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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  in 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 to t h e required standard  THE UNIVERSITY OF BRITISH COLUMBIA May, 1977  (jp B a r b a r a 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 d e g r e e a t the U n i v e r s i t y o f B r i t i s h C o l u m b i a , I a g r e e 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 I f u r t h e r agree that permission f o r s c h o l a r l y p u r p o s e s may by h i s r e p r e s e n t a t i v e s .  for extensive  and  study.  copying of t h i s thesis  be g r a n t e d by the Head o f my Department o r It i s understood that copying or 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 written  permission.  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  my  ii ABSTRACT P l a n n e d 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 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 Stress a s s o c i a t e d with treatments the burn p a t i e n t .  i s a p o t e n t i a l cause o f a n x i e t y i n  T h i s d e s c r i p t i v e s t u d y examined the e m o t i o n a l  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 n f i v e a d u l t burn v i c t i m s  reactions  during  hospitalization. The p u r p o s e 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  information followed  p s y c h o l o g i c a l support i n reducing the e f f e c t s o f treatment 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  anxiety producing  by  stress in  of i n f o r m a t i o n about  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  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  treatments  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 t h e i n v e s t i g a t o r and  the  patient. The d e s i g n o f t h e s t u d y 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 f r o m two  perspectives.  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 t h e o n g o i n g s i t u a t i o n o f burn c a r e . B r i e f l y , t h e n u l l h y p o t h e s e s c h a l l e n g e d were: 1. T h e r e i s no m e a s u r a b l e 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 2. T h e r e i s no m e a s u r a b l e 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 ii 3. T h e r e i s no m e a s u r a b l e 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. T h e r e i s no m e a s u r a b l e 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 m e a s u r a b l e 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. T h e r e i s no c o r r e l a t i o n between the n u r s e s ' a s s e s s m e n t 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 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. T h e r e i s no c o r r e l a t i o n between t h e n u r s e s ' a s s e s s m e n t o f t h e p a t i e n t s ' s t a t e a n x i e t y and t h e 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 subjective stress.  Such v a r i a b l e s were s t a t e and t r a i t  anxiety,  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 t h e d a t a 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 hospitalization.  However, t h e r e was no m e a s u r a b l e i n c r e a s e i n t h e  hours o f s l e e p and no m e a s u r a b l e 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 t h e 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  support,  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 p l a n n e d i n f o r m a t i o n a l and  supportive  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 t h e e f f e c t s o f treatment 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 . T r e n d s 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  throughout  iv 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 t h e 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 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 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 , 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 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  reducing  stress.  V  TABLE OF CONTENTS ABSTRACT  i i  LIST OF TABLES  vii  ACKNOWLEDGEMENTS  viii  Chapter 1.  INTRODUCTION .; Statement o f the Problem Purposes o f the Study Null Hypotheses S i g n i f i c a n c e o f t h e Study D e f i n i t i o n o f Terms Assumptions Limitations Overview o f Methodology Development o f Remaining C h a p t e r s  2.  REVIEW OF THE LITERATURE 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 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 C o n c e p t 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 S l e e p P a t t e r n s Summary  14  3.  THE STUDY ",The S e t t i n g The Sample Method o f Data Delineation of Data G a t h e r i n g Method o f Data  42  , Collection Variables Instruments Analysis  viChapter 4.  THE FINDINGS Introduction Evaluation o f the Planned Nursing Interventions from Data C o l l e c t i n g I n s t r u m e n t s Evaluation o f the Planned Nursing Interventions from P a t i e n t Comments S t a t i s t i c a l Analysis o f the Findings P s y c h o l o g i c a l Phases o f Burn C a r e i n Hospitalized Patients Discussion o f the Findings Summary  5.  SUMMARY, RECOMMENDATIONS, CONCLUSIONS Summary Recommendations I m p l i c a t i o n s f o r Further Study Conclusions  BIBLIOGRAPHY APPENDICES A B C D E F G H  61  118  124  C o n s e n t Form S t a t e - T r a i t Anxiety Inventory S c r i p t o f t h e A u d i o - V i s u a l Program 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 Sleep Record M e d i c a t i o n Record Nurses' Assessment o f P a t i e n t Anxiety P a t i e n t ' s Personal Diary  132b 133b 135b 151b 157b 158b 159b 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 STATE-TRAIT ANXIETY INVENTORY AND TOTAL SCORES OF THE DIARY  6  4  SCORES OF THE "TRAIT" PORTION OF THE STATE-TRAIT 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 h e a s s i s t a n c e g i v e n by many p e o p l e d u r i n g t h e 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 e x t e n d e d t o Dr. Ruth Z i t n i k and Dr. J a c k Yensen f o r t h e hours spent i n c o n s u l t a t i o n d u r i n g t h e 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  appreciated.  S p e c i a l t h a n k s a r e e x t e n d e d t o t h e p a t i e n t s , n u r s e s and o t h e r s t a f f members o f t h e 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 h e r g e n u i n e 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  the preparation o f this  thesis. G r a t i t u d e i s c o n v e y e d 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 h e manuscript.  Chapter 1  INTRODUCTION Stress associated with treatments i s a potential cause of anxiety in the burned p a t i e n t . individuals.  The e f f e c t s of treatment stress vary among  Every burn patient reacts d i f f e r e n t l y to the s t r e s s o r s  in a burn unit and every patient experiences a d i f f e r e n t l e v e l of anxiety.  The problem i s posed:  Would nursing interventions comprised  of psychological support and an i n s t r u c t i o n a l program providing information about treatments, reduce anxiety in selected burn patients? The purpose of t h i s study was to investigate the effectiveness of an i n s t r u c t i o n a l program providing treatment information and psychological support in r e l i e v i n g the e f f e c t s of treatment stress 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 accumulation of information about  anxiety-producing s t r e s s o r s during h o s p i t a l i z a t i o n , as perceived by the p a t i e n t s , was the other major purpose of t h i s 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 i n j u r i e s sustained by man. Burns not only a f f e c t an i n d i v i d u a l ' s p h y s i o l o g i c a l state but also his psychological s t a t e .  Once a burn has occurred, medical therapy  and nursing interventions are d i r e c t e d toward r e s t o r a t i o n and r e p a i r of t i s s u e s .  L i f e - s u s t a i n i n g measures are paramount.  Once they are  D.M. Jackson, "Reconstruction and R e h a b i l i t a t i o n After Burning," Nursing M i r r o r (March 21, 1969), p.30. 1  2 initiated, it  i s usually p o s s i b l e to attend to the psychological process  of adjusting to a burn i n j u r y . During the i n i t i a l  few days post i n j u r y , e f f o r t s are d i r e c t e d  toward r e s o l u t i o n of immediate problems r e s u l t i n g from the burn i n j u r y . Innumerable systemic changes take p l a c e , the most important of which i s the a l t e r a t i o n in f l u i d and e l e c t r o l y t e balance.  Hypovolemic shock,  airway o b s t r u c t i o n , impaired c i r c u l a t i o n to extremities d i s t a l  to  circumferential burns are some of the other major problems which may occur.^ •3 Jacoby's  objectives 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 o n t o f pain are paramount.  Control of b a c t e r i a l growth on the burn wound and w i t h i n  the body as well as conversion of the open wound to a closed wound are major objectives of a long term treatment program. Preservation of body function and appearance are continuous objectives from the time of admission to a burn u n i t .  Of equal importance, however, i s the  r e s t o r a t i o n of the mental and emotional e q u i l i b r i u m of the p a t i e n t . It i s to t h i s l a s t o b j e c t i v e that t h i s study i s d i r e c t e d . Serious emotional problems e x i s t i n extensively burned p a t i e n t s . The management of these problems i s an integral part of o v e r a l l therapy.  Betty G. McGranahan, "Nursing Care of the Burned P a t i e n t , " Journal of the American Operating Room Nurses 20 (November 1974, p.792. Florence G. Jacoby, Nursing Care of the Patient With Burns (St. L o u i s : C.V. Mosby C o . , 1972), p.4.  3 When a severely burned patient i s admitted to h o s p 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 patients are  d i f f i c u l t to manage because of t h e i r i n a b i l i t y to adjust to t h e i r changed physical state and the hospital environment.  Clinical  experience has demonstrated that emotional factors have considerable 4 influence on the p a t i e n t ' s rate of physical recovery. An emotional state which has been disrupted in burn patients 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 s t r e s s of treatments, these are a l l prevalent.  Anxiety may overshadow the patient from the  moment of his conscious awareness of his accident to months a f t e r discharge from the h o s p i t a l . The amount of anxiety experienced by an i n d i v i d u a l i s a highly personal matter determined by many f a c t o r s . i l l u s t r a t e s this point.  The following incident  The i n v e s t i g a t o r was observing two burn  baths on a burn unit of a large c i t y h o s p i t a l .  One p a t i e n t , a  15 year o l d boy, severely burned with t a r to 50% of his body was washing and debriding (removing dead t i s s u e from) his own burns with no overt sign of pain.  He crawled around in the tank as i f he were  enjoying a d a i l y tub bath. was a 50 year old man.  The next patient to go into the burn bath  He was burned l e s s severely and to a l e s s e r  extent than the teenager.  He lay r i g i d on the s t r e t c h e r being lowered  David Hamburg and C u r t i s A r t z et a l , " C l i n i c a l Importance of Emotional Problems in the Care of Patients with Burns," New England Journal of Medicine 248 (February 26, 1953), p.355.  4 i n t o the tank.  He did not move u n t i l asked t o , was thoroughly frightened  and in obvious p a i n .  The d i s t r e s s experienced by t h i s man was great and  i t hindered the debridement of his wounds as well as his a b i l i t y to r e l a x i n the warm whirlpool tank.  This example i l l u s t r a t e s that each  i n d i v i d u a l reacts d i f f e r e n t l y to the e f f e c t s of treatment s t r e s s and every i n d i v i d u a l experiences a d i f f e r e n t l e v e l of anxiety i n s i m i l a r situations. Statement of the Problem The problem i s stated as a question. Does the use of planned nursing i n t e r v e n t i o n s , providing psychological support and treatment information, reduce the e f f e c t s of treatment s t r e s s as measured by various i n d i c a t o r s of anxiety? Purposes of the Study The purpose of t h i s study was t o : 1. Investigate the effectiveness of an i n s t r u c t i o n a l program providing treatment information and psychological support in r e l i e v i n g the e f f e c t s of treatment s t r e s s . 2. I d e n t i f y and accumulate information about anxiety-producing stressors during h o s p i t a l i z a t i o n as perceived by burn p a t i e n t s . Null Hypotheses The f o l l o w i n g n u l l hypotheses were considered. 1.  There i s no measurable change in t r a i t anxiety over unit time i n a  sample of burn patients 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 psychological support during the course of treatments as measured by the S t a t e - T r a i t Anxiety Inventories.  5 2.  There i s no measurable reduction of state anxiety over unit time i n  a sample of burn patients 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 psychological support during the course of treatments as measured by the S t a t e - T r a i t Anxiety Inventories and as indicated by the p a t i e n t s ' personal d i a r i e s . 3.  There i s no measurable increase i n the hours of sleep over u n i t  time in a sample of burn patients 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 psychological support as measured by the nurses' observation on the sleep record and as indicated in the p a t i e n t s ' personal d i a r i e s . 4.  There i s no measurable reduction in expressed need for analgesic  and sedative medication over u n i t time i n a sample of burn patients 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 psychological  support as measured by the nurses' observation on the medication record and as indicated by the p a t i e n t s ' personal d i a r i e s . 5.  There i s no measurable i n d i c a t i o n of increased reported w e l l - b e i n g  over unit time in a sample of burn patients r e c e i v i n g exposure to an instructional  program and psychological support as indicated in the  p a t i e n t s ' personal d i a r i e s . 6.  There i s no c o r r e l a t i o n between the nurses' assessment of the  p a t i e n t s ' t r a i t anxiety l e v e l s and the t r a i t anxiety measured by the S t a t e - T r a i t Anxiety 7.  Inventories.  There i s no c o r r e l a t i o n between the nurses' assessment of the  p a t i e n t s ' state anxiety and the state anxiety measured by the S t a t e - T r a i t Anxiety  Inventories.  6  S i g n i f i c a n c e of the Study The l i t e r a t u r e substantiates the problem of anxiety as a v a r i a b l e in the care of burn p a t i e n t s .  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 p a t i e n t s .  In  reviewing the l i t e r a t u r e on the nursing care of the burned p a t i e n t , systematic approaches to interventions i n t h i s domain, based on assessment of the unique needs of each p a t i e n t , are l a c k i n g . The research aim, t h e r e f o r e , i s to t e s t nursing interventions s p e c i f i c a l l y designed to reduce the e f f e c t s of treatment stress in burn patients. D e f i n i t i o n of Terms Anxiety - a p e r s i s t e n t f e e l i n g of dread, apprehension and 5 impending d i s a s t e r . State Anxiety - a t r a n s i e n t mood r e f l e c t i n g awareness of an impending unpleasant occurrence at any given moment i n time.*' T r a i t Anxiety - a p r e d i s p o s i t i o n to the reaction of anxiety to a v a r i e t y of s t i m u l i and s i t u a t i o n s .  "Lawrence C. Kolb and Arthur P. Noyes, Modern C l i n i c a l Psychiatry (Toronto, Ontario: W. B. Saunders C o . , 1973), p.82. ^Linford Rees, "Anxiety Factors i n Comprehensive P a t i e n t Care," Excerpta Medica Amsterdam (1973), p.2. 7  Ibid.,  p.2.  7  Burn - loss of c o n t i n u i t y of the body surface due to a coagulation and destruction o f skin and subcutaneous t i s s u e s by thermal changes, i n c l u d i n g both heat and o  c o l d , by chemicals, by e l e c t r i c i t y and by r a d i a t i o n . F i r s t degree burn - an erythema of the area involved. Second degree burn - destruction of the epidermis with b l i s t e r formation due to the exudation of plasma from the deeper l a y e r of dermis which elevates the epidermis. Third degree burn - destruction of the f u l l thickness of 9 the skin plus any subcutaneous t i s s u e s involved. Fear - an a f f e c t i v e response to an actual current  external  danger which subsides with the e l i m i n a t i o n of the threatening Instructional  situation.^  Program - an audio-visual a i d , in the form o f  a t a p e - s l i d e program providing a general  orientation  as well as information about s p e c 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 a n t i c i p a t o r y guidance by the nurse. Robert H. A l d r i c h , "Forensic Aspects of Burns," Annals of Surgery 117 (April 1943), p.576. 9  Ibid.,  p.577.  °Kolb, Modern C l i n i c a l P s y c h i a t r y , 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  it.