. When the t v a l u e was compared to the c r i t i c a l v a l u e s f o r t a t t h e .05 l e v e l o f s i g n i f i c a n c e , t h e n u l l h y p o t h e s i s was r e j e c t e d a t t h i s l e v e l . T h e r e f o r e , t h e r e was a r e d u c t i o n o f s t a t e a n x i e t y o v e r u n i t time as measured by the s c o r e s o f the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s . Furthermore, t he f i r s t t h r e e d i a r y s c o r e s o f a l l t h e p a t i e n t s and the l a s t t h r e e d i a r y s c o r e s o f a l l t h e p a t i e n t s were t e s t e d w i t h a p a i r e d t t e s t . A t f o u r t e e n degrees o f freedom, t he t v a l u e was 2.306 w i t h a T p r o b a b i l i t y o f 0.0369. When t h e t v a l u e was compared t o t h e c r i t i c a l v a l u e s f o r t a t the .05 l e v e l o f s i g n i f i c a n c e , t h e n u l l h y p o t h e s i s was r e j e c t e d a t t h i s l e v e l . T h e r e f o r e , t h e r e was a r e d u c t i o n o f s t a t e a n x i e t y o v e r u n i t time as measured by-the s c o r e s o f t h e d i a r i e s . In summary, t h e r e was a measurable r e d u c t i o n o f s t a t e a n x i e t y o v e r u n i t time i n the sample o f burn p a t i e n t s as measured by t h e S t a t e - T r a i t A n x i e t y I n v e n t o r i e s and the d i a r i e s . H y p o t h e s i s Three The t h i r d n u l l h y p o t h e s i s was t h a t , . There i s no measurable i n c r e a s e i n t h e hours o f s l e e p o v e r u n i t time i n a sample o f burn p a t i e n t s r e c e i v i n g exposure to an i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t as measured by the n u r s e s ' o b s e r v a t i o n on the s l e e p r e c o r d and as i n d i c a t e d i n t h e p a t i e n t s ' p e r s o n a l d i a r i e s . The s c o r e s o f the p a t i e n t s ' s e l f r e p o r t o f s l e e p i n t h e d i a r i e s were compared to the hours o f s l e e p noted by t h e nurses on the s l e e p r e c o r d . A product-moment c o r r e l a t i o n c o e f f i c i e n t was 1 u t i l i z e d . T h e r e was no c o r r e l a t i o n , F 0.00, between the v a r i a b l e s . T h e r e f o r e , t h e n u l l h y p o t h e s i s 90 was not r e j e c t e d . There was no measurable i n c r e a s e i n the q u a n t i t y o f s l e e p o v e r u n i t time. H y p o t h e s i s Four The f o u r t h h y p o t h e s i s was t h a t , i There i s no measurable r e d u c t i o n i n e x p r e s s e d need f o r a n a l g e s i c and s e d a t i v e m e d i c a t i o n o v e r u n i t time i n a sample o f burn p a t i e n t s r e c e i v i n g exposure t o an i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t as measured by the n u r s e s ' o b s e r v a t i o n on t h e m e d i c a t i o n r e c o r d and as i n d i c a t e d by the p a t i e n t s ' p e r s o n a l d i a r i e s . The s c o r e s o f t h e p a t i e n t s ' s e l f r e p o r t o f need f o r m e d i c a t i o n were compared to t h e number o f r e q u e s t s f o r m e d i c a t i o n as noted by the nurses on the m e d i c a t i o n r e c o r d . A product-moment c o r r e l a t i o n c o e f f i c i e n t was u t i l i z e d . There was no c o r r e l a t i o n , r 0.00, between the v a r i a b l e s . T h e r e f o r e , the n u l l h y p o t h e s i s was not r e j e c t e d . There was no r e d u c t i o n i n e x p r e s s e d need f o r m e d i c a t i o n o v e r u n i t t i m e . H y p o t h e s i s F i v e The f i f t h h y p o t h e s i s was t h a t , There i s no measurable i n d i c a t i o n o f i n c r e a s e d r e p o r t e d w e l l - b e i n g o v e r u n i t time i n a sample o f burn p a t i e n t s r e c e i v i n g exposure t o an i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t as i n d i c a t e d i n t h e p a t i e n t s ! p e r s o n a l d i a r i e s . The s c o r e s o f t h e p a t i e n t s ' s e l f r e p o r t o f t h e i r g e n e r a l sense o f w e l l - b e i n g were i n s p e c t e d f o r change o v e r u n i t time. No s t a t i s t i c a l measure was a p p l i e d . In t h r e e p a t i e n t s t h e r e was a d e f i n i t e i n d i c a t i o n toward i n c r e a s e d r e p o r t e d w e l l - b e i n g . One p a t i e n t m a i n t a i n e d an "average" w e l l - b e i n g and the o t h e r p a t i e n t m a i n t a i n e d a " f a i r to poor" w e l l - b e i n g t h r o u g h o u t the d a t a c o l l e c t i o n p e r i o d . 91 H y p o t h e s i s S i x The s i x t h h y p o t h e s i s was t h a t , There i s no c o r r e l a t i o n between the n u r s e s ' assessment o f t h e p a t i e n t s ' t r a i t a n x i e t y and the t r a i t a n x i e t y measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s . The s c o r e s ^ o f t he " t r a i t " p o r t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y were c o r r e l a t e d w i t h t he s c o r e s o f the n u r s e s ' assessment o f p a t i e n t s ' t r a i t a n x i e t y on the L i k e r t - t y p e s c a l e . T a b l e 4' l i s t s t h e raw s c o r e s . TABLE 4 SCORES OF THE "TRAIT" PORTION OF THE STATE-TRAIT ANXIETY INVENTORY AND SCORES OF THE NURSES' ASSESSMENT OF TRAIT ANXIETY STAI P a t i e n t 1 STAI Nurse P a t i e n t 2 STAI Nurse P a t i e n t 3 STAI Nurse P a t i e n t 4 STAI Nurse P a t i e n t 5 STAI Nurse DAY 1 50 1 36 1 LAST DAY 40 1 39 1 24 25 37 37 3 2 28 28 4 3 Key: STAI A r b i t r a r y I n t e r p r e t a t i o n o f Scores Low A n x i e t y 20 - 30 30 - 40 High A n x i e t y 40 - 80 Nurse 1 not a n x i o u s 2 f a i r l y a n x i o u s m o d e r a t e l y a n x i o u s 4 h i g h l y a n x i o u s e x t r e m e l y a n x i o u s A product-moment c o r r e l a t i o n c o e f f i c i e n t was u t i l i z e d to compare the v a r i a b l e s . A t n i n e degrees o f freedom, t h e v a l u e o f r was - 0.43. When the v a l u e o f r was compared to t h e c r i t i c a l v a l u e s o f r a t the .05 l e v e l o f s i g n i f i c a n c e f o r a o n e - t a i l e d t e s t , t he c o r r e l a t i o n was not s i g n i f i c a n t . T h e r e f o r e , t he n u l l h y p o t h e s i s was not r e j e c t e d . There was I 92 an i n v e r s e c o r r e l a t i o n between the s c o r e s o f the " t r a i t " p o r t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y and the n u r s e s ' assessment o f t r a i t a n x i e t y . H y p o t h e s i s Seven The s e v e n t h h y p o t h e s i s was t h a t , There i s no c o r r e l a t i o n between the n u r s e s ' assessment o f the p a t i e n t s ' s t a t e a n x i e t y and the s t a t e a n x i e t y measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s . The s c o r e s o f the " s t a t e " p o r t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y were c o r r e l a t e d w i t h the s c o r e s o f t h e n u r s e s ' assessment o f the p a t i e n t s ' s t a t e a n x i e t y . T a b l e 5.. l i s t s t he raw s c o r e s . TABLE 5} SCORES OF THE "STATE" PORTION OF THE STATE-TRAIT ANXIETY INVENTORY AND SCORES OF THE NURSES' ASSESSMENT OF STATE ANXIETY STAI P a t i e n t 1 STAI Nurse DAY 1 '46 2 LAST DAY 48 2 P a t i e n t 2 STAI Nurse 30 32 3 4 P a t i e n t 3 STAI Nurse 30 21 3 4 P a t i e n t 4 STAI Nurse 71 22 2 4 P a t i e n t 5 STAI Nurse 52 . 3 36 1 Key: STAI Nurse A r b i t r a r y I n t e r p r e t a t i o n o f Scores Low A n x i e t y 20 - 30 1 not anxious 2 f a i r l y a n x i o u s s 30 40 m o d e r a t e l y a n x i o u s High A n x i e t y 40 - 80 4 h i g h l y a n x i o u s e x t r e m e l y a n x i o u s A product-moment c o r r e l a t i o n c o e f f i c i e n t was u t i l i z e d to compare the v a r i a b l e s . A t n i n e degrees o f freedom, the v a l u e o f r was - 0.590. When the v a l u e o f r was compared t o t h e c r i t i c a l v a l u e s o f r a t t h e .05 l e v e l 93 o f s i g n i f i c a n c e f o r a o n e - t a i l e d t e s t , the c o r r e l a t i o n was not s i g n i f i c a n t . T h e r e f o r e , the n u l l h y p o t h e s i s was not r e j e c t e d . There was an i n v e r s e c o r r e l a t i o n between the s c o r e s o f the " s t a t e " p o r t i o n o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y and the n u r s e s ' assessment o f s t a t e a n x i e t y . By i n s p e c t i o n , i t was o b v i o u s t h a t t h e nurses d i d not a s s e s s a s i m i l a r amount o f a n x i e t y i n burn p a t i e n t s as measured by the S t a t e - T r a i t A n x i e t y I n v e n t o r y . The s t a t i s t i c a l c o r r e l a t i o n o f - .43 bears t h i s o u t . P o s s i b l e e x p l a n a t i o n f o r t h i s i n c l u d e the f a c t t h a t the nurse assessment t o o l was not v a l i d a t e d o r t e s t e d f o r r e l i a b i l i t y . Thus, the c l i n i c a l assessment o f a n x i e t y , as measured by t h e S t a t e - T r a i t A n x i e t y I n v e n t o r y , as compared w i t h the c l i n i c a l assessment o f a n x i e t y as measured by t h e L i k e r t - t y p e s c a l e d e v e l o p e d f o r the n u r s e s , may not r e p r e s e n t an i n a b i l i t y o f e i t h e r t o o l to r e f l e c t c l i n i c a l assessment o f a n x i e t y . T h i s whole t o p i c i s a study i n i t s e l f . N u r s i n g a b i l i t y t o a s s e s s a n x i e t y v e r s u s the a b i l i t y o f a f o r m a l i z e d w r i t t e n a n x i e t y assessment s c a l e t o a s s e s s p a t i e n t a n x i e t y was beyond the scope o f t h i s study. P s y c h o l o g i c a l Phases o f Burn Care  i n H o s p i t a l i z e d P a t i e n t s The s u b j e c t s were s t u d i e d i n t e n s i v e l y on a d a i l y b a s i s o v e r the p e r i o d o f t h e i r h o s p i t a l i z a t i o n . P s y c h o l o g i c a l r e s p o n s e t o the burn i n j u r y v a r i e d markedly. Each p a t i e n t passed through s i m i l a r "phases." A l t h o u g h a small sample was s t u d i e d , c e r t a i n t r e n d s were e v i d e n t from t h i s s t u d y . P a t i e n t s ' comments about v a r i o u s s o u r c e s o f a n x i e t y were r e p e a t e d t h r o u g h o u t the c o u r s e o f the d a t a c o l l e c t i o n p e r i o d . T h e r e f o r e , the f o l l o w i n g r e p o r t o f the f i n d i n g s w i l l be p r e s e n t e d under v a r i o u s p s y c h o l o g i c a l phases o f burn c a r e . 94 D e p e r s o n a l i z a t i o n Phase In the i n i t i a l r e a c t i o n t o burn i n j u r y , the p a t i e n t s passed t h r o u g h a phase i n which they d i s e n g a g e d themselves from the f a c t s o f the r s i t u a t i o n . The p a t i e n t s seemed t o f u n c t i o n as i f the s i t u a t i o n had not happened t o them p e r s o n a l l y . For the f i r s t few days, the p a t i e n t s were r a r e l y t r o u b l e d about the f u t u r e appearance, d e f o r m i t y o r p o s s i b l e m a l f u n c t i o n o f a l i m b . T h e i r c o n c e r n s l a y i n the s t r a n g e n e s s o f the burn u n i t i t s e l f . They were most anxious t o know about the e x p e c t e d l e n g t h o f h o s p i t a l i z a t i o n . The most prominent s o u r c e o f a n x i e t y a t t h i s time was f e a r o f t h e unknown. Not knowing what t o e x p e c t and l a c k o f i n f o r m a t i o n about what was going t o happen t o them caused t h e s e p a t i e n t s g r e a t a n x i e t y . One p a t i e n t ' s e y e l i d s were so s w o l l e n on a d m i s s i o n t o the burn u n i t , he c o u l d not see. He j u d g e d time by h i s burn bath s c h e d u l e , the human t r a f f i c i n the h a l l w a y and the a u t o m o b i l e t r a f f i c o u t s i d e . Not knowing what was happening to him and what t r e a t m e n t was t o come next c o n c e r n e d him. On a d m i s s i o n , one p a t i e n t seemed e x t r e m e l y nervous and h y p e r s e n s i t i v e to her c i r c u m s t a n c e s . For the next week, she s l e p t a g r e a t deal d u r i n g the day. The n u r s e s ' n o t e s r e p o r t e d a l a c k o f a p p e t i t e and a p p a r e n t c o n f u s i o n when awake. Then, she became more a l e r t , o r i e n t e d and her a p p e t i t e i n c r e a s e d . She e x p l a i n e d to. the i n v e s t i g a t o r t h a t "by s h u t t i n g h e r s e l f o f f " from her s u r r o u n d i n g s , her "body was a b l e t o c a t c h up" t o her " s o u l . " S h o r t l y a f t e r a d m i s s i o n to h o s p i t a l , a l l the p a t i e n t s seemed t o have a need to v e r b a l i z e , r e v i e w and a n a l y z e the events s u r r o u n d i n g the a c c i d e n t . Two p a t i e n t s v e n t i l a t e d t h e i r f r u s t r a t i o n about t h e i r own c a r e l e s s n e s s f o r the cause o f the a c c i d e n t . The o t h e r p a t i e n t s a c c e p t e d the m i s f o r t u n e o f t h e i r w o r k - r e l a t e d a c c i d e n t s as " f a t e . " R e a c t i v e - D e n i a l Phase L a t e n t r e a c t i o n t o burn i n j u r y was marked by i n a p p r o p r i a t e emotional r e a c t i o n s t o s e l f , s t a f f and s u r r o u n d i n g s t h a t were unfounded as f a r as t h e r e a l s i t u a t i o n went. The i n v e s t i g a t o r o b s e r v e d t h a t t h e s e p a t i e n t s d i d not f u l l y e x p r e s s an emotional upheaval i n r e a c t i o n t o t h e i r burn i n j u r y . A t f i r s t , a l l the p a t i e n t s seemed too a c c e p t i n g o f and n o n c h a l a n t about t h e i r i n j u r y . Then, a few days a f t e r a d m i s s i o n t o h o s p i t a l , t h e s e p a t i e n t s seemed aware o f the r e a l i t y o f t h e i r s i t u a t i o n and began t o employ v a r i o u s p s y c h o l o g i c a l d e f e n s e mechanisms. 10 9 S c h l i c t m a n n s u b s t a n t i a t e d t h i s i n v e s t i g a t o r ' s o b s e r v a t i o n . The p r i n c i p a l f i n d i n g s o f S c h l i c t m a n n ' s study c o n c u r r e d w i t h t h e c o n c l u s i o n s found i n the l i t e r a t u r e r e l a t e d t o ^ a d a p t a t i o n t o s t r e s s and p s y c h o l o g i c a l impact brought on by burn i n j u r i e s . Persons r e a c t e d to s t r e s s , f i r s t , by m i n i m i z i n g the impact o f the s i t u a t i o n , t h e n , as t h e y became aware o f r e a l i t y , i n i t i a l e motional r e a c t i o n s were r e p l a c e d by mechanisms t h a t f a c i l i t a t e d r e c o v e r y . The r e a c t i o n o f t h e f i r s t p a t i e n t t o h i s burn i n j u r y o v e r h i s p e r i o d o f r e c o v e r y f l u c t u a t e d g r e a t l y . By the t h i r d day a f t e r a d m i s s i o n t o the burn u n i t , the n u r s e s ' notes r e p o r t e d the p a t i e n t as b e i n g a n x i o u s , S c h l i c t m a n n , " A d a p a t i v e Mechanisms In a S e l e c t e d Group o f Burned P a t i e n t s , " p.379. 96 a p p r e h e n s i v e and v e r y concerned about h i m s e l f . He became s u s p i c i o u s o f t h e n u r s i n g s t a f f and u p s e t f o r not b e i n g t o l d the t y p e o f m e d i c a t i o n s he was r e c e i v i n g . He r e q u e s t e d a n a l g e s i c s c o n s t a n t l y and wondered i f o t h e r burn p a t i e n t s have as much p a i n as he had. The next day, t h e n u r s e s ' notes r e p o r t e d t h e p a t i e n t as b e i n g h o s t i l e , s a r c a s t i c , d e p r e s s e d , s e e k i n g a t t e n t i o n and f e e l i n g v e r y s o r r y f o r h i m s e l f . At the b e g i n n i n g o f t h e data c o l l e c t i o n p e r i o d , t h i s p a t i e n t seemed t o have r e g r e s s e d and had become v e r y dependent on the n u r s i n g s t a f f . L a t e r , when s e l f - c a r e and independence were encouraged, he v e r b a l l y l a s h e d o u t a t t h e n u r s e s . He f e l t t h a t t h e s t a f f were a g a i n s t him. At the b e g i n n i n g o f the d a t a c o l l e c t i o n p e r i o d , t h e second p a t i e n t seemed t o deny the s e v e r i t y o f , not o n l y h i s g r o s s l y i n f e c t e d b u r n s , but a l s o t h e p a i n he was e x p e r i e n c i n g . A l t h o u g h he seemed ve r y b l a s e and n o n c h a l a n t to t h e i n v e s t i g a t o r , t h e n u r s e s ' notes r e p o r t e d t h a t t h i s p a t i e n t was e x t r e m e l y a n x i o u s . A l t h o u g h he was h y p e r v e n t i l a t i n g b e f o r e t r e a t m e n t was i n i t i a t e d , he d i d not v e r b a l l y r e a c t to p a i n . However, the " s t a t e " s c o r e s o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y i n d i c a t e d a low a n x i e t y l e v e l . L a t e r , he began t o f r e e l y d i s c u s s h i s f r u s t r a t i o n and anger about h i s p r e v i o u s h o s p i t a l c a r e . Moreover, h i s c o n v e r s a t i o n became l e s s i n h i b i t e d . ; He began t o r e a l i z e the s e r i o u s n e s s o f h i s i n f e c t e d burn and t o v e r b a l l y r e a c t t o the p a i n he was e x p e r i e n c i n g . The t h i r d p a t i e n t c o n s i s t e n t l y seemed t o be i n c o n t r o l o f h i m s e l f and o f h i s r e c o v e r y e x p e r i e n c e . He seemed v e r y a c c e p t i n g o f h i s burn i n j u r y and t h e r e f o r e h i s emotions d i d not f l u c t u a t e w i d e l y . On a d m i s s i o n t o the burn u n i t , t h e f o u r t h p a t i e n t was e x t r e m e l y a n x i o u s , t e n s e and r e g r e t f u l . As s t a t e d p r e v i o u s l y , h i s i n i t i a l c o n c e r n was the proposed l e n g t h o f h o s p i t a l i z a t i o n and not knowing what was g o i n g to happen to him. Then, he became c o n c e r n e d about the f u t u r e appearance and f u n c t i o n i n g o f h i s hand, e s p e c i a l l y i n r e l a t i o n to h i s l i n e o f work. The f i f t h p a t i e n t was a l s o e x t r e m e l y a n x i o u s and t e n s e on a d m i s s i o n to h o s p i t a l . Her i n i t i a l c o n c e r n about the l e n g t h o f h o s p i t a l i z a t i o n was t h e same as the f o u r t h p a t i e n t ; t h e n , her main concern, was t h e depth o f burn and the p o s s i b i l i t y o f s k i n g r a f t i n g . I t was d u r i n g t h i s l a t e n t r e a c t i o n t o burn i n j u r y t h a t some p a t i e n t s began t o e x p e r i e n c e nightmares about t h e i r a c c i d e n t . D u r i n g t he f i r s t week o f h i s r e c o v e r y , t he t h i r d p a t i e n t was p l a g u e d w i t h n i g h t m a r e s . He r e l i v e d the a c c i d e n t when the memory o f i t would f l a s h t h r o u g h h i s mind. I t was h e l p f u l when he c o u l d t a l k about the nightmare t o the n u r s e s . They were a b l e to r e - o r i e n t him t o h i s p r e s e n t s u r r o u n d i n g s when he was awakened d u r i n g t h e n i g h t . The f i r s t p a t i e n t had r e - o c c u r r i n g v i v i d dreams about the a c c i d e n t , but not nigh t m a r e s . A t t i m e s , he would wake up a t n i g h t , r e l i v i n g the a c c i d e n t . The second p a t i e n t s t a t e d t h a t t h o u g h t s o f t h e a c c i d e n t would awaken him momentarily d u r i n g t he n i g h t . These t h r e e p a t i e n t s ' a c c i d e n t s o c c u r r e d a t work and i n v o l v e d a g r e a t deal o f trauma. W i l l i a m s ^ r e p o r t e d t h a t a n x i e t y i s hi g h a t n i g h t when t h e p a t i e n t i s a l o n e , making i t d i f f i c u l t f o r him to a c q u i r e h i s usual amount o f dreaming s l e e p . T h e r e f o r e , p a t i e n t s c o m p l a i n o f ni g h t m a r e s . Barbara W i l l i a m s , "The Burned P a t i e n t s ' Need f o r T e a c h i n g , " N u r s i n g  C l i n i c s o f North America 6 (December 1971), p. 625. Davidson a l s o r e p o r t e d t h a t many p a t i e n t s i n her study e x p r e s s e d a wish t o escape thr o u g h s l e e p but were p l a g u e d by f r e q u e n t nightmares which i n v o l v e d v i v i d r e l i v i n g o f t h e a c c i d e n t . R e a l i t y T e s t i n g Phase S e v e r a l times d u r i n g t h e i r r e c o v e r y , the p a t i e n t s s e t g o a l s and r e a l i z e d t h e i r p e r s o n a l l i m i t s i n r e l a t i o n t o t h e demands o f burn t r e a t m e n t . T h i s r e a l i t y t e s t i n g was u s u a l l y r e l a t i v e t o p a i n as p a i n was the predominant f o r c e i n the burn p a t i e n t s ' l i v e s w i t h appearance o f the burn wound as a p o s s i b l e secondary f o r c e . However, co n c e r n about f u t u r e appearance o f t h e s c a r t i s s u e was more a p p a r e n t upon d i s c h a r g e . In the r e a l i t y t e s t i n g phase, the g r e a t e s t potentiates o f p a i n and e n s u i n g a n x i e t y were t h e v a r i o u s burn t r e a t m e n t s . T h e r e f o r e , t h e s e w i l l be d i s c u s s e d i n r e l a t i o n t o the p a i n e x p e r i e n c e d . The n a t u r e and s e v e r i t y o f p a i n v a r i e d c o n s i d e r a b l y w i t h burn p a t i e n t s . Some p a t i e n t s e x p e r i e n c e d t h e i r worst p a i n i n donor s i t e s a f t e r 112 a u t o g r a f t i n g . However, i n t h i s s t u d y , t h e p a t i e n t s c o m p l a i n e d o f i n t o l e r a b l e p a i n d u r i n g d r e s s i n g changes and debridement d u r i n g b a t h i n g . M a i n t a i n i n g t h e i r d i s t r e s s from p h y s i c a l p a i n w i t h i n manageable l i m i t s was a goal s e t by a l l t h e p a t i e n t s d u r i n g t h e i r r e c o v e r y p e r i o d . The t h i r d p a t i e n t d e s c r i b e d h i s p a i n e x p e r i e n c e i n v i v i d d e t a i l . He c o u l d not compare the p a i n t o any he had s u f f e r e d b e f o r e . At t i m e s , he would t h i n k t h a t h i s p a i n t h r e s h o l d had been reached but he was always a b l e D a v i d s o n , " N u r s i n g Management o f Emotional R e a c t i o n s o f S e v e r e l y Burned P a t i e n t s During t h e Acute Phase," p. 371. 2 I b i d . , p. 373. 99 a. t o "put up w i t h i t a l i t t l e l o n g e r . " He d e s c r i b e d t h r e e t y p e s o f p a i n : 1) a deep t h r o b b i n g p a i n which f e l t s e a r i n g and b u r n i n g on t h e s u r f a c e , 2) t h e t i n g l i n g " p i n s and n e e d l e s " p a i n when h i s burns were exposed t o a i r , 3) the " n i c e , " " a c c e p t a b l e " d u l l g e n e r a l ache a f t e r the s k i n g r a f t s had been a p p l i e d . P a i n was a c c e n t u a t e d when he c o u l d not see due to h i s s w o l l e n e y e l i d s and h i s a n x i e t y was h e i g h t e n e d due to f e a r o f t h e unknown. When he was a b l e t o see a g a i n , he was amazed t h a t he l o o k e d b e t t e r than he had thou g h t . At t h i s t i m e , the p a i n became more d u l l . F o r t h i s p a t i e n t , w a i t i n g i n a n t i c i p a t i o n o f the p a i n o f t r e a t m e n t s was t h e worst p a r t o f each day. He would be d e p r e s s e d i n the morning, wondering how s e v e r e t h e p a i n would be. H i s day was c o l o u r e d by the p a i n e x p e r i e n c e d i n the burn bath. I f t h e r e was b e a r a b l e p a i n , h i s s p i r i t s would l i f t and he would be i n a good mood. , Now he knew t h a t t h e worst, p a i n was ov e r f o r t h a t day. The second p a t i e n t d e n i e d the s e v e r i t y o f the p a i n he was e x p e r i e n c i n g d u r i n g t he f i r s t week o f the dat a c o l l e c t i o n p e r i o d . However, the n u r s e s ' notes r e p o r t e d t h a t t he p a t i e n t was e x t r e m e l y a n x i o u s and h y p e r v e n t i l a t i n g d u r i n g t r e a t m e n t s . The n u r s e s ' notes a l s o r e p o r t e d t h a t t h e p a t i e n t d i d not v e r b a l l y r e a c t t o p a i n . L a t e r , i n t h e dat a c o l l e c t i o n p e r i o d , t h i s p a t i e n t began to v i v i d l y d e s c r i b e h i s f e a r f u l a n t i c i p a t i o n o f t h e p a i n f u l t r e a t m e n t s . He dreaded t h e t r e a t m e n t f o r an hour b e f o r e i t took p l a c e . H i s mouth became v e r y d r y as he h y p e r v e n t i l a t e d . S i n c e he was i n c o n s t a n t p a i n f o r two hours a f t e r w a r d s , he was unable to c o n c e n t r a t e o r even c o n v e r s e 99 b w i t h h i s w i f e . However, when the nurses t a l k e d to him and d e s c r i b e d h i s p r o g r e s s d u r i n g t r e a t m e n t s , he f e l t t h a t he had some c o n t r o l o v e r h i s p a i n and had a goal t o l o o k f o r w a r d t o . ' The f i r s t p a t i e n t spoke o f t e n o f h i s p a i n e x p e r i e n c e which he a l s o d e s c r i b e d v i v i d l y . I t was t h e most p r e v a l e n t and predominant f a c t o r which a f f e c t e d him p h y s i c a l l y and e m o t i o n a l l y . T h i s p a t i e n t seemed to be a f r a i d o f the p a i n t h a t t he t r e a t m e n t s c r e a t e d r a t h e r than t he t r e a t m e n t s p e r se. He wrote i n h i s d i a r y , " I am not a^fiald o^ my tA.zatmo.nti>, I know what tkzy an.z; I am uAzd to thzm and I know tkzy wWL heJLp me. Bat, I gzt a fuxbh ofa fazon. - a fazon. o{ pain, that As t he p a i n s u b s i d e d o r became more t o l e r a b l e , h i s d i s p o s i t i o n changed p o s i t i v e l y . N e i t h e r the f o u r t h o r f i f t h p a t i e n t s d e s c r i b e d t h e i r p a i n e x p e r i e n c e v i n any d e t a i l . They d i d not deny t h a t p a i n was p r e s e n t , but they p r e f e r r e d hot t o re v i e w t h e i r p a i n e x p e r i e n c e . Perhaps t h e p a t i e n t s ' r e a c t i o n s t o t h e i r p a i n e x p e r i e n c e c o u l d be r e l a t e d to t h e t e r m i n o l o g y t h e y used t o d e s c r i b e t h e i r s u r g e r y . The second p a t i e n t r e p e a t e d l y r e f e r r e d t o h i m s e l f as a wounded animal b e i n g " s k i n n e d , " " c a r v e d up" o r " s c a l p e l e d " ( c u t w i t h t he s c a l p e l ) . The t h i r d p a t i e n t r e f e r r e d t o h i m s e l f as b e i n g " c u t down t o t h e meat." These two p a t i e n t s were ve r y d e s c r i p t i v e o f t h e i r p a i n e x p e r i e n c e and c o n s i s t e n t l y a n a l y z e d t h e i r p a i n t o t h e i n v e s t i g a t o r . The e f