^  T r e a t m e n t 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 f r o m burn treatment  as measured by v a r i o u s i n d i c a t o r s s u c h as  t h e 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  observation  and the s c o r e s a c h i e v e d on t h e S t a t e - T r a i t A n x i e t y Inventory. 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 treatment  s t r e s s i n burn p a t i e n t s i s b a s e d 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 source of  anxiety.  i s a prominent  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 emotional  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 13  and  perceives  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 nurse's r e s p o n s i b i l i t y . T r e a t m e n t s t r e s s e x i s t s i n burn p a t i e n t s . treatment  The e f f e c t s o f  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 M e d i c a S c a n d i n a v i a 191 (1972), p.11. 19  13  George E n g e l , " P s y c h o l o g i c a l Responses o f M a j o r E n 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., 1 9 6 2 ) , p.265. P h y l l i s T r y o n and R o b e r t 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 L e o n a r d ( T o r o n t o : J.B. L i p p i n c o t t Co., 1 9 6 5 ) , p.125.  9 Treatment stress i s r e f l e c t e d in sleep patterns and need f o r analgesic and sedative medications. Treatment stress can be assessed by subjective observations by the s t a f f . Treatment stress can be assessed by o b j e c t i v e psychological t e s t i n g with an anxiety s c a l e . Patients can s u b j e c t i v e l y evaluate t h e i r f e e l i n g s of p a i n , a n x i e t y , sleeplessness and fear of treatments. S t a f f records reporting a p a t i e n t ' s sleep pattern and medication needs r e f l e c t treatment s t r e s s . Limitations As an exploratory study, the only i n t e n t was to examine variables operating in burn care and generate speculative r e l a t i o n s h i p s among the i d e n t i f i e d v a r i a b l e s . Since sample s i z e 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 r e s u l t a n t sample s i z e is small.  It was not the i n t e n t of the study to generalize the  findings to a l l burn p a t i e n t s . No inference of c a u s a l i t y was intended between the nursing interventions and the reductiongof treatment s t r e s s . Internal v a l i d i t y may have been jeopardized due to the e f f e c t s of h i s t o r y , maturation and instrument decay. The uniqueness of the d a i l y d i a r y does not lend i t s e l f to and r e l i a b i l i t y  validity  testing.  Medication records are considered highly v a l i d 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 r o u t i n e l y given. The nurses' recordings of the p a t i e n t s ' sleep was not tested f o r 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 times.  The a l l encompassing  nature of pain and the appearance of a burn would f u r t h e r complicate the i d e n t i f i c a t i o n of anxiety l e v e l s by those c a r i n g f o r these patients. 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 patient  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 p a r t i c i p a t e i n the study. A few days a f t e r admission, the patient was assessed i n an intake interview.  The purpose of the b r i e f v i s i t was to c o l l e c t  information  about the patient and his reactions to his care and treatments.  The  i n v e s t i g a t o r established her r o l e as a nurse s p e c i a l i s t studying burn c a r e , not involved in the day to day c a r e , but gathering on the reactions of burn patients to t h e i r treatments.  information She v i s i t e d  eight times during the period of each p a t i e n t ' s h o s p i t a l i z a t i o n to answer any questions, provide emotional support as needed and prepare him f o r new phases i n his treatment. Since each patient 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 guidance and emotional support was an i n d i v i d u a l process dependent on such things as the p a t i e n t ' s background experience, thought p a t t e r n s , vocabulary and  11 his a b i l i t y to understand what i s going to happen. Shortly a f t e r admission, the S t a t e - T r a i t Anxiety Inventory (see Appendix B) was administered.  Part I of a t a p e - s l i d e program  "Orientation to the Burn Unit" was shown (see Appendix C ) .  This  s p e c i f i c section of the t a p e - s l i d e program and the discussion f o l l o w i n g were evaluated by means of the evaluation tool for the i n s t r u c t i o n a l program (see Appendix D).  A l s o , at t h i s time, the s t a f f  nurses began recording sleep and medications in records prepared f o r t h i s study,(see Appendix E and F ) .  The nurse, caring f o r the p a t i e n t ,  was asked to assess the p a t i e n t ' s l e v e l of state and t r a i t anxiety and rate her subjective observations of the p a t i e n t ' s anxiety l e v e l on a L i k e r t scale (see Appendix G). daily diary.  The patient began to keep a  This day to day subjective evaluation on a L i k e r t scale  reported the pain experienced, need f o r analgesic medication, s l e e p , personal concerns and w e l l - b e i n g .  These f a c t o r s were considered i n  a composite score to i n d i c a t e anxiety l e v e l for that day (see Appendix H). During a s p e c i f i e d time period of not less than three weeks, appropriate sections of an i n s t r u c t i o n a l program were shown to the patient by the i n v e s t i g a t o r .  Depending on the treatment the patient was  r e c e i v i n g , the appropriate portion of the t a p e - s l i d e program and the discussion following were evaluated by the patient i n a structured interview with the i n v e s t i g a t o r .  The S t a t e - T r a i t Anxiety Inventory  was administered to the patient at two i n t e r v a l s before a treatment session and a two i n t e r v a l s a f t e r a treatment session. The i n v e s t i g a t o r v i s i t e d each patient not only at the time of the  administration of the S t a t e - T r a 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 d a i l y diary progress, to encourage the patient to v e r b a l i z e his fears and a n x i e t i e s as expressed i n the content of the d i a r y , to o f f e r appropriate explanations and to answer any questions. The i n d i v i d u a l emotional support and encouragement given to the patient and his family was planned to support the care implemented by the s t a f f nurses. At the end of a s p e c i f i e d time period from admission, the patient was interviewed again and the f i n a l S t a t e - T r a i t Anxiety administered by the i n v e s t i g a t o r . d a i l y diary were terminated.  Inventory  The s l e e p , medication records and  (The patient was given the option to  continue his diary i f he so wished, a f t e r the r e s u l t s were compiled). The nurse, caring f o r the p a t i e n t , was asked to again assess the p a t i e n t ' s anxiety l e v e l on a L i k e r t s c a l e . In most cases the termination of data c o l l e c t i o n coincided with discharge.  Thus discharge planning became part of the i n s t r u c t i o n a l  program and psychological support given to the patient during the study.  13 Development of Remaining Chapters This study i s reported i n f i v e chapters.  The f i r s t chapter introduces  the problem of anxiety due to the e f f e c t s of treatment stress in burn patients.  It addresses the purpose and the s i g n i f i c a n c e of the study, the  assumptions, the l i m i t a t i o n s 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 f u r t h e r knowledge of the psychological i m p l i c a t i o n s of burn c a r e , the r e l a t i o n s h i p of pain to anxiety and the phenomena of anxiety.  Implications for a u d i o - v i s u a l  aids to a s s i s t in patient teaching on burn u n i t s , the therapeutic nurse-patient r e l a t i o n s h i p and the e f f e c t of anxiety on sleep patterns are b r i e f l y discussed. Chapter three describes the methodology of the study.  Sample  s e l e c t i o n , d e l i n e a t i o n of v a r i a b l e s , the research p l a n , data c o l l e c t i n g instruments and method of data a n a l y s i s are presented. Analysis and i n t e r p r e t a t i o n of the data and findings are discussed i n chapter four. The f i n a l chapter includes a summary, plus recommendations and i m p l i c a t i o n s f o r f u r t h e r study.  14  Chapter 2 REVIEW OF LITERATURE S e l e c t e d l i t e r a t u r e was  reviewed to support the development of the  study.  P l a s t i c s u r g e o n s and n u r s e s were i n t e r v i e w e d  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 p r o b l e m s i n burn u n i t s .  i n v e s t i g a t o r ' s working experiences  in Toronto,  i n burn u n i t s i n T o r o n t o and  Ontario The  Vancouver  have f u r t h e r s u b s t a n t i a t e d the p r o b l e m o f i n c r e a s e s t a t e a n x i e t y due 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 .  to  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  of  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 It w i l l d i s c u s s , f i r s t l y , the psychological  the need f o r t h i s s t u d y . 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 anxiety; f o u r t h l y , the i m p l i c a t i o n s of audio-visual aids to 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 relationship. be  nurse-patient  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  will  presented. Considerable  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  and s u r g i c a l t e c h n i q u e s  necessary  care  f o r the treatment 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 e m o t i o n a l p r o b l e m s 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 p r o b l e m s r e l a t e d t o i n - h o s p i t a l c a r e , s u c h as r e s u s c i t a t i o n , d e b r i d e m e n t , 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.R.  skin  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 1 9 6 3 ) , p.323.  grafting.  W h i l e 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 t h 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 documented.  has n o t been w e l l  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 ,  t h e 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 w h i c h 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 recovery.  The p r o b l e m i s o f p a r t i c u l a r i m p o r t a n c e  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  improving 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 . R e c e n t 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 treatment management.  16  and on methods o f  T h e r e has been r e s e a r c h c o n d u c t e d  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 .  by  nurses  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  concluded  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 a b o u t what to e x p e c t v a r i o u s p h a s e s 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  during reduced.  F r e d e r i c Chang and B r i a n t H e r z o g , "Burn M o r b i d i t y : A F o l l o w - u p S t u d y 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 l s o f S u r g e r y 183 ( J a n u a r y 1 9 7 6 ) , p.34. N.J. A n d r e a s e n 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. S h i z u k o F a g e r h a u g h , " 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 ( O c t o b e r 1 9 7 4 ) , 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  reactions of patients during  the  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 for nursing care.  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  to  v e n t i l a t e i n t e n s e a n g e r and f r u s t r a t i o n t o t h e 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 p r o b l e m 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  nurses.  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 by t h e C o c o a n u t Grove N i g h t c l u b f i r e i n Boston i n 1942. Lindemann o b s e r v e d  s e r i o u s emotional  aroused  Cobb and  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  at t h e M a s s a c h u s e t t s G e n e r a l  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  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 as p o s s i b l e .  d i s o r d e r s and t o p r e v e n t  such  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 these p a t i e n t s presented  recognize  to h o s p i t a l .  in-hospital neuropsychiatry  problems.  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 s u c h as " o u t b u r s t s o f p e r i o d s o f a p a t h y and f l u c t u a t i o n i n mood."  Fourteen  of  The  aggression,  O t h e r 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 E m o t i o n a l 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 t h e Cocoanut Grove Burns 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 , " A n n a l s o f S u r g e r y 117 (June 1 9 4 3 ) , pp.814-824.  17 Cobb s u g 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 p h a s e , 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 p r o b l e m s and h i s e f f o r t s t o adjust to his s i t u a t i o n . 20 Adler  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 t o  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 . f o l l o w e d up e l e v e n months l a t e r .  T h e s e p a t i e n t s were  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 f e m a l e p a t i e n t s were n o t 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 s e x e s .  Of t h e s e  46 p a t i e n t s , 20 d i d n o t 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 afterward.  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  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.  time  nervousness  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 general nervousness  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 n o t 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 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.  t h e 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 below one hour.  This suggests that unconsciousness,  prolonged unconsciousness,  consciousness. In  consciousness  and i n p a r t i c u l a r  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 , conducted  by Cobb, Lindemann and A d l e r b u i l t t h e  foundation f o r f u r t h e r research i n the area o f emotional r e a c t i o n s o f burned p a t i e n t s .  T h e s e 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 C o c o a n u t Grove D i s a s t e r , " J o u r n a l o f the A m e r i c a n 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 t h e t y p e s o f  emotional  p r o b l e m s 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 t h e a d j u s t m e n t 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 t h e a d a p t i v e p r o b l e m s 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 emotional  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 to t h e i r  treatments.  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 t h e p a t i e n t ' s c o o p e r a t i o n 22 course of i l l n e s s .  Hamburg  and  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  p r o b l e m 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  sources o f s t r e s s accumulated. inadequate  Hamburg l i s t e d t h e s e s t r e s s o r s a s :  communication between t h e p a t i e n t and p h y s i c i a n  regarding  the i n j u r y , a b s e n c e 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 e r g o i n g t h e same  experience  and t h e r e were o t h e r s who  recovered.  had been s i m i l a r l y i n j u r e d and had  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 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 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 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  profound.  single  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 P r o b l e m s and Mechanisms i n S e v e r e l y 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 1 9 5 3 ) , p . l . Ibid.,  p.3.  Ibid.,  p.11.  of  Burned  19 s e v e r e burns as m a n i f e s t e d by p h o t o g r a p h s o r by d e s c r i p t i o n s and had recovered 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 o f the s e v e r e l y burned p a t i e n t i n t h e a c u t e phase. to p r e f e r t h i s t i m e p e r i o d .  problems  Many a u t h o r s seem  I t i s i n t e r e s t i n g t o n o t e t h a t Hamburg  a l l u d e d t o 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 t o t h e 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 t h e 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 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 on t h e 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 e n c o u r a g e d 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 through photographs.  Brant!  c o n f i r m s t h i s by s t a t i n g t h a t  p h o t o g r a p h s 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 help a l l a y apprehension.  