f e c t s o f the v a r i o u s t r e a t m e n t s were s i m i l a r i n a l l o f t h e p a t i e n t s . T h e i r e m o t i o n a l s t a t u s and mood were dependent on the phase o f tr e a t m e n t t h a t was b e i n g a d m i n i s t e r e d . O b v i o u s l y , some t r e a t m e n t s were more p a i n f u l than o t h e r s . The f o l l o w i n g e f f e c t s o f t r e a t m e n t s t r e s s w i l l 100 be p r e s e n t e d i n the sequence t h a t they u s u a l l y o c c u r d u r i n g burn c a r e . The Burn Bath G e n e r a l l y , the p a t i e n t s enjoyed the burn bath ( o r w h i r l p o o l arm bath i n t h e case o f hand i n j u r i e s ) . They s t a t e d t h a t t h e y f e l t c l e a n a f t e r some o f the c o l l a g e n and exudate were removed. Moreover, t h e bath was r e l a x i n g and s o o t h i n g . However, the f i r s t p a t i e n t c o n s i d e r e d t h e debridement o f dead t i s s u e d u r i n g the baths and subsequent exposure o f t h e burn wound as t h e most p a i n f u l p a r t o f the t r e a t m e n t . The second and t h i r d p a t i e n t s c o n s i d e r e d t h e i r f i r s t burn bath as v e r y t r a u m a t i c because t h e y d i d n o t u n d e r s t a n d what was about t o o c c u r . The t h i r d p a t i e n t s u g g e s t e d t h a t , s i n c e the burn baths were the worst p a r t o f the t r e a t m e n t phase, some method o f d i v e r s i o n be employed. The s i g h t o f h i s wounds b e i n g d e b r i d e d was p a i n f u l p h y s i c a l l y and e m o t i o n a l l y . A l t h o u g h t h i s s i g h t was a l l he c o u l d c o n c e n t r a t e on, he r e a l i z e d t h a t the more h i s wounds were d e b r i d e d , t h e f a s t e r they would h e a l . The f o u r t h p a t i e n t a l s o c o n f i r m e d t h a t debridement d u r i n g h i s arm baths was t h e most p a i n f u l p r o c e d u r e . The f i f t h p a t i e n t e n j o y e d her baths because the d r e s s i n g s were a l l o w e d to soak o f f . D u r i n g the p r e p a r a t i o n f o r and d u r i n g t h e b a t h , the t h i r d p a t i e n t found the s e n s a t i o n o f a l t e r n a t i n g warm and c o o l d i s t r e s s i n g . Exposure t o a c o o l h a l l w a y from a warm room t o a warm bath and back t o t h e c o o l a i r a g a i n was u n c o m f o r t a b l e . Other p a t i e n t s a l s o complained o f s h i v e r i n g d u r i n g r e - a p p l i c a t i o n o f d r e s s i n g s a f t e r the b a t h . They a l l wished more time had been a l l o w e d to soak and r e l a x i n the b a t h . 101 The Compresses The " s t a t e " s c o r e s o f the S t a t e - T r a i t A n x i e t y I n v e n t o r y r o s e d r a m a t i c a l l y f o r most o f the p a t i e n t s when compress t r e a t m e n t was i n i t i a t e d i n p r e p a r a t i o n f o r s k i n g r a f t i n g . The d r e s s i n g changes were not o n l y e x t r e m e l y p a i n f u l , but they .were a l s o c a r r i e d on t h r o u g h o u t t h e n i g h t , t h e r e b y d i s t u r b i n g s l e e p . The f i r s t p a t i e n t commented t h a t h i s compresses were p a i n f u l but t o l e r a b l e . The p a t i e n t f e l t h i s body a d j u s t t o the b e a r a b l e p a i n . The p a i n e x p e r i e n c e d seemed t o depend on which nurse changed h i s d r e s s i n g s . Her a b i l i t y t o r e a l i z e when h i s p a i n t h r e s h o l d had been re a c h e d was v e r y i m p o r t a n t i n h i s o p i n i o n . The second p a t i e n t e x h i b i t e d an e x t r e m e l y anxious r e a c t i o n t o t h e p a i n o f the compress t r e a t m e n t , as d e s c r i b e d p r e v i o u s l y . He t r i e d to use a mental r e l a x a t i o n t e c h n i q u e t o d i v e r t h i s a t t e n t i o n from t he p a i n , however, he soon l o s t h i s c o n c e n t r a t i o n w i t h t h i s t e c h n i q u e . His s t a t e o f a n x i e t y and emotional d i s p o s i t i o n f l u c t u a t e d i n r e l a t i o n t o the t y p e o f t r e a t m e n t he was r e c e i v i n g . The t h i r d p a t i e n t , who demonstrated unusual c o n t r o l t h r o u g h o u t h i s h o s p i t a l i z a t i o n , had e x t e n s i v e compress t r e a t m e n t . I t was noted by the i n v e s t i g a t o r t h a t , g e n e r a l l y , t h e r e was l i t t l e e f f e c t o f t r e a t m e n t s t r e s s on t h i s p a t i e n t . He coped c o n s i d e r a b l y w e l l w i t h t h e t r e a t m e n t s and t h e p a i n e x p e r i e n c e . A l t h o u g h he d i d s t a t e t h a t debridement i n the burn bath and d u r i n g compress changes were u n b e a r a b l y p a i n f u l , t h i s p a t i e n t d i d n o t o v e r t l y e x p r e s s s u f f e r i n g from p a i n . The f o u r t h p a t i e n t d i d not have e x t e n s i v e compress t r e a t m e n t . When he d i d undergo t h i s t r e a t m e n t p o s t - o p e r a t i v e l y , he r e p e a t e d t he same 102 comments as t h e o t h e r p a t i e n t s r e g a r d i n g u n b e a r a b l e p a i n and p r e - t r e a t m e n t a n x i e t y . The o n l y time he i n d i c a t e d i n h i s d i a r y t h a t he needed a n a l g e s i c s was d u r i n g compress changes s i n c e h i s wounds were now more p a i n f u l . The f i f t h p a t i e n t d i d not e x p r e s s p a i n e i t h e r o v e r t l y o r c o v e r t l y . She r e f u s e d a n a l g e s i c s even when her burns were compressed. I t was noted by t h e i n v e s t i g a t o r t h a t t h i s p a t i e n t ' s moods f l u c t u a t e d w i d e l y d u r i n g the c o u r s e o f r e c o v e r y . R e a l i z i n g t h a t compress t r e a t m e n t and subsequent s k i n g r a f t i n g meant a l o n g e r h o s p i t a l i z a t i o n , she became depr e s s e d and withdrawn. I t was d u r i n g t h e s e p e r i o d s o f d e p r e s s i o n she r e f u s e d a n a l g e s i c s . However, she d i d not e x p r e s s any untoward e f f e c t s from compress t r e a t m e n t . A r e a l q u e s t i o n i n the i n v e s t i g a t o r ' s mind was whether t h i s 60 y e a r o l d , f r i e n d l y , q u i e t , n o n - e x p r e s s i v e l a d y was not e x p e r i e n c i n g p a i n o r was d e n y i n g i t . S u r g i c a l P i n n i n g The i n s e r t i o n o f K-wires and subsequent s u s p e n s i o n o f an e x t r e m i t y (or e x t r e m i t i e s ) i n t r a c t i o n was a t r a u m a t i c e x p e r i e n c e f o r two o f t h e s e p a t i e n t s . Fear o f the unknown was p r e v a l e n t p r e - o p e r a t i v e l y . Both p a t i e n t s e x p r e s s e d t h e i r f e a r o f t h e p a i n w i t h a n t i c i p a t i o n o f s u r g i c a l p i n n i n g and a g a i n when t h e p i n s were about to be removed. At t h e s e t i m e s , t h e " s t a t e " s c o r e s o f the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s r o s e toward e l e v a t e d a n x i e t y . S l e e p l e s s n i g h t s and m e d i c a t i o n r e q u e s t s a l s o ensued. The i n v e s t i g a t o r f e l t t h a t " p i n n i n g " was p r o b a b l y the most e x a g g e r a t e d r e a c t i o n i n r e l a t i o n t o p a i n e x p e c t e d v e r s u s a c t u a l p a i n . The p a t i e n t s complained o f o n l y a d u l l ache when t h e i r limbs were 103 i n t r a c t i o n . One p a t i e n t r e i t e r a t e d a p o r t i o n o f t h e t a p e - s l i d e program when he l a t e r s a i d , "bone has no p a i n n e r v e s . " S k i n G r a f t i n g and R o l l i n g o f G r a f t s A f t e r p a i n f u l compress t r e a t m e n t s , the a p p l i c a t i o n o f s k i n g r a f t s was c o n s i d e r e d as a ' t u r n i n g p o i n t ' i n the r e c o v e r y phase f o r a l l o f t h e s e p a t i e n t s . One p a t i e n t t hought t h a t he would f e e l b e t t e r , see more day t o day improvement and f e e l l e s s p a i n . A n o t h e r p a t i e n t r e p o r t e d t h a t p a i n d i d l e s s e n c o n s i d e r a b l y a f t e r s k i n g r a f t i n g . However, donor a r e a p a i n was now more prominent. R e g a r d l e s s , h i s s p i r i t s l i f t e d because now he c o u l d see h i s wounds h e a l i n g . Donor s i t e p a i n w i t h s k i n g r a f t i n g i s p s y c h o l o g i c a l l y and r e a l i s t i c a l l y v e r y p a i n f u l . I t i s not p h y s i o l o g i c a l l y a c c u r a t e t h a t p a t i e n t s s h o u l d f i n d " p i n s " more p a i n f u l than the donor s i t e . There was no p a i n when the g r a f t s were r o l l e d ( t o remove exudate beneath t h e g r a f t ) , o n l y a t o l e r a b l e d u l l ache. One p a t i e n t s t a t e d he f e l t c o m f o r t a b l e w i t h t h i s ache because he had been thr o u g h the worst o f h i s p a i n e x p e r i e n c e . He f e l t t h a t h i s r e c o v e r y was " d o w n h i l l a l l t h e way now." He was "home f r e e . " T h i s phase o f h i s r e c o v e r y was a " w a i t i n g p e r i o d . " A n o t h e r p a t i e n t commented t h a t a f t e r s k i n g r a f t i n g , h i s p a i n was a b e a r a b l e t h r o b b i n g ache around h i s p i n s i t e s and a t the time o f r o l l i n g . His main c o n c e r n was t h e appearance o f the g r a f t s . A f t e r he was i nformed t h a t some a r e a s were n e c r o t i c and would have to be r e - g r a f t e d , he became ve r y d e p r e s s e d and angry a t t h e s t a f f . Moreover, he w o r r i e d about t h e a b i l i t y o f the new g r a f t s 'to t a k e . 1 104 Frequent r o l l i n g o f the g r a f t s , e s p e c i a l l y d u r i n g t h e n i g h t , r e s u l t e d i n i n t e r r u p t e d s l e e p and more r e q u e s t s f o r m e d i c a t i o n . However, a l l the p a t i e n t s r e a l i z e d the n e c e s s i t y f o r r o l l i n g and a c c e p t e d t h e p r o c e d u r e . Decompensation Phase In t h i s phase, the p a t i e n t s a d j u s t e d o v e r time to the ongoing s t r e s s e s o f t h e i r s i t u a t i o n . A f t e r the a c u t e s t a g e s o f v a r i o u s t r e a t m e n t s and a f t e r s k i n g r a f t s had been a p p l i e d t o the wound, t h e p a t i e n t s e n t e r e d i n t o t h i s phase o f r e c o v e r y one p a t i e n t termed as "the w a i t i n g p e r i o d . " Time seemed to pass s l o w l y a t t h i s s t a g e as compared t o the p r e v i o u s s t a g e s . Emotional t r e n d s were seen i n most o f t h e p a t i e n t s . P h i l o s o p h i z i n g Toward the end o f t h e data c o l l e c t i o n p e r i o d , the f i r s t p a t i e n t became p h i l o s o p h i c a l and i n t r o s p e c t i v e . He o f t e n wondered how t h i s e x p e r i e n c e would change h i s o u t l o o k on l i f e . In r e t r o s p e c t , he a n a l y z e d h i s p a i n e x p e r i e n c e and a n t a g o n i s t i c r e a c t i o n t o the n u r s e s . T h i s p a t i e n t a p o l o g i z e d f o r h i s p r e v i o u s a t t i t u d e toward the nurses and s t a t e d t h a t h i s antagonism must have been a phase he was g o i n g t h r o u g h . L a t e r , he thought o f h i s f u t u r e o u t s i d e o f the h o s p i t a l . He dreaded the p o s s i b i l i t y o f b e i n g i n a n o t h e r a c c i d e n t and o f h a v i n g t o go through t h i s e x p e r i e n c e a g a i n . The second p a t i e n t r e f e r r e d to t h i s e x p e r i e n c e as h i s "burn space" i n r e l a t i o n t o h i s t o t a l l i f e . E v e r y p a r t o f " l i f e has a space and t h i s burn space" had " b o u n d a r i e s " and was " f i n i t e . " L a t e r , he a g a i n r e f l e c t e d back o v e r the c o u r s e o f h i s r e c o v e r y and, i n g r e a t d e t a i l , a n a l y z e d t h e p a i n he had s u f f e r e d . S i n c e he had stopped smoking d u r i n g h i s h o s p i t a l i z a t i o n , he commented t h a t some good had r e s u l t e d from h i s a c c i d e n t . A n o t h e r p a t i e n t began t o r e a l i z e how l u c k y he was t o be a l i v e . N o thing c o u l d be a g r e a t problem compared t o what he had gone t h r o u g h . He s t a t e d , " n o t h i n g i s a n y t h i n g anymore a f t e r one r e a l i z e s t h a t he i s a l i v e a f t e r b e i n g t h o u g h t dead. L i f e can be s n u f f e d out so e a s i l y . L i f e cannot be r e p l a c e d . " The f i f t h p a t i e n t began to r e a l i z e the magnitude o f human s u f f e r i n g when peop l e a r e burned. She a l s o p h i l o s o p h i z e d about the c o n d i t i o n s s u r r o u n d i n g her c i r c u m s t a n c e s on the burn u n i t . Boredom and I s o l a t i o n A sense o f i s o l a t i o n and e n s u i n g boredom seemed to plague t h e s e p a t i e n t s d u r i n g the l a t t e r s t a g e s o f r e c o v e r y . Except f o r one p a t i e n t , a l l were nursed i n p r i v a t e rooms. The s i n g l e p a t i e n t s s u f f e r e d the most from l o n e l i n e s s , i s o l a t i o n and boredom. The f i r s t p a t i e n t f e l t d e t a c h e d from h i s environment and p r e - o c c u p i e d w i t h h i s own gloomy t h o u g h t s . He wished t h a t the nurses had time to s t a y and c o n v e r s e w i t h him o r t h a t he c o u l d be a l l o w e d to c o n v e r s e w i t h o t h e r p a t i e n t s . His sense o f c o n f i n e m e n t was overwhelming. He seemed to t h r i v e on v i s i t s w i t h the i n v e s t i g a t o r . The f o u r t h p a t i e n t , a l s o s i n g l e , complained about h i s r e s t r i c t e d movement a l l o w e d o n l y i n h i s room. He was p l e a s e d when he was a l l o w e d t o r o l l h i s own g r a f t s and r e l e a s e the t r a c t i o n on h i s K-wires i n o r d e r t o walk to the bathroom. T h i s gave him a sense o f mastery o v e r a small p o r t i o n o f h i s burn c a r e as w e l l as "something t o do." 106 I t was i n t e r e s t i n g t o note t h e s e men's r e a c t i o n s t o t r a n s f e r t o the e i g h t bed 'porch.' The second, t h i r d and f o u r t h p a t i e n t s became roomates at the end o f the d a t a c o l l e c t i o n p e r i o d . They seemed to e n j o y t a l k i n g to one a n o t h e r immensely as t h e y reviewed each o t h e r ' s c o u r s e o f t r e a t m e n t and r e c o v e r y . A 'men's c l u b 1 atmosphere was p r e v a l e n t . A l l wished t h e y c o u l d have been a b l e t o b o o s t each o t h e r ' s morale sooner. A l t h o u g h she was nursed i n the 'women's p o r c h , ' the f i f t h p a t i e n t a l s o spoke o f a sense o f i s o l a t i o n . She s t a t e d t h a t she f e l t " c u t o f f from the o u t s i d e l i f e . " A c t i v i t y i n t h i s open ward never c e a s e d . There seemed t o be too much s e n s o r y s t i m u l a t i o n . Sensory u n d e r l o a d as w e l l as s e n s o r y o v e r l o a d was a predominant f e a t u r e i n the r e c o v e r y o f t h i s burn p a t i e n t . Antagonism and Empathy The importance o f i n t e r p e r s o n a l dynamics between p a t i e n t and nurse are paramount. When p a t i e n t s a r e h o s p i t a l i z e d f o r a l e n g t h y p e r i o d o f t i m e , the p a t i e n t s ' r e l a t i o n s h i p w i t h t h e d o c t o r s , nurses and p h y s i o t h e r a p i s t s become q u i t e i n t e n s e . The nurse has s p e n t more time w i t h the p a t i e n t than anyone and p o t e n t i a l l y has t h e s t r o n g e s t i n f l u e n c e on the r e h a b i l i t a t i o n p r o c e s s . ^ 3 Y o u n g ^ 4 noted t h a t a r e l a t i o n s h i p e x i s t e d between the time the nurse has a v a i l a b l e to spend w i t h t h e burn p a t i e n t and the q u a l i t y o f the n u r s e - p a t i e n t r e l a t i o n s h i p . 113 I r v i n g F e l l e r e t a l , "The Team Approach t o T o t a l R e h a b i l i t a t i o n o f the S e v e r e l y Burned P a t i e n t , " Heart and Lung 2 (September/October 1973) p.706. 114 Karon Ann Young, " S t i g m a t i z a t i o n o f Burn P a t i e n t s , " J o u r n a l o f t h e  A s s o c i a t i o n o f O p e r a t i n g Room Nurses 20 (November 1974), p.806. 107 Young's comment seems t o be p a r t i c u l a r l y a p p l i c a b l e to the f i r s t p a t i e n t ' s r e l a t i o n s h i p w i t h h i s n u r s e s . He f e l t t h a t t h e n u r s e s d i d not have enough time t o t a l k t o him. However, he complained t h a t they were always "coming i n and d o i n g something." O b v i o u s l y , the q u a l i t y o f time and the q u a n t i t y o f time from t h i s p a t i e n t ' s p e r s p e c t i v e was i m p o r t a n t . He b e l i e v e d t h a t the n u r s i n g s t a f f d i s l i k e d him and he became v e r y a n t a g o n i s t i c towards them. I f a p a i n f u l t r e a t m e n t was t o be a d m i n i s t e r e d and he d i d n ' t get a l o n g w i t h the nurse t h a t day, he s u f f e r e d more p a i n d u r i n g t h e t r e a t m e n t . When s e l f - c a r e and independence were encouraged, he v e r b a l l y l a s h e d out a t the nurses and f e l t t h a t the s t a f f were a g a i n s t him. As the day o f d i s c h a r g e approached, he a p o l o g i z e d f o r h i s p r e v i o u s a t t i t u d e toward the n u r s e s . He s t a t e d t h a t h i s antagonism must have been a phase he was g o i n g t h r o u g h . The second p a t i e n t d i d not comment about h i s r e l a t i o n s h i p w i t h the s t a f f . As a f a r e w e l l g i f t , he drew a c a r t o o n d e p i c t i n g the nurses as 'angels o f mercy.' The t h i r d p a t i e n t c l e a r l y i n d i c a t e d t o the i n v e s t i g a t o r who h i s f a v o u r i t e nurses were. He .had g r e a t c o n f i d e n c e i n t h e i r a b i l i t y t o m i n i m i z e p a i n w i t h s k i l l and s e n s i t i v i t y toward h i s p a i n t o l e r a n c e . These n u r s e s knew when h i s p a i n t h r e s h o l d had been r e a c h e d and would t h e r e f o r e s t o p debridement o f the wound. The n u r s e s who t a l k e d to him d u r i n g d r e s s i n g changes worked w i t h him. Her a c c e p t a n c e o f h i s i n s t r u c t i o n s about which method o f d r e s s i n g change was the l e a s t p a i n f u l a l l o w e d him t o have some c o n t r o l o v e r h i s p a i n and t r e a t m e n t . I f the nurse was w i l l i n g t o be f l e x i b l e i n t h i s way, the p a t i e n t d i d not a n t i c i p a t e h i s t r e a t m e n t w i t h the same f e a r . 108 When h i s s k i n g r a f t s d i d not 'take,' the f o u r t h p a t i e n t v e r b a l l y h a r r a s s e d t he d o c t o r and n u r s e s . He e x p r e s s e d a g r e a t deal o f anger a g a i n s t t he s t a f f a t t h i s t i m e . However, when i t was a p p a r e n t t h a t the new replacement g r a f t s were h e a l t h y , he p r a i s e d the s t a f f h i g h l y . A t no time d i d the p a t i e n t i n d i c a t e f e a r o f h i s t r e a t m e n t s . In f a c t , he l o o k e d f o r w a r d t o t a l k i n g t o " t h o s e g o o d - l o o k i n g n u r s e s . " D i s c h a r g e A n x i e t y In t h r e e c a s e s , t he p a t i e n t s ' a n x i e t y l e v e l s r o s e when n o t i f i e d o f t h e i r d i s c h a r g e day. The c o n c e r n s o f t h e s e p a t i e n t s r e v o l v e d around the appearance o f the s c a r t i s s u e and the s o c i a l a c c e p t a n c e o f the J o b s t ^ e l a s t i c garment on t h e p a r t o f t h e i r f r i e n d s . The f i r s t p a t i e n t t o l d t h e n u r s e s and the i n v e s t i g a t o r t h a t he was anx i o u s about l e a v i n g the s e c u r i t y o f the burn u n i t . R o u t i n e s had become p r e d i c t a b l e . He was a f r a i d o f the " o u t s i d e w o r l d " and the p o s s i b i l i t y o f a n o t h e r i n j u r y . Moreover, t he f a c t t h a t he would have to wear t h e J o b s t g l o v e f o r a t l e a s t a y e a r and r e f r a i n from l y i n g i n t h e sun b o t h e r e d him. T h i s a l t e r a t i o n i n body image was t h r e a t e n i n g . He w o r r i e d about t he appearance o f h i s s c a r s t o o t h e r p e o p l e , e s p e c i a l l y h i s g i r l f r i e n d . The g l o v e and s c a r s would be a c o n s t a n t reminder o f h i s i n j u r y . A l t h o u g h t he second p a t i e n t ' s " s t a t e " s c o r e on the S t a t e - T r a i t A n x i e t y I n v e n t o r y r e v e a l e d a low a n x i e t y l e v e l , and he d e n i e d f e e l i n g a n x i o u s , t h i s p a t i e n t seemed v e r y r e s t l e s s and f i d g i t y . The n u r s e s ' notes r e p o r t e d t h a t he appeared a p p r e h e n s i v e about h i s d i s c h a r g e . A t f i r s t , t h e f o u r t h p a t i e n t was c o n c e r n e d about t he appearance o f h i s g r a f t e d hand t o o t h e r p e o p l e : A l t h o u g h he i n q u i r e d about the purpose 109 (Hi and appearance o f the J o b s t w g l o v e , he l a t e r d e n i e d c o n c e r n about the g l o v e o r the appearance o f h i s rough s c a r t i s s u e . A f t e r s k i n g r a f t s had been a p p l i e d t o her wounds, the f i f t h p a t i e n t r e f e r r e d to the h e a l i n g a r e a as "an u n s i g h t l y mess." She was w o r r i e d about the appearance o f the s c a r t i s s u e , e s p e c i a l l y when she went swimming. I t was a p p a r e n t t h a t c o n c e r n s about a l t e r a t i o n i n body image and s o c i a l a c c e p t a b i l i t y o f the burn s c a r s were p r e v a l e n t a t the time o f d i s c h a r g e . The n e c e s s i t y o f wearing an e l a s t i c g l o v e f o r a y e a r was a t h r e a t e n i n g f o r e c a s t . In t h e h o s p i t a l , t h e s e p a t i e n t s were s e c u r e w i t h the s t a f f who showed no qualms o r " d i s g u s t " a t t h e i r " u n s i g h t l y mess," as one p a t i e n t termed her s k i n g r a f t s . Now, t h e s e p a t i e n t s were about to l e a v e t he s e c u r i t y o f the h o s p i t a l and e n t e r t he environment o f f r i e n d s , f a m i l y and s t r a n g e r s . The q u e s t i o n predominant i n t h e i r thoughts was, " w i l l p e o p l e t u r n away when they see the g l o v e and burn s c a r s ? " . D i s c u s s i o n o f the F i n d i n g s The c o n c e p t o f the c h a n g i n g i n t e n s i t y o f a n x i e t y i n response t o burn i n j u r y and t r e a t m e n t was an i m p o r t a n t f i n d i n g i n t h i s s t u d y . There appeared t o be a t h r e s h o l d o f a n x i e t y , unique t o each p a t i e n t , b e y o n d which de f e n s e mechanisms were c a l l e d i n t o p l a y . T h e r e f o r e , the f o l l o w i n g d i s c u s s i o n w i l l be p a r t i a l l y based on the r e p o r t o f the f i n d i n g s and p r e s e n t e d as b e h a v i o r a l r e s p o n s e s o f burn p a t i e n t s t o a l t e r a t i o n i n body image, l o n e l i n e s s and s e n s o r y d e p r i v a t i o n . Defense mechanisms employed by t he p a t i e n t t o reduce a n x i e t y as w e l l as d i s c h a r g e a n x i e t y on d e p a r t u r e from the h o s p i t a l w i l l a l s o be d i s c u s s e d . n o A l t e r a t i o n i n Body Image: Body image i s t h e c o n s t a n t l y c h a n g i n g t o t a l o f c o n s c i o u s and u n c o n s c i o u s i n f o r m a t i o n , f e e l i n g s and p e r c e p t i o n about one's body as 115 d i f f e r e n t and a p a r t from a l l o t h e r s . Body image i s b a s i c t o i d e n t i t y and p l a y s an i m p o r t a n t r o l e i n d e t e r m i n i n g an i n d i v i d u a l ' s sense o f s e c u r i t y and s e l f - e s t e e m . A burn i n j u r y f o r c e s r e s t r i c t i o n s on a p a t i e n t ' s sense o f freedom. He i s now f o r c e d t o assume a dependent r o l e on t h i n g s and p e o p l e . D i s f i g u r e m e n t b r i n g s unique changes i n body image. The a n x i e t y o f most p a t i e n t s a t a moment o f c r i s i s c r e a t e s t u n n e l v i s i o n ; t h e y see o r hear n o t h i n g e l s e a t t h e time. The sudden change i n body image a l s o produces a d i s t o r t i o n o f s e l f . A wide range o f b e h a v i o r s such as d e s p a i r , d i s c o u r a g e m e n t , p a s s i v e a c c e p t a n c e , anger and h o s t i l i t y may be d e t e c t e d by the n u r s e . ^ 7 In t h i s s t u d y , the f i r s t p a t i e n t r e a c t e d w i t h v e r b a l anger and h o s t i l i t y toward t h e nurses whereas t h e f i f t h p a t i e n t p a s s i v e l y a c c e p t e d her s i t u a t i o n . Two o t h e r p a t i e n t s seemed t o d i s a s s o c i a t e t h e i r b o d i e s from the s i t u a t i o n by r e f e r r i n g t o themselves i n 'animal' t e r m i n o l o g y . 115 C a t h e r i n e N o r r i s , "The P r o f e s s i o n a l Nurse and Body Image," B e h a v i o r a l Concepts and N u r s i n g I n t e r v e n t i o n s , ed. C a r o l y n E. C a r l s o n ( P h i l a d e l p h i a : J . B. L i p p i n c o t t Co., 1970), p. 41. 1 1 6 S h a r o n R o b e r t s , B e h a v i o r a l Concepts and the C r i t i c a l l y 111 P a t i e n t (Englewood C l i f f s : P r e n t i c e - H a l 1 I n c . , 1976), p. 78. 1 1 7 I b i d . , p.83. 11 o Roberts a l s o noted t h a t i t i s d i f f i c u l t f o r the burn p a t i e n t to see improvement i n h i s own c o n d i t i o n . S e e i n g o n l y the o b v i o u s changes i n h i s body image, he becomes d i s c o u r a g e d and p a s s i v e l y a c c e p t s e v e n t s i n h i s environment. S i n c e the burn c a r e team f o c u s ' i t s a t t e n t i o n on t h e r a p y , g r a f t i n g and r e h a b i l i t a t i o n , the burn p a t i e n t has d i f f i c u l t y v i s u a l i z i n g the end r e s u l t s o f t h e s e endeavors i n t h e d i s t a n t f u t u r e . 