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 A n d r e a s e n and Noyes  examines e m o t i o n a l  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 to t h e 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 admission.  T h e r e a f t e r t h e y were v i s i t e d on d a i l y rounds  throughout  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 C a r e 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 E m o 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 , " New E n g l a n d J o u r n a l o f M e d i c i n e 286 ( J a n u a r y 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 w o r k e r . problems c r e a t e d by e m o t i o n a l  A v a r i e t y o f management  c o m p l i c a t i o n s were noted and  methods o f h a n d l i n g them were recommended. depression, r e g r e s s i o n , emotional  appropriate  R e a c t i o n s s u c h as  anxiety,  l a b i l i t y , n i g h t m a r e s and f e a r o f  d e f o r m i t y were n o t e d 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 A n d r e a s e n and Noyes c o n c l u d e d  that 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 and c a u s e s o f t h e s e r e a c t i o n s , e m o t i o n a l 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 . 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  course.  problems c o u l d The a u t h o r s  also  in a confidential  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 treatment  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  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 t h e p a t i e n t w i t h opportunity to a i r his concerns his treatment  the  as w e l l as g i v e him a b e t t e r i d e a o f  program by means o f an a u d i o - v i s u a l a i d and  R e l a t i v e t o A n d r e a s e n ' s comment, " i f the m e d i c a l  explanation.  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, e m o t i o n a l  problems could  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 e m o t i o n s .  I t seems t h a t t h e 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 a d e q u a t e s u p p o r t During the course o f a y e a r , Davidson  s t u d i e d the  system.  emotional  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," H e a r t 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 f o u n d 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  with anxiety.  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 e m o t i o n a l e n e r g y , t h e n t h e 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 u n i q u e 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 t h e 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 findings.  Davidson'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 t o 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 t a p e 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 f o u n d i n t h e 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 t h e p s y c h o l o g i c a l impact b r o u g h t 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 t h e s i t u a t i o n , s e c o n d , by e m p l o y i n g 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 .  such  As t h e y became  D a v i d s o n , " N u r s i n g Management o f E m o t i o n a l 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," p.375. K a t h r y n 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 R e s e a r c h ( 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 facilitated  recovery.  A n d r e a s e n ' s D a v i d s o n ' s , and S c h l i c h t m a n n ' s i n v e s t i g a t e d the emotional immediate a c u t e phase.  s t u d i e s , as j u s t c i t e d ,  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 t h e  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  c o n d u c t 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 p r e - i n j u r y and p o s t - i n j u r y .  status  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 situations.  stressful  M o r e o v e r , 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 even i n t h e p o s t - a c u t e  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  phase o f r e c o v e r y .  T h e r e f o r e , . c o n c l u s i o n s drawn  f r o m 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  study.  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 m e n t i o n was g i v e n t o t h e e f f e c t s o f t r e a t m e n t s i n v e s t i g a t o r ' s b e l i e f that treatment  on t h e s e p a t i e n t s .  It i s this  stress i s a precursor of  emotional  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 f r o m 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 c o n d u c t e d 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 t h e p r o v i s i o n o f e m o t i o n a l  support  as b e i n g paramount t h r o u g h o u t t h e 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  emotional  e q u i l i b r i u m o f the p a t i e n t .  Jacoby  stated that during  the  F l o r e n c e J a c o b y , N u r s i n g C a r e 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., 1 9 7 2 ) , 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 t h e 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 a b o u t 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 h o u l d be s t a r t e d a t t h e t i m e o f a d m i s s i o n .  S u p p o r t i v e h e l p i s needed  and  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 c o m t e m p l a t i o n o f s e l f .  He needs a g r e a t d e a l  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 Jackson  reported t h a t answering questions i s important 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 treatments.  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 the  p a t i e n t ' s f e a r s o f t h e 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 A n d r e a s e n  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 . T h e y 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  s e n s e o f m a s t e r y was i n c r e a s e d when t h 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  m o r a l e 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 n o t 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 . T h e s e 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 . 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 e v e r e 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 f r o m 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 f o r m e r burn p a t i e n t s , Chang and Herzog concluded  that emotional  s u p p o r t i n some f o r m s h o u l d be g i v e n on a r e g u l a r  basis during 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  response to the  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 . ^  Such i m p l i c a t i o n s go beyond t h e  3  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  question 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 a p p e a r a n c e . The e m o t i o n a l  r e s p o n s e to t h e trauma i n t h e 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 . the heightened suggested  A u t h o r s have r e p e a t e d l y  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.  stressed  A few have  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 a t t e m p t 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 e m o t i o n a l has been f o c u s e d on t h e e m o t i o n a l  support.  L i t t l e a t t e n t i o n , however,  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 during the lengthy h o s p i t a l i z a t i o n o f the post acute  recovery  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 e v e r e 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 H e r z o g , "Burn M o r b i d i t y : A F o l l o w - u p S t u d y 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 W e i s z , " 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 T r e a t m e n t 4 (November 1 9 6 7 ) , 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 t h e 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 stressor.  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 a s 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 h e a v e r a g e 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 t h e c a p a c i t y t o t o l e r a t e p a i n a p p e a r s t o d e c r e a s e o v e r t h e course 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 .  Anxious  expectation o f pain i s the s a l i e n t f a c t o r i n causing i t s progressive 35 increase. 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 t h e 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 , d e b r i d e m e n t , 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 , d o n o r s i t e p a i n was s e v e r e b u t g e n e r a l was n o t i c e a b l y r e d u c e d .  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 . author concluded  pain  This  i n h e r 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 a b o u t what  t o e x p e c t d u r i n g p h a s e s 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. 35  3 7  N.J. A n d r e a s e n and R u s s e l l Noyes, "Management o f Emotional i n S e r i o u s l y Burned A d u l t s , " p.66.  Reactions  36  S h i z u k o F a g e r h a u g h , " 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 c a n be a s t r e s s o r i n i t s e l f .  N u r s e s 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 p e r s o n ' s s o c i a l b a c k g r o u n d p r e s u m a b l y 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 experience  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 ,  w h e t h e r he w i l l f r e e l y e x p r e s s h i s e m o t i o n a l  a g i t a t i o n o r t r y t o keep  i t hidden f r o m 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 t h a n i s g e n e r a l l y s u p p o s e d ; 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 p r o b l e m than i s g e n e r a l l y recognized.  P a t i e n t s f r e q u e n t l y do n o t 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 e m o t i o n a l r e g a r d l e s s o f o r i g i n , as p a i n .  tension.  They r e p o r t a l l d i s c o m f o r t ,  I t i s o f great importance to r e a l i z e  t h a t t h e p a t i e n t needs n o t o n l y r e l i e f o f p a i n b u t r e l i e f o f f e a r as w e l l . 40 Bruegel person.  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 f r o m p e r s o n t o  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  in v i r t u a l l y a l l discussions o f the pain H i l l and K o r n e t s k y ^  concluded  experience.  f r o m 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 w h i c h 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 a p p e a r t o overestimate  the i n t e n s i t i e s of painful 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 Y o r k : John W i l e y and Sons., I n c . , 1 9 5 8 ) , p.9. D a 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 E m o t i o n a l P r o b l e m s i n C a r e o f P a t i e n t s w i t h B u r n s , " New England o f M e d i c i n e 248 ( F e b r u a r y 26, 1 9 5 3 ) , p.357.  Journal  '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 R e s e a r c h 20 ( J a n u a r y / F e b r u a r y 1 9 7 1 ) , p.26. H. G. H i l l and C. H. K o 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 M o r p h i n e 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 t h e t e n d e n c y 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 t h e 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 sensation highly s a l i e n t . 42 Moss and Meyer conducted  noxious  a study which d e a l t with the c a p a b i l i t y  o f nurses i n p r o v i d i n g care which i s e f f e c t i v e i n reducing 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 . T h u s , 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 a p p e a r s 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 r e d u c e o r r e l i e v e t h e f e e l i n g o f pain.  I f r e s p o n s e s w h i c h cope d i r e c t l y w i t h t h e 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 p r o v o k e d from t h e p a t i e n t and r e i n f o r c e d , then t h e t e n d e n c y 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 t h e a t t i t u d e o f t h e 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 t h e s t i m u l i , one can a l s o v a r y t h e p e r c e p t i o n o f t h e 43 s t i m u l i and t h e 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  t h e 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 t h e importance  of discussing pain  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 B u r t o n 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 1 9 6 6 ) , 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 , " A m e r i c a n J o u r n a l o f N u r s i n g 67 (June 1 9 6 7 ) , 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. emphasize t h e i m p o r t a n c e  M c C a f f e r y and Moss  o f remaining with t h e p a t i e n t .  i n c r e a s e s , so does t h e 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 .  As a n x i e t y Therefore, the  presence o f the nurse i s important during l a t t e r stages o f pain 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 t i m e a p p r o a c h e s 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 t h e 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 t h e body's i n t e g r i t y . the expression o f strong emotions.  The l i s t e n e r must be p r e p a r e d f o r P a t i e n t s b e n e f i t from  ventilation  o f such emotions and s u b s e q u e n t 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 C o n c e p t 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 many v i e w p o i n t s .  from  T h o s e who have w r i t t e n a b o u t 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  McCaffery  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 Schachter, Psychological A p p l i c a t i o n , (Stanford: Stanford U n i v e r s i t y P r e s s , 1 9 5 9 ) , p.6b.  4 7  N o y e s and 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 Severe p.421.  Burns,"  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  in varying  d e g r e e s 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 t o 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 t h e 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 m e a s u r i n g 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  counted  more than 120 p e r s o n a l i t y - t y p e t e s t s w h i c h have been c l a i m e d t o measure 49 anxiety.  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  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  precludes  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 . Highly i n d i v i d u a l f a c t o r s determine whether a p a r t i c u l a r s i t u a t i o n constitutes a psychological stress for a particular individual.  The  judgement as t o w h e t h e r 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 t h e e x t e r n a l e v e n t 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 Y o r k : Academic P r e s s , 1 9 6 6 ) , p.7. 50 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 M a j o r E n 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. S a u n d e r s , 1 9 6 2 ) , p.264. D U  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 s u c h 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 . pscyhosocial anxiety.  Levi  ' stated that  "every  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  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 f o u n d a t t h e extremes o f  the stimulus continuum, that i s , during exposure to over- or  under-stimulation."  Levi concedes that there are d i f f i c u l t i e s implied i n a l l attempts to 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 s u c h p u r e l y p h y s i c a l s t i m u l i , as t r a u m a , f r o m 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.  It is  well e s t a b l i s h e d t h a t the 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 the stimulus l a s t s  t o o l o n g o r i s r e p e a t e d t o o 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 disturbances  i n v a r i o u s o r g a n s and o r g a n s y s t e m s .  i f long-standing  o r i n t e n s e , may  Such a  dysfunction,  r e s u l t i n permanent s t r u c t u r a l changes  o f pathogenic s i g n i f i c a n c e , at l e a s t to predisposed  individuals.  To  i l l u s t r a t e the 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 V a n c o u v e r 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 f r o m developing. 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 f r o m 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 types of concepts.  A n x i e t y i s most commonly used i n an e m p i r i c a l  sense  t o d e n o t e 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 t i m e . 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 M e d i c a S c a n d i n a v i a 191, ( S t o c k h o l m 1972,) pp.14-15.  The t e r m 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  trait,  that 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 extent 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 a n d by p r o m i n e n t d e f e n s e s 53 against 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 f r o m 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 . T h e s e 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 w h i c h t h e y l a b e l e d t r a i t anxiety and s t a t e anxiety.  