119 R oberts a l s o noted t h a t t h e burn p a t i e n t f e a r s t h a t h i s p h y s i c a l i n j u r i e s and p o s s i b l e d i s f i g u r e m e n t w i l l i s o l a t e him s o c i a l l y . The once whole body has been r e n d e r e d i m p e r f e c t . A l l he sees a r e the u g l y burns which s e r v e as a c o n s t a n t reminder o f h i s i m p e r f e c t i o n . As r e p o r t e d e a r l i e r , the f i r s t p a t i e n t was c o n c e r n e d about the r e a c t i o n o f h i s g i r l f r i e n d t o h i s s c a r s . The f i f t h p a t i e n t , an a v i d swimmer, was e q u a l l y c o n c e r n e d about the appearance o f her l e g s . T h i s p a t i e n t , , however,tended to d i v e r t the i n v e s t i g a t o r ' s c o n v e r s a t i o n away from the t o p i c o f the e f f e c t o f the burns on her emotional s t a t u s . " T h r e a t s may f o r c e the p a t i e n t t o a v o i d r e a l i t y by r e t r e a t i n g i n t o p e r i p h e r a l a r e a s , t o p i c s o f d i s c u s s i o n t h a t f o c u s on something o r someone o t h e r than t h e 1 ?D p a t i e n t h i m s e l f . " 118 R o b e r t s , B e h a v i o r a l Concepts and the C r i t i c a l l y 111 P a t i e n t , p. 83. 119 " y I b i d . , p. 84. 1 2 0 I b i d . , p. 85. Combs and Snygg noted t h a t p a t i e n t s who a n a l y z e the e v e n t s s u r r o u n d i n g t h e i r a c c i d e n t a r e t r y i n g t o g i v e some meaning to the a c c i d e n t from the r e l a t i o n they p e r c e i v e between the a c c i d e n t and 121 t h e m s e l v e s . Four p a t i e n t s i n t h i s study, d i s c u s s e d i n d e t a i l the e v e n t s s u r r o u n d i n g t h e i r burn a c c i d e n t . They seemed t o a n a l y z e and s e a r c h out a r e l a t i o n s h i p between themselves and the f a t e o f t h e i r i n j u r y . T h i s a n a l y s i s became a chance to p h i l o s o p h i z e about t h e i r l i f e i n g e n e r a l . L o n e ! i n e s s I l l n e s s not o n l y i m p l i e s a p h y s i c a l trauma; i t a l s o i m p l i e s a p s y c h o l o g i c a l trauma. I l l n e s s and t h r e a t o f l o s s o r d i s f i g u r e m e n t c r e a t e both p s y c h o l o g i c a l and p h y s i o l o g i c a l ' p a i n . Both t y p e s o f p a i n which were r e a l e x p e r i e n c e s to the i n d i v i d u a l , narrow p e r c e p t i o n , impose i s o l a t i o n , cause withdrawal and f o c u s a t t e n t i o n on the i n d i v i d u a l 1 22 A usual outcome i s t h e c r e a t i o n o f f e e l i n g s o f l o n e l i n e s s . L o n e l i n e s s , which a l l the p a t i e n t s i n t h i s s t u d y e x p r e s s e d , seemed to h e l p them l o o k w i t h i n themselves and p h i l o s o p h i z e about t h e i r "space" i n l i f e . "As a man communes w i t h h i m s e l f , he d i s c o v e r s l i f e , who he i s , the meaning o f h i s e x i s t e n c e and t h e t r u e n a t u r e o f h i s r e l a t i o n w i t h o t h e r s . " 1 2 3 121 R o b e r t s , _ B j ^ h a y i o r ^ ^ P' 8 8 1 2 2 I b i d . , p. 142. 1 2 3 C 1 a r k Moustakas, L o n e l i n e s s (Englewood C l i f f s : P r e n t i c e - H a l l , I n c . , 1961), p. 102. 113 The f i r s t p a t i e n t ' s sense o f i s o l a t i o n and l o n e l i n e s s was overwhelming. He l o n g e d f o r c o n v e r s a t i o n w i t h t h e nurses and t h r i v e d on v i s i t s w i t h t h e i n v e s t i g a t o r . The f o u r t h p a t i e n t was bored and f r u s t r a t e d w i t h the slow p r o g r e s s o f h i s r e c o v e r y . The f i f t h p a t i e n t f e l t " c u t o f f from the o u t s i d e l i f e . " L o n e l i n e s s c r e a t e d an a n x i e t y w i t h i n t h e s e p a t i e n t s . Even though t h e y were p h y s i c a l l y c l o s e to the s t a f f and o t h e r p a t i e n t s on t he burn u n i t , l o n e l i n e s s made them f e e l as i f they were i n a n o t h e r w o r l d . Sensory A l t e r a t i o n Sensory a l t e r a t i o n i s d e f i n e d as "an a b s o l u t e r e d u c t i o n i n v a r i e t y 124 and i n t e n s i t y o f s e n s o r y i n p u t , w i t h o r w i t h o u t a change i n p a t t e r n . " A l t h o u g h h i s h e a r i n g i s not i m p a i r e d , a burn p a t i e n t can e x p e r i e n c e e i t h e r a r e d u c t i o n o r o v e r s t i m u l a t i o n i n v i s u a l and b o d i l y s e n s a t i o n . As r e p o r t e d e a r l i e r , t h e t h i r d p a t i e n t , i n t h i s s t u d y , was unable t o see due t o s e v e r e edema o f h i s e y e l i d s . He was unable to p e r c e i v e changes o r happenings w i t h i n h i s environment. He had no v i s u a l frame o f r e f e r e n c e . A t f i r s t , he heard sounds but d i d not know t h e i r s i g n i f i c a n c e o r l o c a t i o n . Then, he began t o judge time on the b a s i s o f the human t r a f f i c i n the c o r r i d o r and the a u t o m o b i l e t r a f f i c o u t s i d e . Moreover, h i s body s e n s a t i o n s were d i s t o r t e d due to h i s burns. The s e n s a t i o n s o f heat and c o l d were i n t e n s i f i e d d u r i n g p r e p a r a t i o n f o r and a f t e r h i s burn bath. He s t a t e d t h a t h i s s e n s a t i o n o f p a i n was a l s o i n t e n s i f i e d because " b l i n d n e s s " d e p r i v e d him o f h i s v i s i o n . J u d i t h D. W o r r e l l , " N u r s i n g I m p l i c a t i o n s i n the Care o f the P a t i e n t E x p e r i e n c i n g Sensory D e p r i v a t i o n , " Advanced Concepts i n C l i n i c a l  N u r s i n g , ed. Kay C. K i n t z e l ( T o r o n t o : J.B. L i p p i n c o t t Co.,1971),p.133. 114 "Because o f the r e d u c t i o n i n amount and i n t e n s i t y o f s t i m u l a t i o n , 125 t h e p a t i e n t may withdraw i n t o s l e e p . " P e r c e p t u a l monotony may cause 1 26 the p a t i e n t to become i n a t t e n t i v e t o the environment. The f i f t h p a t i e n t s l e p t a g r e a t d e a l d u r i n g the day f o r a week a f t e r a d m i s s i o n . She e x p l a i n e d to the i n v e s t i g a t o r t h a t by " s h u t t i n g h e r s e l f o f f " from her e nvironment, her "body was a b l e t o c a t c h up" t o her " s o u l . " A n o t h e r p a t i e n t a l s o commented t o t h e i n v e s t i g a t o r t h a t he was u n a b l e t o s l e e p a t n i g h t because he had s l e p t so much d u r i n g the day. He s a i d t h a t s l e e p i n g h e l p e d pass t h e time. I t was t h i s p a t i e n t who s u f f e r e d t h e most from an overwhelming sense o f boredom, i s o l a t i o n and l o n e l i n e s s . 127 R oberts noted t h a t when s t i m u l a t i o n i s r e d u c e d , "the r e s u l t i n g b e h a v i o r i s boredom, i n a c t i v i t y and s l e e p . S l e e p o f f e r s i t s own s t i m u l a t i o n . At l e a s t i n s l e e p the p a t i e n t can dream. S l e e p a l s o h e l p s pass the time which, t o the p a t i e n t , seems t o s t a n d s t i l l . F u r t h e r m o r e , s l e e p i s an a c c e p t a b l e way t o withdraw from one's monotonous environment." Defense Mechanisms 190 A c c o r d i n g t o L a z a r u s , "Defenses a r e p s y c h o l o g i c a l manoeuvres i n which t h e i n d i v i d u a l d e c e i v e s h i m s e l f about the a c t u a l c o n d i t i o n s o f 1 2 5 R o b e r t s , B e h a v i o r a l Concepts i n t h e C r i t i c a l l y 111 P a t i e n t , p. 279 1 2 6 I b i d . , p. 280. 1 2 7 I b i d . , p. 286. 1 2 8 R i c h a r d L a z a r u s , P s y c h o l o g i c a l S t r e s s and t h e C o o i n g P r o c e s s (New York: M c G r a w - H i l l , 1966), p. Zbb. 115 t h r e a t . In t h i s way, harm i s not a n t i c i p a t e d , e i t h e r from an e x t e r n a l o r an i n t e r n a l s o u r c e . " D e n i a l i s a d e f e n s e mechanism o p e r a t i n g o u t s i d e o f and beyond c o n s c i o u s awareness i n the endeavor t o r e s o l v e emotional c o n f l i c t and a l l a y a n x i e t y . I t i s a normal c o p i n g b e h a v i o r by which the a d a p t i v e p r o c e s s i s brought about. T h e r e f o r e , d e n i a l s e r v e s to d e c r e a s e the 129 i n d i v i d u a l ' s a n x i e t y l e v e l . As s t a t e d e a r l i e r , the p a t i e n t s , i n t h i s s t u d y , d i d not f u l l y e x p r e s s an e m o t i o n a l upheaval i n the i n i t i a l r e a c t i o n t o t h e i r burn i n j u r y . A t f i r s t , t h e y seemed too a c c e p t i n g and n o n c h a l a n t . One p a t i e n t c l e a r l y d e n i e d the s e v e r i t y o f h i s burns and h i s p a i n . A n o t h e r p a t i e n t s k i l l f u l l y s t e e r e d c o n v e r s a t i o n away from d i s c u s s i o n o f the e m o t i o n a l impact o f her burn i n j u r y and the p o s s i b i l i t y o f s k i n g r a f t i n g . P r e - o p e r a t i v e l y , she r e f u s e d any t e a c h i n g about p o s t - o p e r a t i v e c a r e , i n c l u d i n g v i e w i n g o f the p o r t i o n o f t h e t a p e - s l i d e program on s k i n g r a f t i n g . In both p a t i e n t s , d e n i a l may have m i n i m i z e d the a n x i e t y p r o v o k i n g a s p e c t o f the r e a l i t y t h a t c o n s t i t u t e d a t h r e a t . F u r t h e r m o r e , d e n i a l may have s e r v e d as an e f f e c t i v e p r o t e c t i o n a g a i n s t overwhelming a n x i e t y . 1 3 0 H o s t i l i t y i s d e f i n e d as "a r e sponse to s u b j e c t i v e l y e x p e r i e n c e d h u m i l i a t i o n . A p e r s o n t h i n k s t h a t a n o t h e r person does not have the e x p e c t e d r e s p e c t f o r him. Rather than f e e l a n x i o u s , he f e e l s and/or 131 e x p r e s s e s h o s t i l i t y . " 129 R o b e r t s , B e h a v i o r a l Concepts i n the C r i t i c a l l y 111 P a t i e n t , p. 182. 1 3 0 I b i d . , p. 192. 1 3 1 I b i d . , p. 201. 116 The p a t i e n t , t h e r e f o r e , p r o j e c t s blame f o r h i s s i t u a t i o n onto someone i n h i s environment. The dependency r o l e , f o r c e d upon them by t h e i r i n j u r y , a r o u s e d f e e l i n g s o f h o s t i l i t y and anger i n two p a t i e n t s . One p a t i e n t d i s p l a y e d v e r b a l h o s t i l i t y toward the nurses s e v e r a l t i m e s . He b e l i e v e d t h a t the nurses d i s l i k e d him and were ' a g a i n s t ' him. I f a p a i n f u l t r e a t m e n t had been a d m i n i s t e r e d and i f he d i d n ' t g e t a l o n g w i t h t h e n u r s e who a d m i n i s t e r e d the t r e a t m e n t , he s u f f e r e d more p a i n d u r i n g and a f t e r the t r e a t m e n t . T h e r e f o r e , he b e l i e v e d the n u r s e c r e a t e d h i s i n t e n s e p a i n . A n o t h e r p a t i e n t d i s p l a y e d anger when a n u r s e came i n t o h i s room, w i t h o u t w a r n i n g , and removed h i s n e c r o t i c s k i n g r a f t . In h i s a n g er, he p r o j e c t e d the blame f o r the f a i l u r e o f h i s s k i n g r a f t t o 'take' on the s t a f f . The e x p r e s s i o n o f "anger r e v e a l s a sense o f f r u s t r a t i o n i n 132 a t t e m p t i n g t o a c h i e v e a goal t h a t has been o b s t r u c t e d . " H o s t i l i t y and anger a r e p s y c h o l o g i c a l d e f e n s e mechanisms t h a t s e r v e to mask the vagueness and p o w e r l e s s n e s s o f a n x i e t y . T h r e a t s t o t h e p a t i e n t ' s p s y c h o l o g i c a l , b i o l o g i c a l and s o c i a l i n t e g r i t y become overwhelming. Such awareness enhances h i s a l r e a d y e x i s t i n g f e e l i n g s o f a n x i e t y . T h e r e f o r e , a n x i e t y makes t h e p a t i e n t respond i n abnormal 133 ways. R o b e r t s , B e h a v i o r a l Concepts and the C r i t i c a l l y 111 P a t i e n t , p. 203. I b i d . , p. 209 , 117 D i s c h a r g e A n x i e t y In t h i s s t u d y , t h r e e p a t i e n t s ' a n x i e t y l e v e l s r o s e when n o t i f i e d o f t h e i r d i s c h a r g e day. A f t e r n e a r l y a month o f h o s p i t a l i z a t i o n , t h e s e p e o p l e had become c o m f o r t a b l e i n t h e i r f a m i l i a r s u r r o u n d i n g s . They had a l s o become f a m i l i a r w i t h t h e s t a f f p r o v i d i n g t h e i r c a r e . Now, the p a t i e n t s r e a l i z e d they were about t o l e a v e t h e i r s e c u r e and p r e d i c t a b l e s u r r o u n d i n g s . While f e e l i n g s e c u r e i i n t h i s p r o t e c t i v e environment, t h e y had r e g a r d e d the burn u n i t as a "haven o f s a f e t y . " They had depended on t h e n u r s e s ' knowledge, competency and s k i l l i n p r o v i d i n g c a r e . T h e r e f o r e , the a b r u p t t e r m i n a t i o n o f t h i s emotional attachment t o t h e i r e n vironment and t h e s t a f f appeared t o r e s u l t i n i n c r e a s e d a n x i e t y . One p a t i e n t was a f r a i d o f the " o u t s i d e w o r l d " and dreaded the p o s s i b i l i t y o f a n o t h e r i n j u r y . He and the o t h e r p a t i e n t s w o r r i e d about t h e response o f s t r a n g e r s and s i g n i f i c a n t p e o p l e i n t h e i r l i v e s t o t h e d i s f i g u r e m e n t l e f t by the s c a r t i s s u e . These p a t i e n t s f a c e d a t h r e a t t o t h e i r s o c i a l i n t e g r i t y w i t h the p o s s i b i l i t y o f r e j e c t i o n and s o c i a l i s o l a t i o n . Summary The f i n d i n g s o f t h i s s t u d y c l e a r l y i n d i c a t e t h a t even the l e s s s e v e r e l y burned p a t i e n t e x p e r i e n c e s emotional t u r m o i l d u r i n g h o s p i t a l i z a t i o n . The i d e n t i f i c a t i o n and a c c u m u l a t i o n o f i n f o r m a t i o n about a n x i e t y p r o d u c i n g s t r e s s o r s , as p e r c e i v e d by t h e s e p a t i e n t s , has been v e r y r e v e a l i n g . The i m p l i c a t i o n s f o r the nurse i n r e d u c i n g the e f f e c t s o f t r e a t m e n t s t r e s s are s u b s t a n t i a l . 118 C h a p t e r 5 SUMMARY RECOMMENDATIONS CONCLUSIONS Summary The p r i m a r y purpose o f t h e s t u d y was t o i n v e s t i g a t e t h e e f f e c t i v e n e s s o f ah i n s t r u c t i o n a l program p r o v i d i n g t r e a t m e n t i n f o r m a t i o n and p s y c h o l o g i c a l s u p p o r t i n r e d u c i n g the e f f e c t s o f t r e a t m e n t s t r e s s f o r burn p a t i e n t s . I d e n t i f i c a t i o n and a c c u m u l a t i o n o f i n f o r m a t i o n about a n x i e t y p r o d u c i n g s t r e s s o r s d u r i n g h o s p i t a l i z a t i o n , as p e r c e i v e d by the sample o f p a t i e n t s , was a n o t h e r major outcome o f the s t u d y . The i n s t r u c t i o n a l program a l l o w e d the f i v e p a t i e n t s not o n l y t o p r e p a r e f o r new phases o f burn t r e a t m e n t but a l s o , due to the p r e s e n c e o f the i n v e s t i g a t o r , t o v e n t i l a t e t h o u g h t s , pent-up emotions and f r u s t r a t i o n s to an o b j e c t i v e p e r s o n not i n v o l v e d i n d a i l y p h y s i c a l c a r e . T h e r e f o r e , , e v i d e n c e o f the e f f e c t i v e n e s s o f t h e s e p l a n n e d i n t e r v e n t i o n s l i e i n s u b j e c t i v e e v a l u a t i o n o f t h e i n s t r u c t i o n a l program by t h e p a t i e n t as w e l l as o b j e c t i v e e v a l u a t i o n o f t h e program by s t a t i s t i c a l measurements. S i n c e a d e s c r i p t i v e approach was s e l e c t e d , i t was not the s o l e purpose o f t h e s t u d y t o c o n v i n c i n g l y demonstrate t h a t t h e planned n u r s i n g i n t e r v e n t i o n s d i d i n d e e d reduce a n x i e t y due to t h e e f f e c t s o f t r e a t m e n t s t r e s s . I t became i n c r e a s i n g l y d i f f i c u l t t o i d e n t i f y b e h a v i o r r e l a t e d s o l e l y t o t h e e f f e c t s o f t r e a t m e n t s t r e s s s i n c e i t was t h e burn w i t h i t s a l l - e n c o m p a s s i n g p a i n t h a t dominated the s i t u a t i o n . N e v e r t h e l e s s , the s t a t i s t i c a l measurements a p p l i e d to the n u m e r i c a l data 119 produced by the S t a t e - T r a i t A n x i e t y I n v e n t o r i e s and the d i a r i e s i n d i c a t e d a t r e n d i n s t a t e a n x i e t y o v e r u n i t time i n t h e sample o f burn p a t i e n t s . However, i t appears t h a t t h e r e i s no measurable change i n ( t r a i t a n x i e t y o v e r time. In o t h e r words, t h e r e was no change i n the p a t i e n t s ' t r a i t a n x i e t y d u r i n g r e c o v e r y from a burn i n j u r y . Moreover, t h e r e was no measurable i n c r e a s e i n the hours o f s l e e p and no measurable d e c r e a s e i n e x p r e s s e d need f o r m e d i c a t i o n o v e r u n i t time. S l e e p and m e d i c a t i o n r e q u e s t s f l u c t u a t e d w i d e l y from day t o day d u r i n g the r e c o v e r y p e r i o d . E x t r a n e o u s v a r i a b l e s such as t h e i n i t i a t i o n o f a new t r e a t m e n t , a r e l a p s e i n r e c o v e r y , such as an i n f e c t i o n o r a r e j e c t i o n o f a s k i n g r a f t , as w e l l as d i s t u r b a n c e d u r i n g the n i g h t due t o r o u t i n e t r e a t m e n t s , h i n d e r e d r e l i a b l e and v a l i d measurement o f t h e s e i n d i c a t o r s o f a n x i e t y . P a t i e n t s ' comments as t o the h e l p f u l n e s s o f the i n s t r u c t i o n a l program and p s y c h o l o g i c a l s u p p o r t were a n o t h e r s o u r c e o f e v i d e n c e o f the e f f e c t i v e n e s s o f the program i n r e d u c i n g a n x i e t y due t o the e f f e c t s o f t r e a t m e n t s t r e s s . As r e p o r t e d i n t h e p r e v i o u s c h a p t e r , t h e r e were many o v e r t and c o v e r t i n d i c a t o r s upon which the i n v e s t i g a t o r drew i n o r d e r t o e v a l u a t e the e f f e c t i v e n e s s o f the planned v i s i t s w i t h the p a t i e n t s . F u r t h e r m o r e , t h e s e p a t i e n t s were unanimously i n f a v o u r o f the u s e f u l n e s s o f t h e t a p e - s l i d e program and the d i s c u s s i o n f o l l o w i n g . The n u r s e s ' assessment o f - t h e p a t i e n t s ' t r a i t and s t a t e a n x i e t y was somewhat i n v e r s e l y r e l a t e d . T h i s suggested t h a t the nurse c a r i n g f o r the p a t i e n t was e i t h e r not a s s e s s i n g s t a t e a n x i e t y as i n t e r p r e t e d by t h e i n v e s t i g a t o r o r not aware o f t h e p a t i e n t ' s t r u e a n x i e t y l e v e l compounded by a n u r s e - r a t i n g --' s c a l e o f ' unknown r e l i a b i l i t y and v a l i d i t y . 120 There were many a n x i e t y p r o d u c i n g s t r e s s o r s d u r i n g h o s p i t a l i z a t i o n as p e r c e i v e d by the p a t i e n t s . G e n e r a l l y , t h e s t r e s s o r s were a s s o c i a t e d w i t h burn t r e a t m e n t and p a t i e n t - n u r s e r e l a t i o n s h i p s . S i n c e t h e s e p a t i e n t s ' l i v e s a t t h i s time r e v o l v e d around t h e i r burn i n j u r y and t h e peopl e c a r i n g f o r t h a t i n j u r y , t h e s e s t r e s s o r s were to be e x p e c t e d . The a t t i t u d e s , a c t i o n s and statements o f s t a f f members had a g r e a t b e a r i n g on t h e r a p i d i t y w i t h which a t r u s t i n g r e l a t i o n s h i p d e v e l o p e d and th e e x t e n t t o which t h i s r e l a t i o n s h i p p r o g r e s s e d . F u rthermore, the p a t i e n t s passed through s i m i l a r phases d u r i n g t h e r e c o v e r y p e r i o d . Trends among a l l t h e s e p e o p l e were seen t h r o u g h o u t t h e e n t i r e data c o l l e c t i o n p e r i o d . However, i n t e r p r e t a t i o n o f t h e f i n d i n g s must be done w i t h c a u t i o n due to the small number o f p a t i e n t s i n t he study. (N=5). Recommendations In l i g h t o f t h e f i n d i n g s o f t h i s s t u d y , t he f o l l o w i n g recommendations were made. F i r s t l y , a n u r s e , not r e s p o n s i b l e f o r t h e p a t i e n t s ' d a i l y p h y s i c a l c a r e be a v a i l a b l e i n o r d e r t o p r o v i d e i n f o r m a t i o n a l and s u p p o r t i v e n u r s i n g i n t e r v e n t i o n s as i m p l i e d i n t h i s s t u d y . The d i s t i n c t i o n as t o whether o r not t h i s " s u p p o r t i v e n u r s e " s h o u l d be a p s y c h i a t r i c nurse s p e c i a l i s t remains u n r e s o l v e d . N e v e r t h e l e s s , t he approach t o a p a t i e n t ' s emotional problems may be b e t t e r o r g a n i z e d and more c o n s i s t e n t when t h e p a t i e n t has e s t a b l i s h e d a t h e r a p e u t i c r a p p o r t and i n t e r a c t i o n w i t h a nurse who does not r e p r e s e n t a s o u r c e o f t r e a t m e n t s t r e s s l e a d i n g to p a i n . A l s o , t h o s e r e s p o n s i b l e f o r p h y s i c a l c a r e may be b e t t e r a b l e to 121 cope w i t h t he p a t i e n t ' s d a i l y f r u s t r a t i o n s and a n x i e t y i f major emotional d i s r u p t i o n has been s u c c e s s f u l l y h a n d l e d . S e c o n d l y , a c o n t i n u i n g i n - s e r v i c e program f o r s t a f f n u rses and p h y s i o t h e r a p i s t s s h o u l d be i n i t i a t e d to enhance t h e i r u n d e r s t a n d i n g o f the p s y c h o l o g y o f the burn p a t i e n t and phases he may be e x p e c t e d to pass t h r o u g h . Emphasis s h o u l d be p l a c e d on p s y c h o l o g i c a l d e f e n s e mechanisms and b e h a v i o r a l r e s p o n s e s t h e p a t i e n t may e x h i b i t w h i l e t r y i n g t o a d j u s t and cope w i t h h i s a n x i e t y . How t h e p a t i e n t h a n d l e s t h e p a i n and s t r e s s o f t r e a t m e n t s may depend on what the nurse does i n a s s i s t i n g him t o cope w i t h t h e e x p e r i e n c e . T h i r d l y , some s t i m u l a t i n g d i v e r s i o n a l t e c h n i q u e s h o u l d be u t i l i z e d d u r i n g t he burn bath t o h e l p t he p a t i e n t f o c u s h i s a t t e n t i o n away from the debridement and accompanying p a i n . As one p a t i e n t s u g g e s t e d , a p e r s o n , engaged i n c o n v e r s a t i o n w i t h him d u r i n g t he b a t h , would p r o v i d e a welcomed d i v e r s i o n . I t was recommended by a n o t h e r p a t i e n t t h a t a former burn p a t i e n t , who has r e c o v e r e d p h y s i c a l l y and p s y c h o l o g i c a l l y , be asked to v i s i t s e l e c t e d h o s p i t a l i z e d p a t i e n t s upon r e q u e s t . T h i s former p a t i e n t may boost t he morale o f t h e h o s p i t a l i z e d p a t i e n t when l i v i n g e v i d e n c e i s p r o v i d e d t h a t even s e v e r e l y burned p a t i e n t s can and do l e a r n t o resume normal l i v e s and a c q u i r e an a c c e p t a b l e appearance. F i f t h l y , e a r l i e r c o n t a c t w i t h o t h e r p a t i e n t s on the burn u n i t , when f e a s i b l e , would h e l p d e c r e a s e the p a t i e n t s ' sense o f i s o l a t i o n and boredom. The p a t i e n t s may be a b l e to m o b i l i z e an o p t i m i s t i c a t t i t u d e t hrough r e a l i z a t i o n t h a t o t h e r s have been burned and a r e i n the same s i t u a t i o n . 122 The l a t t e r t h r e e recommendations were s u g g e s t e d by the p a t i e n t s t h e m s e l v e s . A g r e a t depth o f i n s i g h t and u n d e r s t a n d i n g o f t h e i r own e m o t i o n a l needs and b e h a v i o r a l r e s p o n s e s as w e l l as t h e p h y s i c a l a s p e c t s o f burn c a r e , was g a i n e d by t h e s e i n d i v i d u a l s . T h e i r s u g g e s t i o n s t o enhance the p r o v i s i o n o f t o t a l burn c a r e , both p h y s i c a l and p s y c h o l o g i c a l , were very w o r t h w h i l e . T h e r e f o r e , a t t e n t i o n t o the e m o t i o n a l needs o f t h e s e p a t i e n t s , e a r l y i n t h e r e c o v e r y phase, w i l l f a c i l i t a t e t h e i r a djustment t o the burn i n j u r y and its,.consequences. I m p l i c a t i o n s f o r F u r t h e r Study R e p l i c a t i o n w i t h a l a r g e r study sample i s needed to c o n f i r m the f i n d i n g s s i n c e g e n e r a l i z a t i o n o f the f i n d i n g s t o the t a r g e t p o p u l a t i o n has not been attempted. S i n c e i t was recommended t h a t a n u r s e , not r e s p o n s i b l e f o r d a i l y p h y s i c a l c a r e , be a v a i l a b l e to p r o v i d e t h e r a p e u t i c p s y c h o l o g i c a l s u p p o r t , a s t u d y s h o u l d be c o n d u c t e d t o d e t e r m i n e which t y p e o f n u r s i n g e x p e r t i s e would be most e f f e c t i v e i n r e l i e v i n g the e f f e c t s o f t r e a t m e n t s t r e s s . An e x p e r i m e n t a l s t u d y c o u l d compare the r e l a t i v e e f f e c t i v e n e s s o f a p s y c h i a t r i c nurse s p e c i a l i s t v e r s u s a n o n - s p e c i a l i s t nurse i n o r d e r to d e t e r m i n e which d i s t i n c t i o n o f n u r s e would b e s t s e r v e the purpose. F u r t h e r m o r e , t h e l i t e r a t u r e l a c k s i n f o r m a t i o n about not o n l y the emotional r e s p o n s e s o f t h e l e s s s e v e r e l y burned p a t i e n t , but a l s o the p o s t - d i s c h a r g e phase o f r e c o v e r y i n a l l burn p a t i e n t s . Permanent i n d i v i d u a l and f a m i l y changes o f l i f e l o n g importance may ensue as a consequence o f burn i n j u r y . T h e r e f o r e , more f o l l o w - u p s t u d i e s a r e needed to d e t e r m i n e t h e problems, both p h y s i c a l and p s y c h o l o g i c a l , t h a t t h e s e 123 p a t i e n t s f a c e a f t e r d i s c h a r g e from h o s p i t a l . L i t t l e r e s e a r c h a t t e n t i o n has been g i v e n to the emotional problems o f s e v e r e l y burned p a t i e n t s w i t h g r o s s p h y s i c a l d i s f i g u r e m e n t . I t was a p p a r e n t i n t h i s s t u d y t h a t a l t e r a t i o n i n body image c o n c e r n e d even the l e s s s e v e r e l y burned p a t i e n t . Moreover, no i n f o r m a t i o n about the e f f e c t s o f the n e c e s s i t y o f wearing t h e J o b s t * * - 7 e l a s t i c garment f o r a p p r o x i m a t e l y a y e a r i s a v a i l a b l e i n the l i t e r a t u r e . ConcT u s i o n s The f i n d i n g s o f t h i s s t u d y i n d i c a t e d t h a t even l e s s s e v e r e l y burned p a t i e n t s s u f f e r i n t e n s e p s y c h o l o g i c a l r e s p o n s e t o the burn i n j u r y and g r e a t a n x i e t y d u r i n g h o s p i t a l i z a t i o n . Planned n u r s i n g i n t e r v e n t i o n s , p r o v i d e d by a p e r s o n not r e s p o n s i b l e f o r d a i l y p h y s i c a l c a r e , reduced t h a t a n x i e t y a t t r i b u t a b l e to the e f f e c t s o f t r e a t m e n t s t r e s s . 