The t r a i t a n x i e t y  factor  was i n t e r p r e t e d a s m e a s u r i n g 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 t h e o r g a n i s m which f l u c t u a t e d over time. R e s e a r c h o n t h e 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  anxiety  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 f r o m 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 a n d t h e c o g n i t i v e a n d 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 b e c a u s e 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 .  It  would a p p e a r t h a t r e s e a r c h o n 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 a s 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 t i m e and 55 as a p e r s o n a l i t y t r a i t t h a t r e m a i n s r e l a t i v e l y s t a b l e o v e r t i m e . 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 t h e 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 a n d 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 M a r g a r e t Newman, A S o u r c e Book o f N u r s i n g R e s e a r c h ( P h i l a d e l p h i a : F.A. D a v i s Co., 1 9 7 3 ) , p . 1 1 .  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 a p p r o a c h f o r p a t i e n t s who a p p e a r 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 a p p r o a c h 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.  Devising  ways t o r e d u c e 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 T o o l 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 procedure  i s l i k e l y to decrease anxiety i n the p r e - s u r g i c a l p a t i e n t . 57  According to Saylor, unknown.  p r e - s u r g i c a l a n x i e t y i s rooted i n f e a r o f the  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 t h e 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 t h e p r o c e d u r e 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 In r e f e r e n c e to t h e burn p a t i e n t , A n d r e a s e n  Williams  procedure.  stated that patients should  be warned w e l l i n a d v a n c e o f any p r o c e d u r e and g i v e n a broad 59 o f t h e i r t r e a t m e n t program.  accompanying  perspective  supported t h i s statement  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 , "Understanding P r e - S u r g i c a l Anxiety," Journal o f the A m e r i c a n O p e r a t i n g Room N u r s e s 22 ( O c t o b e r , 1975), p.626. 58 A n d r e a s e n and Noyes, "Management o f E m o 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 o r t h A m e r i c a 6 ( D e c e m b e r ! 9 7 1 ) , p.616.  A p a t i e n t i n Williams' study requested  t h e 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 t o do and what would happen t o him. By e x p l a i n i n g t h e procedure beforehand, the patient could prepare himself mentally was about t o o c c u r .  Therefore,  f e a r o f t h e unknown was  f o r what  diminished. *^ 6  T h i s i s a l s o one o f t h e m a j o r 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  present  study. Any new e v e n t w h i c h i m p i n g e s 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 t h e p e r s o n s u b j e c t e d t o t h e 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 in the reduction o f tension.  B a s i c t o t h e need t o a t t a c h some meaning t o  t h e e v e n t i s t h e need t o 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 . 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  Reduction o f  c a n be done e f f e c t i v e l y .  When t h e 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 c o m m u n i c a t i o n , r e a l i s t i c i n nature, can lessen f e a r .  6 1  Nurses' attempts t o give t h e 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 necessary  i n helping the patient face 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 w h i c h he c a n s t r u c t u r e t h e i m p e n d i n g 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  stress.  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  g o 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 t h e 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 r o u t i n e way. cooperation 6 0  61  Williams,  p a t i e n t being treated i n a  R a t h e r , he i s b e i n g t r e a t e d as a p e r s o n o f i n t e l l i g e n c e whose i s b e i n g s o u g h t by h i s n u r s e . "The Burned P a t i e n t ' s Need f o r T e a c h i n g , " p.638.  M..E. M e y e r s , "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 R e s e a r c h 13 ( S p r i n g 1 9 6 4 ) , 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 t h e 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 motivated to achieve these goals. 64 Hamburg and A r t z  s p e c i f i c a l l y e n d o r s e d 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 e m o t i o n a l s u p p o r t and e x p l a n a t i o n t o burn p a t i e n t s as r e l a t e d e a r l i e r in this chapter.  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  the l i k e l i h o o d of uneventful recovery i s p a r t i c u l a r l y encouraging 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 t e n d s 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 t h r o u g h t h e 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 t i m e 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 t h a n v e r b a l r e a s s u r a n c e b u t c a n n o t t a k e i t s place. 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 experience supports the assumption t h a t i t i s p o s s i b l e t o r e d u c e 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 t h e 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 t h e t r e a t m e n t o f b u r n s . belief.  O t h e r a u t h o r s were i n a c c o r d w i t h t h i s  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. D a 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 E m o t i o n a l Problems i n t h e C a r e o f P a t i e n t s w i t h Burns," New E n g l a n d 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.  35 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 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 n u r s e 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 t h e 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 treatments.  Her p u r p o s e 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 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 f o r new phases o f h i s t r e a t m e n t .  him  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 relationships.  Travelbee  involved in caring.  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  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  maintain helping r e l a t i o n s h i p s with others.  Travelbee defined nursing  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 t h e 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 in these experiences. In a s s i s t i n g t h e i n d i v i d u a l t o 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 t h e n u r s e and p a t i e n t .  This  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 m e a n i n g f u l 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 . Joyce Travelbee, Interpersonal Aspects of Nursing ( P h i l a d e l p h i a : F.A. D a v i s 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 a c h i e v e m e n t and  f o r s o l v i n g h i s own p r o b l e m s .  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 a s w e l l a s p r o v i d i n g an e n v i r o n m e n t i n w h i c h t h e p a t i e n t c a n 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 process  by making  i t e a s i e r f o r t h e p a t i e n t t o d i s c u s s p r o b l e m s and e n c o u r a g i n g him t o 67  explore 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 in a state o f homeostasis. interchanges  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  between t h e i n d i v i d u a l and h i s e n v i r o n m e n t and i s p a r t i c u l a r l y  d e p e n d e n t 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 w h i c h he g r a t i f i e s h i s e m o t i o n a l 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 p r o b l e m s  t h a t have been b r o u g h t a b o u t 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 previous equilibrium, 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 e m o t i o n a l u p s e t e n s u e 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 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  This c r i s i s affect  Nurses, 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 t h e 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 t i m e . * The p u r p o s e o f t h e p l 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 emotional e q u i l i b r i u m over the  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 o r H e a l t h S c i e n c e s , p.72. D o r o t h y M e r e n e s s , P s y c h i a t r i c N u r s i n g , 2nd e d . (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 . 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  By s h a r i n g t h e c o n c e r n s o f t h e  s u p p o r t as w e l l as i n f o r m a t i o n a b o u t 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 therapeutic r e l a t i o n s h i p with the p a t i e n t .  Gazda e t a l  7 0  stated that 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 through phases o f treatment;  i f n o t , e v e r y t h i n g t h a t happens ( o r does n o t  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 his  increase  anxiety. 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 study.  Basic to t h i s r e l a t i o n s h i p i s the communication o f the  b e l i e f i n t h e 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 understanding  and a s s i s t i n g i n h i s own c a r e .  This shared  understanding  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  nurse. The E f f e c t o f A n x i e t y on S l e e p  Patterns  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  dimensions,  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 general medicine are enormous.^ I t has been p o s t u l a t e d t h a t p o o r 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 indicators of increased anxiety.  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,  ^U.S.  7 2  p.174  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 R e s e a r c h 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, 1 9 7 3 ) , p . l .  Ibid.,  p.28.  S n y d e r and S c o t t  73  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 o n 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 psychophysiologists.  However, t h e s e a u t h o r s d i d n o t s u p p o r t t h i s t h e o r y  with f a c t s . The l i t e r a t u r e r e l a t e d t o s l e e p and a n x i e t y t e n d s 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 "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 .  than  Most o f t h e r e s e a r c h  studies  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 t h e e f f e c t s o f s l e e p deprivation in relation to c r i t i c a l l y ill patients. Luce and S e g a l ^ 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 7  during sleep.  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 .  Electroencephalograms  of  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 tensions and s t r e s s e s which occurred during d i s t u r b e d s l e e p . 75 CIift  concluded  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 t h e same age. sleep.  T h e women r e p o r t e d  poorer  A l s o , s e x 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  with age. Johns 73  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 .  Although  F r e d e r i c k S n y d e r a n d 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 , e d . 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 Y o r k : H o l t , R h i n e h a r t a n d W i n s t o n I n c . , 1 9 7 2 ) , p.680.  G a y G. Luce and J u l i u s S e g a l , Insomnia (Garden C i t y , New Y o r k : D o u b l e d a y and Co. I n c . , 1 9 6 9 ) , pp.62-63. 75 A n t h o n y 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: A m e r i c a n E l s e v i e r P u b l i s h i n g Co. I n c . , 1 9 7 5 ) , p.59. 7 4  7 6  M u r r a y W. J o h n s , "Methods F o r 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 1 9 7 1 ) , p.485-491.  39 d a i l y s l e e p c h a r t s have t h e a d v a n t a g e 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 information about d a i l y v a r i a t i o n s o f sleep over prolonged  p e r i o d s , no  s i n g l e method o f s l e e p a s s e s s m e n t , w h e t h e r 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. noted t h a t when d e p r e s s e d  7 7  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 , they tended to overestimate disturbance.  Johns  t h e i r degree o f sleep  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 w h e t h e r o r n o t t h e 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 t h e  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 t h e s u b j e c t i v e r e p o r t o f t h e 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  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 . 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  the  O f t e n , under  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 t h e r e l e a s e o f intrapsychic tension.  suppressed  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 t h e s t a f f  nurses  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 t h e 12 hour t i m e p e r i o d .  The  p a t i e n t was a s k e d 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 daily basis.  As t h e 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 t h e 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 J.B. L i p p i n c o t t Co., 1 9 7 2 ) , p.T33T.  (Toronto:  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 c a n be r e d u c e d a n d what f a c t o r s need t o be c o n s i d e r e d t o d i v e r t .  .  .  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 .  70  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 e m o t i o n a l 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 u n d e r s t a n d these p a t i e n t s ' b a s i c emotional processes so t h a t they 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 c a n 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 t h e 80 provision o f humanistic care. 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 person t o person.  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 .  stressor, increases anxiety.  P a i n , as a  Most p e o p l e r e s p o n d t o s t r e s s f u l  situations  with a r i s e i n t h e i r anxiety l e v e l . A n x i e t y a s 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 t h e d i s t i n c t i o n between a n x i e t y a s 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 .  Anxiety i s also  related to disturbance i n sleep patterns. 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 h e 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 and f r u s t r a t i o n s .  emotions  E x p l a n a t i o n , e m o t i o n a l 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 to S t r e s s , " p.12.  i n Patients' Reactions  'Norman B e r n s t e i n , "The Care o f Burned V i c t i m s , " New E n g l a n d J o u r n a l o f M e d i c i n e 286 ( J a n u a r y 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 anxiety. The r e v i e w o f t h e 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 t h e p r o b l e m 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 .  Chapter 3 THE STUDY A d e s c r i p t i v e a p p r o a c h 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 data c o l l e c t i n g instruments multiple post-test research plan. compared from two p e r s p e c t i v e s .  was used w i t h a one group p r e - t e s t , S e v e r a l v a r i a b l e s w i t h i n t h e group were  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 t h e s t r e n g t h o f t h e r e l a t i o n s h i p o f t h e two p e r s p e c t i v e s t o t h e s e v a r i a b l e s i n t h e r e a l i t y o f t h e o n - g o i n g s i t u a t i o n o f burn c a r e . A c a s e s t u d y a p p r o a c h was a l s o used The  simultaneously.  Setting  The s t u d y took p l a c e on t h e burn u n i t o f a l a r g e g e n e r a l 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 .  teaching  T h i s b u r n u n i t was  c o m p r i s e d 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  plastic  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  therapist.  A p s y c h i a t r i c nurse i s often consulted 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 e m o t i o n a l problems i n a d j u s t i n g t o t h e burn trauma. Burn T r e a t m e n t : 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 c o m p r e s s e s , d a i l y d e b r i d e m e n t o f e s c h a r and c o l l a g e n , b u r n b a t h s i n a Hubbard t a 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 frequent periods o f exercise.  