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" The I n t e r n a t i o n a l J o u r n a l o f C l i n i c a l and E x p e r i m e n t a l Hypnosis 10 ( J u l y 1962) :183-202. S t r a u s s , Anselm; and Fagerhaugh, S h i z u k o . " P a i n : An O r g a n i z a t i o n a l - W o r k -I n t e r a c t i o n a l P e r s p e c t i v e . " N u r s i n g Outlook 22 (September 1974): 560-566. Weisz, A l f r e d . Treatment " P s y c h o t h e r a p e u t i c Support o f Burned P a t i e n t s . " 4 (November 1967):1291-1303. Modern 132 a'-W i l e y , Loy. "The P e r f e c t E x p l a n a t i o n May Not Be R i g h t A t A l l . " N u r s i n g '76 6 (September 1976):52-57-W i l l i a m s , B a r b a r a . "The Burned P a t i e n t s ' Need f o r T e a c h i n g . " N u r s i n g  C l i n i c s o f North America 6 (December 1971):616-638. W i l l i a m s , Barbara. " L i f e s t y l e s o f S e v e r e l y Burned Men. N u r s i n g Research 20 ( J a n u a r y / F e b r u a r y 1971):82. W i l l i a m s , Rosemary. " H a n d l i n g A n x i e t y . " N u r s i n g '73 3 (September 1973): W o r r e l l , J u d i t h D. " N u r s i n g I m p l i c a t i o n s i n t h e Care o f t h e P a t i e n t E x p e r i e n c i n g Sensory D e p r i v a t i o n . " Advanced Concepts i n C l i n i c a l  N u r s i n g , ed. Kay C. K i n t z e l . T o r o n t o : J . B. L i p p i n c o t t Co., 1971. Young, Karon Ann. " S t i g m a t i z a t i o n o f Burn P a t i e n t s . " J o u r n a l o f the A s s o c i a t i o n o f O p e r a t i n g Room Nurses 20 (November 1974):802-808. ADDITIONAL SOURCES Johnson, Jean E. "The I n f l u e n c e o f P u r p o s e f u l N u r s e - P a t i e n t I n t e r a c t i o n on t he P a t i e n t ' s P o s t - O p e r a t i v e Course." ( u n p u b l i s h e d t h e s i s Y a l e U n i v e r s i t y School o f N u r s i n g , 1965.) Johnson, Jean E. " C o g n i t i v e C o n t r o l o f the Emotional Component o f t h e Pa i n E x p e r i e n c e . " Ph.D. d i s s e r t a t i o n . U n i v e r s i t y o f W i s c o n s i n , 1971. Te r s h a k o w i c , Marc. P l a s t i c Surgeon, Y o r k - F i n c h H o s p i t a l , T o r o n t o , O n t a r i o . I n t e r v i e w , J u l y 3, 1975. U.S. Department o f H e a l t h , E d u c a t i o n and W e l f a r e . C u r r e n t Research on  S l e e p and Dreams. Washington D.C.: Government P r i n t i n g O f f i c e , P u b l i c H e a l t h S e r v i c e P u b l i c a t i o n No.1389, 1973. APPENDIX A 133*~ CONSENT FORM I do agr e e t o p a r t i c i p a t e as a s u b j e c t i n t h i s s t u d y c o n d u c t e d on the Burn U n i t o f t h e Vancouver General H o s p i t a l by Barbara P e e l i n g , R.N. I t has been e x p l a i n e d t o me t h a t the purpose o f t h i s s t u d y i s t o a c q u i r e knowledge about t h e e f f e c t s o f burn t r e a t m e n t s and methods o f r e d u c i n g t r e a t m e n t s t r e s s . I u n d e r s t a n d t h a t p a r t i c i p a t i o n i n t h i s s t u d y i n v o l v e s answering the same b r i e f q u e s t i o n n a i r e s i x t i m e s o v e r a p e r i o d o f one month as w e l l as keeping a d i a r y r e g a r d i n g my r e a c t i o n s t o t r e a t m e n t . The r e s u l t s o f the s t u d y w i l l be c o n f i d e n t i a l and anonymous. I u n d e r s t a n d t h a t I am f r e e t o withdraw from t h e s t u d y a t any ti m e . S i g n a t u r e Witness Date 133b APPENDIX B SELF-EVALUATION QUESTIONNAIRE Developed by C. D . Spielberger, R. L . Gorsuch and R. Lushene STAI FORM X-1 NAME DATE DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each state-ment and then blacken in the appropriate circle to the right of the statement to indicate how you feel right now, that is, at this moment. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe your present feelings best. NOT AT ALL SOMEWHAT MODERATELY SO, VERY MUCH SO 1. I feel calm .. : : © ® ® © 2. I feel secure ; © ® . ® © 3. I am tense © ® ® ® 4. I am regretful © ® ® ® 5. I feel at ease •. © ® ® ® 6. I feel upset © ® ® ® 7. I am presently worrying over possible misfortunes © ® ® © 8. I feel rested © ® ® ® 9. I feel anxious © ® ® ® 10. I feel comfortable © ® ® © 11. I feel self-confident © ® @ © 12. I feel nervous © ® ® ® 13. I am jittery © ® ® © 14. I feel "high strung" © ® ® ® 15. I am relaxed © ® ® ® 16. I feel content © ® ® © 17. I am worried . ... © ® ® © 18. I feel over-excited and "rattled" © ® ® © 19. I feel joyful © ® ® ® 20. I feel pleasant ..... © ® ® ® S p e c i a l p e r m i s s i o n t o rep r o d u c e g r a n t e d by C h a r l e s S p i e l b e r g e r C o n s u l t i n g PsychfijLflfljsts P r e s s . -Bfflm CONSULTING PSYCHOLOGISTS PRESS Wmdms 577 College Avenue, Palo Alto, California 94306 SELF-EVALUATION QUESTIONNAIRE STAI FORM X-2 135*_ NAME DATE DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each state-ment and then blacken in the appropriate circle to the right of the statement to indicate how you generally feel. There are no right or wrong answers. Do not spend too much time on any one statement but give the answer which seems to describe how you generally feel. ALMOST NEVER SOMETIMES OFTEN ALMOST ALWAYS 21. I feel pleasant .. © ® ® ® 22. I tire quickly © © ® © 23. I feel like crying © ® ® © 24. I wish I could be as happy as others seem to be © ® ® © 25. I am losing out on things because I can't make up my mind soon enough.... ® ® © 26. I feel rested ; © ® ® © 27. I am "calm, cool, and collected" © ® ® © 28. I feel that difficulties are piling up so that I cannot overcome them © ® ® © 29. I worry too much over something that really doesn't matter © ® ® © 30. I am happy '. © ® ® © 31. I am inclined to take things hard © ® ' ® © 32. I lack self-confidence © © ® © 33. I feel secure © ® ® © 34. I try to avoid facing a crisis or difBculty © ® ® © 35. I feel blue © ® ® © 36. I am content © ® ® © 37. Some unimportant thought runs through my mind and bothers me © ® ® © 38. I take disappointments so keenly that I can't put them out of my mind .... © ® ® © 39. I am a steady person © ® ® © 40. I get in a state of tension or turmoil as I think over my recent concerns and interests © S p e c i a l p e r s m i s s i o n t o r e p r o d u c e g r a n t e d by C h a r l e s S p i e l b e r g e r C o n s u l t i n g P s y c h o l o g i s t s P r e s s . ® ® © Copyright © 1968 by Charles D. Spielberger. Reproduction of this test or any portion thereof by any process without written permission of the Publisher is prohibited. 135* APPENDIX C P a t i e n t T e a c h i n g '^ A u d i o - V i s u a l P r e s e n t a t i o n " E x p l a i n i n g Your Burn Care" PART I: ORIENTATION TO THE BURN UNIT We'd l i k e t o h e l p o r i e n t you t o t h i s h o s p i t a l ward & t o i n f o r m you o f some o f the t r e a t m e n t s you w i l l r e c e i v e . Your n u r s e w i l l e x p l a i n a l l p r o c e d u r e s t o you and answer any q u e s t i o n s . The Burn U n i t o f the Vancouver General H o s p i t a l i s l o c a t e d on the f o u r t h f l o o r o f the F a i r v i e w P a v i i i o n . T h i s u n i t i s c o n s i d e r e d an " i s o l a t i o n " ward. Each room i n the c o r r i d o r i s a s i n g l e room. A t each end o f the c o r r i d o r i s an 8 bed open ward c a l l e d "the p o r c h . " 137 You may move from y o u r s i n g l e room i n t o the porch when you do not need e x t e n s i v e n u r s i n g c a r e . T h i s w i l l be a s t e p forward i n y o u r independence and p a r t o f y o u r r e h a b i l i t a t i o n . One o r two nurses a r e a s s i g n e d to a l l o f the p a t i e n t s here. There i s a l s o an i n t e n s i v e c a r e u n i t on t h i s ward f o r c r i t i c a l l y i l l p a t i e n t s . You may have n o t i c e d v i s i t o r s and nurses wearing gowns and masks. On i s o l a t i o n wards, p r e c a u t i o n s a r e taken t o help p r e v e n t the s p r e a d o f i n f e c t i o n as w e l l as p r o t e c t i n g our p a t i e n t s from c o n t a c t i n g f u r t h e r i n f e c t i o n . 138 When the nur s e o r v i s i t o r i s about t o l e a v e the room, t h e gown i s removed and p l a c e d i n a l i n e n bag hanging on the w a l l i n the room. Those i n v o l v e d i n c a r i n g f o r p a t i e n t s w i t h burn i n j u r i e s i n c l u d e the p l a s t i c s u r g e o n , t h e burn r e s i d e n t d o c t o r , n u r s i n g s t a f f , p h y s i o t h e r a p i s t s , d i e t i t i a n s and s o c i a l w orkers. These p e o p l e w i l l make "rounds" and d i s c u s s y o u r c a r e as a team as w e l l as answer any q u e s t i o n s . Your l e n g t h o f s t a y i s v a r i a b l e . I t depends on y o u r t r e a t m e n t s and r a t e o f h e a l i n g . 139 A burned a r e a d e s t r o y s v a r i o u s l a y e r s o f s k i n . Your t r e a t m e n t depends on the e x t e n t o f i n j u r y . A f i r s t degree burn i s o n l y a r e d n e s s , s i m i l a r to a sunburn and w i l l heal i n about 5 t o 7 days. A second degree burn i n v o l v e s the deeper l a y e r s o f t h e s k i n and produces a " b l i s t e r burn." A second degree burn w i l l u s u a l l y heal i n about 10 t o 14 days. 140 A t h i r d degree burn i n v o l v e s complete d e s t r u c t i o n o f the f i r s t two l a y e r s o f the s k i n and p e n e t r a t e s the f a t t y t i s s u e beneath. V a r i o u s p a i n m e d i c i n e s a r e a v a i l a b l e to ease y o u r p a i n . S i n c e some a r e a d d i c t i v e n a r c o t i c s , you w i l l be g i v e n d i f f e r e n t m e d i c a t i o n s as h e a l i n g t a k e s p l a c e . Your burn a r e a s may be c o v e r e d by bandages o r d r e s s i n g s - u s u a l l y wet compresses. The nurse w i l l p r o b a b l y wear a s t e r i l e green s u r g i c a l gown and mask s i n c e y o u r burned area w i l l be exposed. The d r e s s i n g t r a y has v a r i o u s bowls o f s o l u t i o n s , i n s t r u m e n t s , ointments and pads. 141 I t w i l l be n e c e s s a r y f o r her t o d e b r i d e or remove any dead s k i n , and c l e a n s e the a r e a w e l l b e f o r e a p p l y i n g f r e s h d r e s s i n g s . U s u a l l y d r e s s i n g s a r e done e v e r y 4 hours but may not be a t a s p e c i f i c time e v e r y day. You a r e not b e i n g n e g l e c t e d i f p r i o r i t i e s have to be s e t f o r o t h e r p a t i e n t s . E x e r c i s e s must be done e v e r y 4 hours. The p h y s i o t h e r a p i s t w i l l i n s t r u c t and a s s i s t you. There a r e s p e c i f i c e x e r c i s e s and they a r e i m p o r t a n t t o p r e v e n t t i g h t e n i n g o f burned a r e a s and to m a i n t a i n good movement i n the f i n g e r s , hands and l e g s . i 142 Your h e a l i n g s k i n may be i t c h y a t times. A g r e a s y ointment i s a p p l i e d to keep i t smooth and l u b r i c a t e d . T e n s o r bandages o r e l a s t i c s t o c k i n g s w i l l be a p p l i e d to the l e g s a f t e r h e a l i n g has taken p l a c e . They a r e a p p l i e d whenever you ar e w a l k i n g t o p r o v i d e s u p p o r t to the newly h e a l e d t i s s u e . Good n u t r i t i o n and f l u i d i n t a k e a r e ver y i m p o r t a n t i n h e l p i n g new t i s s u e grow. M i l k i s an i m p o r t a n t p a r t o f y o u r d i e t and you a r e encouraged to d r i n k i t d a i l y . Feel f r e e to ask y o u r n u r s e o r d o c t o r any q u e s t i o n s you may have. You a r e p a r t o f t h e team i n an e f f o r t t o p r o v i d e you w i t h t he be s t p o s s i b l e c a r e . Your mature assessment r e g a r d i n g y o u r c o n d i t i o n , when sh a r e d o p e n l y w i t h o t h e r members o f t h e team, w i l l add g r e a t l y t o t h e speed anci s u c c e s s o f y o u r r e c o v e r y . 143 PART I I : THE BURN BATH One o f the most common t r e a t m e n t s on the u n i t i s the Burn Bath. You w i l l be p l a c e d i n a v e r y l a r g e w h i r l p o o l tank where yo u r burn wounds a r e c l e a n s e d . The tank i s f i l l e d w i t h warm water. The water l o o k s orange due t o a medical s o l u t i o n added. I t i s not r u s t . The t r o l l e y on t h e c e i l i n g h e l p s the nurses move you on a p o r t a b l e s t r e t c h e r and lower i t i n t o t he bath. You w i l l s t a y on t h i s metal c o t w h i l e i n the tank. The warm.bubbling water s t i m u l a t e s c i r c u l a t i o n . The nurse w i l l d e b r i d e the dead t i s s u e from y o u r wounds as w e l l as c l e a n s e them. 144 The warmth o f t h e water and n a t u r a l buoyancy w i l l e n a b l e you to e x e r c i s e e a s i l y w i t h s u p e r v i s i o n by the p h y s i o t h e r a p i s t s . You w i l l then be removed from t h e tank the o p p o s i t e way to which you were put i n . The nurse w i l l d r y you e n t i r e l y and c o v e r you w i t h a f l a n n e l s h e e t . Once back i n t o y o u r room, y o u r d r e s s i n g s w i l l be r e - a p p l i e d . The bath' i s g i v e n d a i l y u n t i l a l l burned a r e a s a r e w e l l d e b r i d e d and c l e a n s e d . P a t i e n t s seem t o e n j o y t h e i r bath even though they may f e e l f a t i g u e d a f t e r w a r d . 145 THE ARM BATH One o f the most common tr e a t m e n t s on the u n i t i s a d a i l y w h i r l p o o l bath g i v e n to y o u r arm o r hand. The arm bath i s a p o r t a b l e w h i r l p o o l tank f i l l e d w i t h warm water. The water may be an orange c o l o u r due t o a medical s o l u t i o n added to the water. I t i s not r u s t . The warm b u b b l i n g water s t i m u l a t e s c i r c u l a t i o n . U s u a l l y t he t r e a t m e n t l a s t s 20 minutes. The nurse w i l l d e b r i d e o r remove the dead t i s s u e from y o u r wounds as w e l l as c l e a n s e them. 146 The warmth o f the water and n a t u r a l buoyancy e n a b l e you t o e x e r c i s e e a s i l y w i t h s u p e r v i s i o n by the p h y s i o t h e r a p i s t . Your arm and hand a r e d r i e d and d r e s s i n g s a r e r e - a p p l i e d . The arm bath i s u s u a l l y g i v e n more than once a day. Most p a t i e n t s seem to enj o y the bath. 147 PART IV: SKIN GRAFTING When t h e burn has d e s t r o y e d deeper l a y e r s o f s k i n t i s s u e , the s k i n i s not a b l e to r e g e n e r a t e i t s e l f w i t h o u t some h e l p . T h e r e f o r e , t h e d o c t o r w i l l remove a t h i n l a y e r o f s k i n from a heal t h y n o n - b u r n area o f yo u r body f o r a p p l i c a t i o n t o a n o n - h e a l i n g burn a r e a . T h i s p r o c e d u r e t a k e s p l a c e i n the o p e r a t i n g room. The s k i n g r a f t i s g e n t l y l a i d on t h e burn area. No s t i t c h e s o r d r e s s i n g s a r e r e q u i r e d . The ar e a i s l e f t exposed. Because d r a i n a g e and pus accumulate under t he g r a f t , t h e nurse must r o l l each g r a f t w i t h a " Q - t i p " v e r y f r e q u e n t l y i n o r d e r to remove t h i s d r a i n a g e . When the d r a i n a g e q u i c k l y d e c r e a s e s i n amount, f r e q u e n t r o l l i n g i s not as n e c e s s a r y . 148 The g r a f t s a r e v e r y d e l i c a t e . T h e r e f o r e , i t i s i m p o r t a n t t h a t you remain i n one p o s i t i o n f o r a l o n g p e r i o d o f time. Your d o c t o r w i l l d i s c u s s t he approximate l e n g t h o f time. The donor area from which the s k i n comes, i s exposed to the a i r . I t d e v e l o p s a dry brown scab and may be q u i t e p a i n f u l a t f i r s t . As i t h e a l s , i t may become i t c h y . I t i s im p o r t a n t t h a t you do not s c r a t c h t h i s a r e a . The donor a r e a s q u i c k l y heals and f a d e s w i t h time. Your newly h e a l e d s k i n appears s l i g h t l y d i s c o l o u r e d f o r many months but w i l l f a d e g r a d u a l l y . Scar t i s s u e i s u s u a l l y minimal. You w i l l be g i v e n an e x p l a n a t i o n and a b o o k l e t o f i n s t r u c t i o n s f o r s k i n c a r e upon d i s c h a r g e . 149 PART V: SPLINTING The p h y s i o t h e r a p i s t may make s p e c i a l hand o r l e g s p l i n t s which w i l l be used d u r i n g the e a r l y and l a t e r s t a g e s o f burn c a r e . S p l i n t s a r e made from mouldable p l a s t i c and may r e q u i r e f r e q u e n t a d j u s t m e n t . These a r e p r e s c r i b e d to m a i n t a i n t he a f f e c t e d j o i n t i n good p o s i t i o n and t o p r e v e n t t i g h t e n i n g o f the burned a r e a s . I n i t i a l l y t h e y may be worn c o n s t a n t l y e x c e p t d u r i n g t r e a t m e n t and e x e r c i s e . L a t e r , t h e y may be p r e s c r i b e d t o be worn a t n i g h t and w h i l e r e s t i n g t o p r o v i d e good f u n c t i o n a l p o s i t i o n . 150 PART VI: SURGICAL PINNING Metal p i n s a r e sometimes i n s e r t e d i n t o an a f f e c t e d limb. These p i n s a r e screws p l a c e d through the bone and a r e thus h e l d i n p l a c e . These p i n s p r e v e n t new s k i n g r a f t s from r u b b i n g o f f and m a i n t a i n p r o p e r limb p o s i t i o n d u r i n g h e a l i n g . They can w i t h s t a n d y o u r a c t i v i t y w i t h o u t b r e a k i n g and w i t h o u t h u r t i n g . A l t h o u g h t h e y l o o k p a i n f u l , t he p i n s do not r e a l l y h u r t s i n c e bone has no p a i n n e r v e s . 151a The nurse w i l l c l e a n s e the p i n s i t e s f r e q u e n t l y and a p p l y an ointment. T h i s p r e v e n t s i n f e c t i o n and i n f l a m m a t i o n . The l e n g t h o f time you a r e s t r u n g up v a r i e s . Feel f r e e t o d i s c u s s t h i s w i t h y o u r d o c t o r . 151b APPENDIX D 152 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM A. Evaluation of the informative component: Yes No 1. Do you understand why you are on " i so l a t i on "? 2. Do you know the degrees of burns and what degree of burn you have? 3. Do you know why your pain medications are changed per iod ica l l y? 4. Do you know how your dressings are done? 5. Do you understand why debridement of your burns i s necessary? 6. Do you know why i t i s necessary for you to exercise often? 7. Do you know why e l a s t i c stockings are appl ied on your healing legs? 8. Do you understand why good nu t r i t i on i s important? B. Evaluation of the support component: Please rate the fo l lowing questions on th is scale 1 2 3 4 5 very helpful uncertain not useless helpful helpful How helpful did you f ind the tape-s l ide program? 1 2 3 4 5 How helpful did you f ind our discussion of the tape-s l ide program? 1 2 3 4 5 153 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -C. Evaluation of the Burn Bath component: Yes No 1. Do you understand why the colour of the water i s orange? 2. Do you understand why the water i s bubbling? 3. Do you understand why removal of dead skin (debridement) i s necessary? Evaluation of the support component: Please rate the fo l lowing questions on th is scale 1 2 3 4 5 very helpful uncertain not useless helpful helpful How helpful d id you f ind the tape-s l ide program? 1 2 3 4 5 How helpful did you f ind our d iscussion of the tape-s l ide program? 1 2 3 4 5 154 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -E. Evaluation of the Arm Bath component Yes No 1. Do you understand why the colour of the water i s orange? 2. Do you understand why the water i s bubbling? 3. Do you understand why the removal of dead skin (debridement) i s necessary? F. Evaluation of the support component: Please rate the fo l lowing questions on th is sca le . 1 2 3 4 5 very helpful uncertain not useless helpful helpful How helpful did you f ind the tape-s l ide program? 1 2 3 4 5 How helpful did you f ind our discussion of the tape-s l ide program? 1 2 3 4 5 155 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -Evaluation of the Skin Graf t ing component: Yes No 1. Do you understand why skin graf t ing i s necessary? 2. Do you understand why the nurse must r o l l each graf t with a "Q- t ip " frequently? 3. Do you understand why you must remain in one pos i t ion for a period of time? 4. Do you understand why you must not scratch an i tchy donor area? H. Evaluation of the support component: Please rate the fo l lowing questions on th i s sca le . 1 2 3 4 5 very helpful uncertain not useless helpful helpful How helpful d id you f ind the tape-s l ide program? 1 2 3 4 5 How helpful did you f ind our discussion of the tape-s l ide program? 1 2 3 4 5 156 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -I. Evaluation of the Sp l in t ing component: Yes No 1. Do you understand why you must wear sp l i n t s? 2. Do you understand why exercise i s important when the sp l i n t i s removed from your hand or leg? J . Evaluation of the support component: Please rate the fo l lowing questions on th is sca le : 1 2 3 4 5 very helpful uncertain not useless helpful helpful How helpful did you f ind the tape-s l ide program? 1 2 3 4 5 How helpful did you f ind our discussion of the tape-s l ide program? 1 2 3 4 5 157*~ INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -K. Evaluation of the Surgical Pinning component: Yes No 1. Do you understand why pinning i s necessary? 2. Do you understand why frequent, c leansing of the p ins i tes are necessary? 3. Do you bel ieve that , although the pins look p a i n f u l , they do not r ea l l y hurt? L. Evaluation of the support component: Please rate the fo l lowing questions on th is sca le . 1 2 3 4 5 very helpful uncertain not useless helpful helpful How helpful did you f ind the tape-s l ide program? 1 2 3 4 5 How helpful did you f ind our discussion of the tape-s l ide program? 1 2 3 4 5 1571) APPENDIX E Key: u^= a> = awake asleep sleeping p i l l pain p i l l nursing task SLEEP RECORD Name Room Date Day 1900 2000 2100 2200 2300 2400 0100 0200 0300 0400 0500 0600 0700 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Comments: 158b APPENDIX F Key: (Tj) = request (&)= given ( )= time 159a MEDICATION RECORD Room Analgesic i z e ? ^ 1 1 " Sedative Sleeping P i l l Day Day Evng. Night Day Evng. Night Evng. Night 1 2 3 4 5. 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Comments: 159b APPENDIX G NURSES ASSESSMENT OF PATIENT ANXIETY 1. Would you a s s e s s t h i s p a t i e n t ' s g e n e r a l p e r s o n a l i t y as b e i n g : 1 2 3 4 5 not f a i r l y m o d e r a t e l y h i g h l y e x t r e m e l y a n x i o u s a n x i o u s a n x i o u s anxious a n x i o u s 2. Under the e f f e c t s o f t r e a t m e n t s t r e s s , would you a s s e s s t h i s p a t i e n t as b e i n g : 1 2 3 4 5 not f a i r l y m o d e r a t e l y h i g h l y e x t r e m e l y a n x i o u s a n x i o u s a n x i o u s a n x i o u s a n x i o u s 160b APPENDIX H 161 YOUR DAILY DIARY The purpose of your diary i s to keep a da i l y account of your reactions to your treatments. Your feel ings and concerns are important to nurses. Although your diary w i l l be conf ident ia l during your hospital s tay , the researcher hopes to accumulate s im i la r comments and concerns common in a l l pat ients in th is study. This w i l l help give the nursing and medical s ta f f ins ight into the concerns of burn pat ients during t he i r recovery. INSTRUCTIONS: 1. Try to enter comments into your diary at the same time of day, every day, a f te r your treatments - - perhaps from 4-6 p.m. 2. Try to think of 5 possib le responses 1 2 3 4 5 6 strongly agree uncertain disagree disagree does not agree strongly apply 3. C i r c l e the appropriate number. 4. In the space below each sentence, enter comments, as much as you feel necessary, descr ib ing how you f e l t during the day with regard to that pa r t i cu la r top ic . DAILY DIARY 1. I found the dressings painful but to lerab le today. 1 2 3 4 5 6 strongly agree uncertain disagree disagree does not agree strongly apply Comments: 162 2. The p a i n does n o t seem as s e v e r e today. 1 2 3 4 5 6 s t r o n g l y .agree. u n c e r t a i n d i s a g r e e • s t r o n g l y .does n o t agre e d i s a g r e e a p p l y Comments: 3. .1 was a f r a i d o f my t r e a t m e n t s today. 1 2 3 4 5 6 s t r o n g l y a g r e e u n c e r t a i n d i s a g r e e s t r o n g l y does not agree d i s a g r e e a p p l y Comments: 163 I f e e l t h a t I don't need as many p a i n k i l l e r s today. \ 2 . 3 4 5 6 s t r o n g l y agree u n c e r t a i n d i s a g r e e s t r o n g l y does n o t a g r e e d i s a g r e e a p p l y Comments: I s l e p t w e l l l a s t n i g h t . 1 2 3 4 5 6 s t r o n g l y a g r e e u n c e r t a i n d i s a g r e e s t r o n g l y does not agree d i s a g r e e a p p l y Comments: 164 I was a n x i o u s today. 1 2 3 4 5 6 s t r o n g l y a g r e e u n c e r t a i n d i s a g r e e s t r o n g l y does not a g r e e d i s a g r e e a p p l y Comments: I,am c o n c e r n e d about r e t u r n i n g t o my j o b o r way o f l i f e . 1 2 3 4 5 6 s t r o n g l y a g r e e u n c e r t a i n d i s a g r e e s t r o n g l y does not agree d i s a g r e e a p p l y Comments: 165 8. I am c o n c e r n e d about my f a m i l y . 1 2 3 4 5 6 s t r o n g l y agree u n c e r t a i n d i s a g r e e s t r o n g l y does not a g r e e d i s a g r e e a p p l y Comments: 9.,I g e n e r a l l y f e e l b e t t e r today than I d i d y e s t e r d a y . 1 2 3 4 5 6 s t r o n g l y agree u n c e r t a i n d i s a g r e e s t r o n g l y does not a g r e e d i s a g r e e a p p l y Comments: 166 10. I feel discouraged today because I can see no improvement. 1 2 3 4 5 6 strongly agree uncertain disagree strongly does not agree disagree apply Comments: 11. I/f my general sense of wel l -being could be rated on a sca le , with (1) being "poor" and (5) being "g rea t ! " , today I am: 1 2 3 4 5 poor f a i r average good great! Comments: 

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