and a r e worn c o n s t a n t l y e x c e p t f o r  S k i n g r a f t i n g o f t h i r d d e g r e e burns u s u a l l y  takes p l a c e soon a f t e r d e b r i d e m e n t o f t h e burn i n j u r y .  After skin grafts  43 have been p l a c e d on t h e 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 in order to express accumulated  f l u i d e x u d a t e from beneath t h e g r a f t .  times, surgical pinning of a limb i s necessary.  At  The p i n s , a t t a c h e d t o  t r a c t i o n , a r e n e c e s s a r y t o keep t h e l i m b 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 ! r e m o v a l . The a v e r a g e 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 t h e 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 t o t h e 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 a p p r o a c h e d and an e x p l a n a t i o n o f t h e 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 d e p e n d e n t upon the number o f burn v i c t i m s a d m i t t e d t o t h e 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 , t h e sample o f  t h i s s t u d y was c o m p r i s e d o f a t o t a l o f f i v e s u b j e c t s .  Subject C r i t e r i a 1.  A d u l t , 16 t o 65 y e a r s o f age. I t was t h o u g h t a s u b j e c t y o u n g e r 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 s t u d y o r the c o n t e n t o f t h e 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 there 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 with the  burn might a f f e c t t h e 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 t h e 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 t h e s u b j e c t s u n s u i t a b l e f o r the s t u d y .  A l s o , t h e p a t i e n t may be t o o s e d a t e d t o comprehend t h e  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 e x p o s u r e t o t h e program. 3.  Depth o f burn - second and/or t h i r d d e g r e e . 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 n o t a d m i t t e d t o hospital.  4.  A r e a 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 h e 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 t o p a r t i c i p a t e i n  the study.  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 t h e purpose o f t h e s t u d y was g i v e n .  The p a t i e n t was  i n f o r m e d t h a t he c o u l d withdraw f r o m t h e s t u d y a t any t i m e . 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 t h e information l i m i t e d to those i n v o l v e d i n t h e study.  A number, n o t t h e  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. c o l l e c t e d was n e c e s s a r y f o r t h e p u r p o s e s o f t h e s t u d y .  A l l information  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 t h e p a r t i c i p a n t s upon c o m p l e t i o n of the study, i f requested. i n s t r u c t i o n a l program.  Usual, r o u t i n e treatment d i d not include the  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 a p p r o a c h e d a few days a f t e r a d m i s s i o n and an explanation o f the study given before being requested to 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 n u r s e 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 t h e 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 h e p a t i e n t not l e s s than e i g h t t i m e s d u r i n g t h e 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 to p a r t i c i p a t e i n the study, the w r i t t e n consent form was s i g n e d by t h e 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 t h e n e x t day. a s s e s s e d by t h e i n v e s t i g a t o r .  The p a t i e n t was  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 a b o u t t h e p a t i e n t as w e l l as r e a c t i o n s t o c a r e and treatments. 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 Inventory  was a d m i n i s t e r e d by t h e i n v e s t i g a t o r . " E x p l a i n i n g Your Burn Care" was shown.  P a r t I o f t h e t a p e - s l i d e program, (In t h r e e c a s e s , i t was  necessary  t o show s u b s e q u e n t p a r t s o f t h e 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 t h e p r e s e n t a t i o n o f the program, t h e p a t i e n t was e n c o u r a g e d t o 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 e m o t i o n a l 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 time.  p r o v i d e d by t h e i n v e s t i g a t o r a t t h i s  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 t h e 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 d a t a 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 a s k e d t o e n t e r comments i n a d a i l y d i a r y  46  a r o u n d t h e same t i m e e v e r y day. On t h i s f i r s t day 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 , t h e n u r s e c a r i n g f o r the patient t r a i t anxiety.  was a s k e d t o a s s e s s h e r p a t i e n t ' s l e v e l o f s t a t e and She r a t e d h e r s u b j e c t i v e o p i n i o n o f t h e a n x i e t y l e v e l she  p e r c e i v e d i n h e r 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 patient's chart.  r e c o r d s were p l a c e d on t h e f r o n t o f t h e  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 t h e 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 p u r p o s e o f t h i s c a r d was t o i n f o r m t h e n u r s e s 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  study.  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 , t h e p a t i e n t was v i s i t e d by t h e i n v e s t i g a t o r e i g h t times.  Appropriate  sections o f the i n s t r u c t i o n a l  program were shown t o t h e p a t i e n t d e p e n d i n g on t h e t r e a t m e n t t h e 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 t h e  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 t h e 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 n o t a t random.  Two v i s i t s t o o k p l a c e i n  the m o r n i n g , 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 . high s t r e s s p e r i o d .  T h i s was c o n s i d e r e d a  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  by t h e i n v e s t i g a t o r d u r i n g each v i s i t . 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 .  administered  The p a t i e n t was e n c o u r a g e d t o  S i n c e each p a t i e n t i s an u n i q u e  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 d a n c e and e m o t i o n a l 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 t h e p a t i e n t ' s background  experience,  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 t h e r e a l i t y o f t h e burn t r e a t m e n t situation.  47 Two v i s i t s took p l a c e i n t h e 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 t h e 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 e n c o u r a g e d problems.  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  T h i s i n t e r a c t i o n w i t h t h e n u r s e s p e c i a l i s t was c o n s i d e r e d  supportive care. Two v i s i t s d i d t a k e p l a c e a t random where 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 was n o t a d m i n i s t e r e d . w h a t e v e r was on h i s mind.  The p a t i e n t took t h e l e a d i n d i s c u s s i n g  A t h e r a p e u t i c r a p p o r t was always  by c r e a t i n g a s u p p o r t i v e e n v i r o n m e n t  sought  on t h e p a r t o f t h e n u r s e  specialist.  A f t e r each v i s i t , t h e i n v e s t i g a t o r c o l l e c t e d t h e c o m p l e t e d  diaries.  Nurses' notes were r e v i e w e d 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 sleeping medications.  S i n c e t h e v i s i t s were n o t t a p e r e c o r d e d , t h e  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 t h e p a t i e n t i n on-going f i e l d notes. On t h e f i n a l day 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 , t h e 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 t h e i n v e s t i g a t o r . The p a t i e n t was asked t o e v a l u a t e t h e 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 t h o u g h t s and a n x i e t i e s . A r e v i e w o f t h e c o n t e n t s o f t h e 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 w i s h e d . The n u r s e c a r i n g f o r t h e 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 t h e 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 t h e time o f a d m i s s i o n . di s c o n t i n u e d .  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  48 Delineation of Variables 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 t h e 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 .  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  If  v a r i a b l e , i t i s necessary  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 c o n d i t i o n o f t h e human o r g a n i s m  state or  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 . may v a r y 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 .  State anxiety  I t i s an e m p i r i c a l  process  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 t i m e and a t a g i v e n 82  level of intensity. " T r a i t " anxiety refers to r e l a t i v e l y stable individual differences in anxiety proneness,  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 t h e  t e n d e n c y t o r e s p o n d 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 t h e 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 differences i n the strength o f the latent d i s p o s i t i o n t o manifest a c e r t a i n type o f r e a c t i o n . 81 Paul M c R e y n o l d s , "The A s s e s s m e n t 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 A s s e s s m e n t ( 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. G o r s u c h e t a l , Manual f o r t h e S t a t e - T r a i t Anxiety Inventory (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 , 1 9 6 8 ) , p. 2. I b i d . , p. 2. 8 3  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 t h o s e 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  "trait"  i n d i v i d u a l s because t h e y 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 " p e r s o n s a r e a l s o more l i k e l y  respond to s t r e s s f u l s i t u a t i o n s with i n c r e a s e d " s t a t e " i n t e n s i t y . whether o r n o t 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  to But  corresponding  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 w h i c h 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 d a n g e r o u s 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 experience. 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 of apprehension,  t e n s i o n and a c t i v a t i o n o f t h e a u t o n o m i c n e r v o u s  s y s t e m . 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 w h i c h the s t r e n g t h o f t h e s e e m o t i o n a l 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 e v e n t s t h a t i s evoked by some form o f stress.  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  State anxiety  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. G o r s u c h e t a l , 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 , 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 John W i l e y and Sons, 1 9 7 5 ) , V o l . 1, p. 129. I b i d . , pp. 137-139.  York:  50 i n f l u e n c e d by t h e e f f e c t s o f t r e a t m e n t in t h i s  s t r e s s i s t h e dependent v a r i a b l e  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 C a r e , " was p r o d u c e d by t h e 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 a b o u t t h e phases o f burn c a r e .  T h e r e 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  treatment. The c o n t e n t a r e a s o f t h e 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 I I  The Burn Bath  PART I I I  The Arm Bath  PART IV  Skin G r a f t i n g  PART V  Splinting  PART VI  Surgical  Pinning  A f t e r an e x p l a n a t i o n o f t h e p u r p o s e o f t h e program, a l l p a t i e n t s were shown P a r t I by t h e i n v e s t i g a t o r . treatment,  Depending on each p a t i e n t ' s phase o f  s u b s e q u e n t p a r t s were shown s e p a r a t e l y , b e f o r e t h e new  was i n i t i a t e d .  I f the treatment  treatment  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 t h e program was shown t o t h e p a t i e n t .  A f t e r t h e v i e w i n g o f each  s e c t i o n o f t h e t a p e - s l i d e program, t h e p a t i e n t was e n c o u r a g e d t o e x p r e s s his f e e l i n g s about h i s treatments  and t o a s k q u e s t i o n s a b o u t h i s c a r e .  S i n c e t h e p u r p o s e o f t h e program was t o a l l o w t h e p a t i e n t t o v i s u a l i z e his treatment  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 t h e  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 t h e 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 before his d a i l y treatments.  reality  T h i s approach was based on t h e p r e m i s e  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 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  that  "fit"  and  87  comprehension to prepare f o r the experience.  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 g u i d a n c e 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 t h e a n s w e r i n g o f h i s questions.  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 i n d e p e n d e n t  v a r i a b l e was an i n s t r u c t i o n a l program  c o m p r i s e d 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 L e v e l s o f a n x i e t y were m o n i t o r e d instruments.  Instuments 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  As m e n t i o n e d 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 t h e d a t a 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 k e y s , on t h e 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. J o h n s o n , "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 h e 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 o f the data c o l l e c t i o n p e r i o d .  and a t t h e end  E v a l u a t i o n o f t h e i n f o r m a t i o n a l and s u p p o r t  components o f t h e t a p e - s l i d e program and t h e 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 o u t 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 p u r p o s e .  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 t e s f o l l o w i n g e v e r y v i s i t w i t h each patient.  The n u r s e s ' n o t e s f o r each p a t i e n t were r e v i e w e d f o r d e s c r i p t i o n s  of behavior  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 . gathering instruments all  These data  were i n e f f e c t o v e r an a v e r a g e o f 25 days f o r  subjects. J u s t i f i c a t i o n f o r t h e above d a t a g a t h e r i n g i n s t r u m e n t s  1.  The S t a t e - T r a i t A n x i e t y  Inventory  follow.  (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 t h e 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 single  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 d e m o n s t r a t e d r e l a t i o n s h i p t o 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  t o 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 c o m p r i s e d 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 m e a s u r i n g t h e two d i s t i n c t a n x i e t y  concepts.  The STAI t r a i t s c a l e c o n s i s t s o f 20 s t a t e m e n t s t h a t ask p e o p l e t o d e s c r i b e how t h 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 , b u t t h e 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 t i m e . T h e s e 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 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 , 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 v a r y i n t h e i r d i s p o s i t i o n t o r e s p o n d t o p s y c h o l o g i c a l different levels of "state" intensity.  stress with  I t has been d e m o n s t r a t e d t h a t  s c o r e s on t h e s t a t e s c a l e i n c r e a s e i n r e s p o n s e 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 . R e g a r d i n g t h e r e l i a b i l i t y and v a l i d i t y o f t h e STAI, t h e t e s t retest reliability  ( s t a b i l i t y ) o f t h e t r a i t s c a l e i s r e l a t i v e l y high b u t  s t a b i l i t y c o e f f i c i e n t s f o r t h e s t a t e s c a l e t e n d t o 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 h i g h d e g r e e o f i n t e r n a l c o n s i s t e n c y .  Evidence  of the concurrent  v a l i d i t y o f t h e 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 t h e 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 m o d e r a t e l y high.  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 t h e i n t e r c o r r e l a t i o n s among t h e s e s c a l e s a p p r o a c h t h e 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 t h e  construct v a l i d i t y o f the state' scale i s impressive.  The STAI s t a t e  s c a l e was d e v 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 (that i s , differences i n the a b i l i t y o f the i n d i v i d u a l state items t o 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 d e g r e e s and k i 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 intensity). ^ 1  s t a t e which vary i n  The s c a l e may be used o v e r a wide range o f " s t a t e "  intensities. 99 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 1 0 0 1 0 1  I b i d . , p. 10. I b i d . , p. 11.  Inventory.  54 102 L e v i t t e n d o r s e s 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 developed standpoints.  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  methodological  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 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 r e 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 suggested  that  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 .  Trait  s c o r e s ought t o 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  respondents.  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 p r o v e d u s e f u l i n the measurement o f s t a t e and 104 t r a i t anxiety in surgical patients. 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 t o a d m i n i s t e r t o 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 A p p e n d i x 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 anxiety.  P a i n i s worsened by a n x i e t y and 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 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. I b i d . , p. 72. 1 0 3  104 105  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. N. J . A n d r e a s e n and R u s s e l l Noyes, e t a l , "Management o f E m o t i o n a l 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 E n g l a n d J o u r n a l o f M e d i c i n e 286, ( J a n u a r y 13, 1972):66.  55 Perceptions o f pain vary g r e a t l y from person t o person.  Anxiety i s  considered 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 discussions o f the pain 106 experience. 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 analgesic medication  r e f l e c t not only h i s level o f pain experience  but  also his level o f state anxiety.  I t follows that h i s requests 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  also r e f l e c t his level of anxiety.  As a method o f d a t a c o l l e c t i o n , a r e c o r d o f t h e f r e q u e n c y 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  and t i m e  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 t h e s t a f f n u r s e s o v e r t h e data c o l l e c t i o n p e r i o d . f r o m t h e nurses' n o t e s .  The t y p e and s t r e n g t h o f m e d i c a t i o n  noted  (See A p p e n d i x F ) . No a t t e m p t was made t o r e f i n e  the r e l i a b i l i t y o f t h e m e d i c a t i o n 3.  was  record.  S l e e p Record I t has been d e m o n s t r a t e d 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 that the 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 interesting to psychophysiologists. ^ 1  7  T h e r e f o r e , a r e c o r d was kept by t h e s t a f f n u r s e s o f t h e 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 R e s e a r c h 20, ( J a n u a r y - F e b r u a r y 1 9 7 1 ) : 26. F r e d e r i c k S n y d e r 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 . , 1 9 7 2 ) , p.680.  0700 hours (See A p p e n d i x E ) .  No a t t e m p t was made to d e t e r m i n e 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 c o m p a r i s o n a v a i l a b l e between the p a t i e n t ' s a s s e s s m e n t o f h i s s l e e p and the r e c o r d i n g o f the hours o f s l e e p 4. The P a t i e n t ' s P e r s o n a l  was  nurse's  obtained.  Daily Diary  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 a s k e d t o keep a personal d a i l y d i a r y of his thoughts,  f e e l i n g s and e m o t i o n s .  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. c o n s i d e r e d how he f e l t t h a t day a b o u t t r e a t m e n t s , experience,  He  then  p a i n a n t i c i p a t i o n and  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 A p p e n d i x H). The g o a l s o f the d i a r y were: a)  To a c c u m u l a t e 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 treatment,  including his perception of his pain, sleep patterns,  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 a c c u m u l a t e o n g o i n g 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 d e t e r m i n e 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  during  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 interview.  by a f o r m e r p a t i e n t d u r i n g an  T h i s p a t i e n t w i s h e d 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 p a p e r 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 r e d u c e s t a t e a n x i e t y .  57 The d i a r y was  k e p t 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 t h a n t h r e e weeks o r more t h a n one month.  The p a t i e n t was  instructed  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 Likert-type scale.  I f t h e p a t i e n t was  hands, a, r e l a t i v e was The p a t i e n t was  delegated  this  u n a b l e t o w r i t e due to burned task.  g i v e n f e e d b a c k by the i n v e s t i g a t o r a t the end  of  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 personal  perceptions  patient's  o f the e l e m e n t s o f the v a r i a b l e under study  for  c o m p a r i s o n w i t h the e x t e r n a l m e a s u r i n g d e v i c e s , namely the S t a t e - T r a i t Anxiety  Inventory,  s t a f f ' s perceptions  o f the p a t i e n t ' s a n x i e t y  5.  Nurses' Assessment o f  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  level.  Anxiety  The n u r s e c a r i n g f o r the p a t i e n t t h a t day was  a s k e d 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 scale.  T h i s a s s e s s m e n t 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 A p p e n d i x G). The p u r p o s e 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 r s e ' s a s s e s s m e n t 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 Anxiety  Inventory  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  anxiety from his 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 f o r m a t .  i n v e s t i g a t o r a s k e d the p a t i e n t q u e s t i o n s t a p e - s l i d e program he had been shown. the i n v e s t i g a t o r and i t was  The  p e r t a i n i n g t o the s e c t i o n o f the I f the p a t i e n t ' s answer s a t i s f i e d  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 ,  "yes" column o f the f o r m a t was c h e c k e d .  I f the p a t i e n t ' s r e p l y  s a t i s f y the i n v e s t i g a t o r , the "no" column was c h e c k e d and 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  given.  the  did.not  further  The p a t i e n t was t h e n a s k e d 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 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 .  discussion  (See A p p e n d i x D).  Method o f Data A n a l y s i s The methodology was  s e t up as a c o m p a r i s o n .  Appropriate  measures f o r c o m p a r i s o n were u t i l i z e d t o t e s t the n u l l 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  statistical  hypotheses.  s c o r e d as d e s c r i b e d i n the  ,108 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 Inventory  Anxiety  v a r i e s f r o m 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  subscales.  A p a i r e d c o m p a r i s o n between the means o f the " s t a t e " s c o r e s may d e t e r m i n e d 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 e r e i s no m e a s u r a b l e 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  be  that tested  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  Inventory,  pp.4-5.  59 A c o m p a r i s o n 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 the s l e e p r e c o r 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  A c o m p a r i s o n o f the means o f t h e s e two v a r i a b l e s  on was  determined. A c o m p a r i s o n 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 analgesic sedative medication amount o f m e d i c a t i o n  as e x p r e s s e d  requested,  i n h i s d a i l y d i a r y and  as r e c o r d e d on the m e d i c a t i o n  c o m p a r i s o n o f the means o f t h e s e v a r i a b l e s was  the  record.  A  determined.  A c o m p a r i s o n was made between the p a t i e n t ' s o p i n i o n o f h i s d e g r e e 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  measured by the S t a t e - T r a i t A n x i e t y o f t h e s e two v a r i a b l e s was  Inventory.  anxiety  A c o m p a r i s o n o f the means  determined.  A c o m p a r i s o n 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 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 by the S t a t e - T r a i t A n x i e t y  Inventory.  to  anxiety  A c o m p a r i s o n 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  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 t h e S t a t e - T r a i t Anxiety  Inventory.  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  support  component o f the i n s t r u c t i o n a l program was made f r o m 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.  T h e s e , however, were u t i l i z e d i n an i n d i v i d u a l c a s e s t u d y  r e p o r t o r g a n i z e d a r o u n d t h e 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 d a t a a n a l y s i s was s e t up as a c o m p a r i s o n The n u l l h y p o t h e s e s 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 for comparison.  O t h e r 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 .  Chapter 4 THE  FINDINGS  Introduction 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 the form  o f i n d i v i d u a l c a s e 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 t h e d a t a as o b j e c t i v e l y gathered  by t h e 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 .  subjective evaluation of the planned  Secondly, a  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  t h r o u g h 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 , the 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 t h e 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 t h e hypotheses o f the study. findings addressing will  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 t h e  the behavioral  phenomena e x h i b i t e d by t h e p a t i e n t s  follow. Since the S t a t e - T r a i t Anxiety  the s c o r e s o f t h e I n v e n t o r y , the i n v e s t i g a t o r . Inventory  Inventory  Manual d i d n o t i n t e r p r e t  t h e scores' were i n t e r p r e t e d a r b i t r a r i l y  The i n t e r p r e t a 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  follows: TABLE 1 INTERPRETATION STAI S c o r e s  OF THE STAI SCORES Interpretation  80 - 70  highly anxious  55 - 69  high-moderately anxious  45 - 54  moderately anxious  40 - 44  moderate-fairly  35 - 39  f a i r l y anxious  20 - 34  low a n x i e t y / n o n - a n x i o u s  anxious  by  62 R e g a r d i n g t h e s l e e p r e c o r d , t h e 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 t h a n 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 t o n u r s i n g t a s k s was n o t e d b u t n o t  t a k e n i n t o a c c o u n t when j u d g i n g t h e 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 h e 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 h e numbers on t h e L i k e r t s c a l e a f t e r each s t a t e m e n t i n t h e 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 t h e maximum s c o r e was 55, i n d i c a t i n g a high anxiety l e v e l . Evaluation o f the Planned Nursing 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 I n s t r u m e n t s P a t i e n t One T h i s 20 y e a r o l d male was burned t o 15% o f h i s body.  Second and  t h i r d d e g r e e burns c o v e r e d h i s hands, f o r e a r m s 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 h e s i x t h day a f t e r a d m i s s i o n t o t h e 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 T r e a t m e n t A d m i n i s t e r e d DAY 1  -  S a l i n e compresses i n t h e 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 t h e r i g h t hand, e v e n i n g arm b a t h t o t h e l e f t hand  DAYS 2-6  -  skin grafts r o l l e d every 2 hours, l a t e r , every 4 hours morning t u b bath f o l l o w e d by c l e a n s i n g o f t h e 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 t u b baths  DAYS 13-20  -  Porcine dressings applied to the right side o f t h e body. p a t i e n t t o be d i s c h a r g e d from h o s p i t a l t h e n e x t -. day.  DAY 21  -  Analysis o f the S t a t e - T r a i t Anxiety  Inventories  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  Anxiety  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 t o as t h e STAI, d i d n o t change  dramatically  over t h i s p a t i e n t s period o f recovery.  score,  A consistent middle  1  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  State  Portion  Trait  Portion  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 f r o m DAY 7 t o DAY 12 when t h e p a t i e n t was u n d e r g o i n g compress t r e a t m e n t t o h i s back.  However, t h e ' s t a t e '  score  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 t h e day o f d i s c h a r g e ,  t h e ' s t a t e ' s c o r e r o s e t o 48.  The p a t i e n t  a d m i t t e d t o t h e n u r s e s 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 a b o u t l e a v i n g the s e c u r i t y o f t h e burn u n i t . T h e r e 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 t h e 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 a p p e a r e d v e r y  apprehensive 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 .  This apprehension  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  progress. In summary, v i s u a l a n a l y s i s o f t h e 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 t i m e . toward heightened  A r i s e i n t h e s t a t e and t r a i t  anxiety c o i n c i d e d with p a i n f u l treatment.  no r e m a r k a b l e change i n t r a i t a n x i e t y o v e r  scores  T h e r e was  time.  A n a l y s i s o f t h e S l e e p Record Over t h e 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 nights o f consecutive sleep 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  every  2 hours and d u r i n g DAYS 9, 10 & 11 when compresses were b e i n g a p p l i e d t o 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 t h e STAI  were a t t h e i r h i g h e s t l e v e l on DAY 10. Analysis o f the Medication  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 by t h e p a t i e n t . DAY 5.  were r e q u e s t e d  frequently  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 f r o m DAY 1 t o  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 n o t e 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 t o h i s back.  O n l y one a n a l g e s i c was  g i v e n by t h e n u r s e 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 t h e 6 day compress p e r i o d . r e q u e s t e d by t h e p a t i e n t .  A f t e r DAY 9, o n l y 2 a n a l g e s i c s were  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, t h e n 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 t h e n u r s e s ' n o t e s 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 t u b b a t h . t o l e r a t e d the debridement frequently.  Although  he  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  The n u r s e s 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 . e x p r e s s i n g h i s anger i n words."  He a p p e a r e d a n g r y but was  not  He f e l t a l l p e n t - u p , c o u l d n ' t l e t o u t 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 t o c r y but j u s t couldn'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 t h e 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 t u b b a t h ; he had a new n u r s e 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 these reasons,plus the dreadful p a i n , r a i s e d h i s a n x i e t y level 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 t o n i g h t l y d r e s s i n g changes and subsequent  due  lack of sleep, depressed,  l o n e l y , bored and t h o u g h t t h a t time was "so slow i n p a s s i n g . " On DAY 10 and DAY 11, t h e 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 anxiety.  heightened  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 .  lacked sleep for three consecutive nights.  He  However, t h e n u r s e s ' n o t e s  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 c o m p l a i n e d 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 w r o t e t h a t he e n j o y e d  t a l k i n g w i t h t h e 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 a p p e a r s t h a t t h e c o m b i n a t i o n o f d e b r i d e m e n t o f t h e burn wound i n t h e t u b b a t h 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 t h e STAI, d i a r i e s , s l e e p r e c o r d and t h e e x p r e s s i o n o f  a n x i e t y i n t h e d i a r y comments.  P a t i e n t Two 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 covered 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 h e f o u r t h day a f t e r a d m i s s i o n t o t h e burn u n i t t o 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, 14, 17, 24, 29 and 31. The Burn T r e a t m e n t A d m i n i s t e r e d DAYS 1 - 3  - Burn b a t h s f o l l o w e d by P o l y m i x i n compresses e v e r y 4 hours  DAY 3  - Surgery - 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 - d e b r i d e m e n t 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 . 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 b a t h s resumed.  Skin grafts applied  67  DAYS 1 7 - 1 8  - K-wires removed. - S a l i n e compresses a p p l i e d t o open a r e a s between  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 u b b a t h s resumed.  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 17  grafts  Patient  mobilized  Day b e f o r e  A n a l y s i s o f t h e S t a t e -- T r a i t  discharge.  Inventories  The r e s u l t 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 s i g n i f i c a n t l y over the patient's period o f recovery. TABLE 1-2 SCORES OF THE STAI DAY  STAI  State Portion  T r a i t Portion  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 a p p e a r s t h a t s t a t e a n x i e t y r o s e from DAY 1 t o DAY 14. The p a t i e n t was u n d e r g o i n g compress t r e a t m e n t t o h i s l e g s f r o m DAY 1 t o DAY 8.  After  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,  the p a t i e n t complained  o f s e v e r e heel and knee p a i n .  p r e v a l e n t from DAY 11 t o DAY  This pain  was  14.  The " s t a t e " s c o r e o f t h e STAI d i 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 t o 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  t h e 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 anxiety. On DAY 24, the " s t a t e " s c o r e r o s e t o 38. m o b i l i z a t i o n was about t o b e g i n .  I t was noted t h a t  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 .  Furthermore,  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 t o t h e awkward p o s i t i o n he had t o m a i n t a i n . his  M o r e o v e r , s l e e p i n g d u r i n g t h e day  hindered  nocturnal sleep. The " s t a t e " s c o r e o f t h e 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 a b o u t 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 " v e r y h i g h . " There 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 t h e STAI.  The s c o r e s were t h e h i g h e s t on DAYS 17, 24 & 31. 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.  It is i n t e r e s t i n g to I t was n o t e d 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 t h e " 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 response to the e f f e c t s o f  69 treatment  stress.  T h e r e a p p e a r e d t o be no r e m a r k a b l e 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 t h e S l e e p Record Over t h e 31 days 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 , 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 . " occurred three times.  Three nights o f consecutive sleep l o s s  From DAY 18 t o DAY 24, t h e p a t i e n t had seven n i g h t s  of consecutive sleep loss.  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 b e i n g c o m p r e s s e d , 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  rolled  frequently. " 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 n o t 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 f r o m DAY 1 t o DAY 8.  However, t h e 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 state.  anxiety  On t h i s d a y , i t i s noted t h a t t h e compresses were b e i n g changed  e v e r y 4 h o u r 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  frequently.  Analysis o f the Medication  Record  S e d a t i v e s were a d m i n i s t e r e d  t o t h e p a t i e n t f o u r times a day f r o m  DAY 3 t o DAY 16, and t w i c e a day f r o m DAY 17 t o 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 h e 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  period.  the p a t i e n t requested a n a l g e s i c s f r e q u e n t l y .  From DAY 8 t o DAY 13,  During these days, h i s legs  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 b e i n g 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 v e r 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 - w i r e s 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 t h e r e m a i n d e r 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 . 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 n o t e d 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, 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 " e x t r e m e l y 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 . " sleep the previous night.  anxious,  The p a t i e n t had  little  H i s d i a r y s c o r e peaked on DAY 4 t o 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 .  D u r i n g a v i s i t w i t h t h e 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 a b o u t 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 t h e p a i n and the a n t i c i p a t i o n o f the s u r g i c a l pinning. On DAY 7, t h e s c o r e o f h i s d i a r y peaked a g a i n .  Although his " t r a i t "  s c o r e o f t h e STAI r e m a i n e d 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 t h e 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 ' n o t e s 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 complaining of t h i r s t .  and  No comments were w r i t t e n i n t h e d i a r y .  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  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 technique  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 in his recovery.  point  W i t h t h e s k i n g r a f t s on h i s l e g s , he t h o u g h t 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 " The d i a r y s c o r e r o s e to 31 on DAY p a t i e n t was day.  I t was  He a d m i t t e d  t h a t he was w o r r i e d a b o u t t h e removal o f the K-wires walking.  D i a r y e n t r y was m i s s e d from DAY  18 t o DAY  26 w i t h the e x c e p t i o n  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 .  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 On DAY  noted t h a t the  i n f o r m e d t h a t h i s K-wires would be removed on the f o l l o w i n g  and the a n t i c i p a t i o n o f p a i n on  DAY  16.  experience.  30, the d i a r y s c o r e r o s e f r o m DAY  He f e l t  miserable  his d i a r i e s . 19 to DAY  27.  The  notes reported that the p a t i e n t appeared apprehensive about his On DAY  of  nurses' discharge.  29, when the i n v e s t i g a t o r a s k e d the p a t i e n t i f he was w o r r i e d  g o i n g home, he answered n e g a t i v e l y . 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 He was r e s t l e s s and  However, on DAY  t h a t he was  31, t h e day  about  before  v e r y e x c i t e d a b o u t g o i n g home.  fidgity.  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 of treatment s t r e s s . Patient Three T h i s 30 y e a r o l d male was burned to 26% o f h i s body. t h i r d d e g r e e burns c o v e r e d  Second and  both hands, l e f t f o r e a r m , back, neck and  face.  Data was c o l l e c t e d f r o m t h i s p a t i e n t o v e r a 25 day p e r i o d , f r o m 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  investigator  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  Administered  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 E v e n i n g arm baths  DAYS 5 - 1 1  - As above p l u s S a l i n e compresses 4 hours  DAY 10  - Surgery - debridement - Skin f o r g r a f t s taken - Compresses resumed p o s t - o p 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  - Skin g r a f t s t o ear  t o neck and both arms e v e r y  - G r a f t s r o l l e d e v e r y 2 hours DAY 20  - Severe  earache  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 .  Analysis o f the State-Trait Anxiety Inventories 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 n o t change s i g n i f i c a n t l y over the p a t i e n t ' s p e r i o d o f recovery. a n x i e t y l e v e l was m a i n t a i n e d .  A c o n s i s t e n t low  73 TABLE 1-3 SCORES OF THE STAI DAY 1  STAI  State Portion  1  Trait Portion  30  24  4  2  22  22  8  3  22  22  15  4  21  22  18  5  20  21  25  6 Although  2  1  2  5  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 n o t ; c h a n g e  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 h e r e was no s i g n i f i c a n t 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.  A " n o n - a n x i o u s " p e r s o n a l i t y t r a i t was  maintained.  In summary, v i s u a l , a n a l y s i s o f t h e 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 Sleep Record Over t h e 25 days 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 , t h e 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  loss. 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 t h e p a t i e n t was i n severe pain p o s t - o p e r a t i v e l y . t h i s patient s t i l l maintained when compress t r e a t m e n t  However, i t i s i n t e r e s t i n g t o note t h a t a "good s l e e p " p a t t e r n f r o m DAY 5 t o DAY 10  was b e i n g a d m i n i s t e r e d .  This i s contrary to the  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  sleeplessness  d u r i n g t h e compress t r e a t m e n t A n a l y s i s of the Medication  period.  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 t h e p a t i e n t f r e q u e n t l y from DAY to DAY 11, d u r i n g t h e compress t r e a t m e n t  period.  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 on DAY  5  earache  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 t i m e s 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  collection period.  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  and DAY 19 when he was s u f f e r i n g from an A n a l y s i s of the Diary  18  earache.  Scores  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  w r o t e 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. post-operatively.  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 A f t e r s u r g i c a l d e b r i d e m e n t 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, t h e 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 a b o u t a l i s t o f  "independent  a c t i v i t i e s " t a p e d t o t h e w a l l above h i s bed as w e l l as t h e manner i n w h i c h t h e 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 t h e day o f d i s c h a r g e , t h e 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 .  T h e r e a p p e a r s 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 t h e h o s p i t a l was  imminent.  In summary, t h e d i a r y s c o r e s d i d not f l u c t u a t e r e m a r k a b l y to t h e e f f e c t s o f t r e a t m e n t  stress.  in  response  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 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 . 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 f o 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 t h e f i r s t day a f t e r a d m i s s i o n t o t h e burn u n i t t o t h e day b e f o r e discharge.  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 T r e a t m e n t A d m i n i s t e r e d DAY 1 - 4 DAY 4 DAYS 4 - 6 DAY 6  -  D a i l y tub bath E v e n i n g arm b a t h Surgery - 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 t a k e n from donor a r e a S a l i n e compresses p o s t - o p Compresses e v e r y 4 hours Krwire to t r a c t i o n  - Skin grafts a p p l i e d DAYS 6 - 14 -  - Grafts rolled frequently  DAY 14  -  DAY 15 DAY 16 DAY 17 DAYS 1 7 - 2 2 DAY 22 DAY 24  D a i l y t u b baths resumed E v e n i n g arm b a t h s K-wire removed Necrotic skin graft debrided S a l i n e compresses a p p l i e d  - Compresses d u r i n g morning Skin g r a f t s a p p l i e d i n afternoon - Grafts rolled frequently - D a i l y t u b baths resumed - E v e n i n g arm b a t h s P a t i e n t moved t o " p o r c h " - 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 S t a t e - T r a i t A n x i e t y  76  Inventories  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 over the p a t i e n t ' s p e r i o d o f recovery. TABLE  1-4  SCORES OF THE STAI DAY  STAI  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  State Portion  Trait Portion  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  time,  t h e p a t i e n t was r e c e i v i n g arm baths accompanied by d e b r i d e m e n t o f t h e burns.  On DAY  7, s k i n g r a f t s , w h i c h had been a p p l i e d t h e day  were b e i n g r o l l e d f r e q u e n t l y .  By t h e time t h e t h i r d STAI was  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 . maintained  This level  administered, was  during the remainder o f the data c o l l e c t i o n p e r i o d .  T h e r e was no r e m a r k a b l e t h e STAI.  before,  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 r a i t a n x i e t y was m a i n t a i n e d  at a " f a i r l y anxious"  level  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 t h e 24 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 nights o f consecutive sleep l o s s occurred  three times during the data c o l l e c t i o n p e r i o d .  T h e s e were a f t e r  77 a d m i s s i o n t o t h e 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 h e 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 . s c o r e s 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  I t was noted t h a t t h e " s t a t e "  anxiety during these periods.  The s c o r e s o f t h e 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  during  these s l e e p l e s s periods. Analysis o f the Medication  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 t h e 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  requested f o r the remainder o f t h e 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 t h e 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 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 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 h o u r s .  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 . Analysis o f the Diary  Scores  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 t h e p a t i e n t a p p e a r e d v e r y t e n s e and a n x i o u s , t i r e d f r o m 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 a b o u t t h e . f u t u r e f u n c t i o n i n g and a p p e a r a n c e o f h i s hand. On DAY 2, t h e d i a r y s c o r e was 24.  In t h e 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 h e 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 t h e n u r s e s .  M o r e o v e r , he had g a i n e d a  sense o f s e c u r i t y a b o u t 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 telephone. A l t h o u g h t h e d i a r y s c o r e r o s e t o 33, a g a i n , on DAY 3, t h e p a t i e n t  a p p e a r e d w e l l r e s t e d , more c h e e r f u l and e a g e r t o t a l k to t h e 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 w o r r i e d a b o u t h i s s u r g e r y on DAY 4.  The p a r t s 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 " and " S p l i n t i n g " were shown t o t h e p a t i e n t . appeared very i n t e r e s t e d . fruitful.  was  He  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  He s t a t e d t h a t the t e a c h i n g and e m o t i o n a l  was  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 a b o u t t h e surgery. The d i a r y s c o r e s r o s e u n t i l DAY  5 when t h e h i g h e s t s c o r e o v e r  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 . was  u n d e r g o i n g compress t r e a t m e n t  the  At t h i s time, the p a t i e n t  post-operatively.  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 c o m p l e t e d 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 . compress changes were v e r y p a i n f u l .  6.  E v i d e n t l y he  had  He/commented t h a t the  He l a c k e d s l e e p from t h e  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 f r o m the u n b e a r a b l e p a i n . By DAY  7, t h e 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 .  being r o l l e d every 2 hours. but b e a r a b l e .  The g r a f t s were  He w r o t e t h a t t h e p a i n was a t h r o b b i n g ache  His main c o n c e r n s  were the a p p e a r a n c e o f t h e s k i n g r a f t s  and t h e method t h a t t h e d o c t o r would use t o remove t h e K-wire. 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 . down t o 41, q u i t e a d e c r e a s e  f r o m a h i g h o f 71 on DAY  t h e K-wire f r o m t h e p a t i e n t ' s hand was t o be removed.  was  Moreover,  The " s t a t e " s c o r e o f t h e STAI  was  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.  informed  (  At t h i s  time,  F u r t h e r m o r e , he  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 . "  l o o k i n g forward t o d i s c h a r g e by t h e end o f t h e week, t h i s  Since  was  he  information  79 was v e r y d i s a p p o i n t i n g . On DAY 16, t h e n e c r o t i c g r a f t s were d e b r i d e d . t h e s e a r e a s were resumed.  S a l i n e compresses t o  Diary scores continued to r i s e .  On DAY 17, t h e a r e a s on h i s hand were r e - g r a f t e d . was v e r y d e p r e s s e d .  He w r o t e t h a t he  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 b e c a u s e t h e 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, t h e 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, t h e s c o r e r o s e s l i g h t l y .  I t was n o t e d i n t h e d i a r y  t h a t t h e 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 e a g e r t o l e a v e t h e h o s p i t a l , t h e p a t i e n t d i d  express concern 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 h e f u n c t i o n i n g o f h i s hand. On DAY 24, t h e day b e f o r e d i s c h a r g e , t h e p a t i e n t d e n i e d or anxiety.  any  concerns  He appeared c h e e r f u l and r e l a x e d .  In summary, t h e s c o r e s o f both t h e STAI and d i a r y changed s i g n i f i c a n t l y i n response to the e f f e c t s o f treatment s t r e s s . At t h e b e g i n n i n g 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 , 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 . Patient Five T h i s 60 y e a r o l d l a d y was burned t o 10% o f h e r 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 h e r 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 T r e a t m e n t DAYS 1 - 6  Administered - Tub baths f o l l o w e d by c l e a n s i n g o f t h e 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 c o m p r e s s e s 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  S u r g e r y - d e b r i d e m e n t o f t h e 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 c o m p r e s s e s t o a s m a l l 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 frequent r o l l i n g .  Analysis of the S t a t e - T r a i t Anxiety  Inventories  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 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  State Portion  Trait Portion  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 t h e 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 n e r v o u s on a d m i s s i o n t o t h e 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 h e STAI.  On DAY 8, t h e 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, t h e " 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 heightened  anxiety.  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  that  she would be g o i n g t o t h e o p e r a t i n g room e a r l y t h e next day. As r e c o v e r y p r o g r e s s e d , t h e s c o r e s o f t h e 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 . T h e r e 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 the Sleep  Record  Over a p e r i o d o f 25 days, t h e p a t i e n t had t w e l v e n i g h t s o f "good sleep."  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 d e a l  d u r i n g t h e day from DAY 1 t o DAY 8.  The p a t i e n t c o m p l a i n e d  unable t o s l e e p a t n i g h t due t o t h e e x t r a n e o u s  o f being  sounds i n h e r ward room.  T h e r e 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 h e f i r s t compress treatment period.  However, from DAY 21 t o DAY 26, t h i s p a t i e n t had s i x  consecutive nights o f sleeplessness.  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 n o t ' t a k e . ' Analysis of the Medication  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 the 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 n o 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  compress t r e a t m e n t was i n i t i a t e d on DAY 6.  r o u t i n e l y g i v e n when  By DAY 13, a l t h o u g h  compress  t r e a t m e n t was s t i l l i n p r o g r e s s , t h e p a t i e n t began t o r e f u s e a n a l g e s i c medication.  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 given a n a l g e s i c s before  treatment.  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 a p p e a r e d t o be drowsy and s l e e p i n g t h r o u g h o u t  t h e 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 g i v e n r o u t i n e l y f o r t h e remainder o f the data c o l l e c t i o n p e r i o d . Analysis of the Diary  Scores  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 DAY 1 t o DAY 14. of surgery.  from  Then, t h e s c o r e s peaked d r a m a t i c a l l y on DAY 15, t h e day  They r e m a i n e d h i g h 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, t h e d i a r y s c o r e s were m a i n t a i n e d pre-surgery scores.  near the l e v e l o f the  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 n o t c o m p l e t e d , on DAY 12 and DAY 13. A t t h i s t i m e , t h e p a t i e n t was v e r y d e p r e s s e d when n o t i f i e d t h a t h e r t h i r d d e g r e e burns would have t o be g r a f t e d . In summary, t h e 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 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 was l a u g h i n g about h e r 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 h e r y e t e n u m e r a t i n g t h i n g s w h i c h 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 c o m p a r i s o n t o 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  circumstances.  E v a l u a t i o n o f the Planned Nursing 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 s t u d y was b e n e f i c i a l f o r these 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 , e m o t i o n s and c o n c e r n s r e g a r d i n g t h e i r b u r n ,  treatment,  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 .  t h e i n v e s t i g a t o r was an u n b i a s e d  The f a c t t h a t  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 . i n s t r u c t i o n a l program. expression of concerns.  They a p p e a r e d very i n t e r e s t e d i n t h e  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  O n l y one p a t i e n t r e f u s e d v i e w i n g o f t h e p a r t o f  t h e program on s k i n g r a f t i n g . "scare"  and  She f e a r e d t h a t t h e p h o t o g r a p h s might  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 a b o u t t h e o f the d i s c u s s i o n s with the i n v e s t i g a t o r .  helpfulness  He s a i d t h a t he l o o k e d  to t h e v i s i t s because he " f e l t so good a f t e r w a r d s . "  Expressing  his  f r u s t r a t i o n s and a n g e r to someone who was w i l l i n g t o l i s t e n , who h i s e m o t i o n s and who was non-judgmental r e l i e v e d h i s t e n s i o n .  forward  accepted  The  nurses  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 v i s i t s were i n i t i a t e d . diary responses.  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  these hard on h i 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  t h e 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  tension.  The s e c o n d 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 a b o u t 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  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 .  to 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 a b o u t 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 p e n t - u p f e e l i n g s and c o n c e r n s , and t o h e a r e a c h 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  beforehand.  He t h o u g h t t h a t t h e t a p e - s l i d e program Was  "superb."  I t was  helpful  84 to s e e what was g o i n g t o happen b e f o r e i t t o o k 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 t h e 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 t h e d i a r y and S t a t e - T r a i t Inventory  Anxiety  scores.  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 .  It  was noted t h a t , a t t i m e s , t h e p a t i e n t a p p e a r e d drowsy when t h e i n v e s t i g a t o r entered  t h e room.  D u r i n g t h e v i s i t , he p e r k e d 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 e m o t i o n a l 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 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 . p o s i t i v e effects o f the nursing  Although the  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 n o t have a g r e a t c o n t r i b u t i o n i n i reducing  s t a t e 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 .  The t h i r d p a t i e n t was a v e r y a r t i c u l a t e and i n f o r m a t i v e man. a l w a y s 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 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 g i v i n g s e s s i o n s on h i s p a r t .  He  experience.  information-  H i s use o f m e d i c a l 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 a b o u t t h e p u r p o s e s 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 t o 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 during v i s i t s with the 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 g e t my  b o t t l e d f e e l i n g s o u t , I'd g e t t h e meemies."  V e n t i l a t i o n o f day t o d a y  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 t h o u g h t s t o a p e r s o n w i t h t h e time t o l i s t e n , was v e r y i m p o r t a n t t o him.  F o r 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 f o u n d t h e 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 his right foot. tension.  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  A t 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  that  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. shaking  his foot.  He had s t o p p e d  D u r i n g t h e l a s t v i s i t , on t h e day b e f o r e  discharge,  he s a i d t h a t p a t i e n t s need a " s o u n d i n g b o a r d " t o g e t f r u s t r a t i o n s o u t 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 f o r w a r d  to the v i s i t s .  O f t e n , he a p p e a r e d bored and d e p r e s s e d o r a n g r y when t h e i n v e s t i g a t o r e n t e r e d t h e room.  By t h e end o f t h e v i s i t , t h e p a t i e n t was s m i l i n g ,  laughing a t h i s circumstances  and f e l l a s l e e p a f t e r t h e v i s i t .  This  p a t i e n t b e n e f i t t e d f r o m p a r t i c i p a t i o n i n t h e r e s e a r c h study i n t h e 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  onset o f the v i s i t .  and o f t e n e x p r e s s e d  anger a t the  A f t e r t h e 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 his f e e l i n g s regarding  to share  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 h e v i s i t s f r o m t h e i n v e s t i g a t o r would c h e e r h e r up and h e l p boost h e r m o r a l e .  Furthermore, the v i s i t  was t h e c h e e r i e s t p a r t o f h e r 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 p r o g r a m was " s u p e r b " and v e r y helpful.  She o n l y w i s h e d t h a t she had seen i t as soon as she was  admitted. 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 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 seemed t o r e d u c e e m o t i o n a l 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 treatment 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  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 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 Analysis o f the Findings 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 hypotheses.  null  To t e s t h y p o t h e s i s o n e , u s i n g t h e 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 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 p a i r e d t t e s t was a p p l i e d t o t h e f i r 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 and t h e l a s t t h r e e scores o f a l l the 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 t o c o r r e l a t e t h e p a t i e n t s ' s c o r e s on t h e "state" portion o f the S t a t e - T r a i t Anxiety Inventory with the scores 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 h e n u l l To t e s t hypotheses  hypothesis.  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 t o d e t e r m i n e t h e s t r e n g t h o f t h e c o r r e l a t i o n o f t h e v a r i a b l e s named i n t h e s e h y p o t h e s e s . inspection.  To t e s t h y p o t h e s e s  H y p o t h e s i s f i v e was a p p a r e n t by  s i x and s e v e n , 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 t h e p a t i e n t s ' s c o r e s on 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 n u r s e s ' assessment a n x i e t y on t h e L i k e r t - t y p e s c a l e .  of patient  A s i g n i f i c a n c e l e v e l o f .05 was  considered acceptable to r e j e c t the null  hypotheses.  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 d a t a i s p r e s e n t e d i n r e l a t i o n t o each  hypothesis.  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 m e a s u r a b l e 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 i n a sample o f burn p a t i e n t s r e c e i v i n g e x p o s u r e 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 as measured by t h e S t a t e - T r a i t A n x i e t y Inventories.  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 Anxiety the  Inventory,  administered  s i x t i m e s to each p a t i e n t .  T a b l e ,2 l i s t s  raw s c o r e s . TABLE 2 TOTAL SCORES OF THE "TRAIT" PORTION OF STATE-TRAIT ANXIETY INVENTORY  STAI  Patient 1  1  50  2  Patient 2  THE Patient 5  Patient 3  Patient 4  36  24  37  28  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 . d e g r e s s o f f r e e d o m , the t v a l u e was  At  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.  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 was  not r e j e c t e d .  Therefore,  T h e r e was  fourteen  Since hypothesis  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 .  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 ,  occurred  in  a sample o f burn p a t i e n t s o v e r u n i t t i m e . Hypothesis  Two  The second n u l l h y p o t h e s i s  t e s t e d was  that,  T h e r e i s no m e a s u r a b l e 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 t i m e i n a sample o f burn p a t i e n t s r e c e i v i n g e x p o s u r e 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 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 as i n d i c a t e d by 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 . 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 t i m e s 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 .  Table 3  l i s t s t h e 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  Patient 1 STAI d i a r y  Patient 2 STAI d i a r y  Patient 3 STAI d i a r y  Patient 4 STAI d i a r y  Patient 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 on t h e c o r r e s p o n d i n g d i a r i e s . f i n d i n g was  At twenty-nine  patients  degrees o f freedom, the  r .72 w h i c h 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 t h e .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  degrees'of  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 t h e .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 .  Therefore, the 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 . Furthermore,  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 t h e 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 were t e s t e d w i t h a p a i r e d t t e s t .  Inventory  A t f o u r t e e n degrees o f freedom, t h e  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 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 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 a s measured by t h e s c o r e s o f the S t a t e - T r a i t Anxiety I n v e n t o r i e s . Furthermore,  t h e 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  t h e 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 test.  A t f o u r t e e n d e g r e e s o f f r e e d o m , t h e 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 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 rejected at this level.  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 m e a s u r a b l e 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 t i m e i n t h e 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 t h e d i a r i e s . Hypothesis  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 , . T h e r e i s no m e a s u r a b l e 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 e x p o s u r e 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 t h e n u r s e s ' o b s e r v a t i o n on t h e 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 t h e 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 t o t h e hours o f s l e e p n o t e d by t h e n u r s e s on t h e 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 u t i l i z e d . 1  T h e r e was no  c o r r e l a t i o n , F 0.00, between t h e 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  hypothesis  90 was not r e j e c t e d . T h e r e was no m e a s u r a b l e  i n c r e a s e i n the q u a n t i t y o f  sleep over u n i t time. H y p o t h e s i s Four i  The f o u r t h h y p o t h e s i s was t h a t , T h e r e i s no m e a s u r a b l e 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 t i m e i n a sample o f burn p a t i e n t s r e c e i v i n g e x p o s u r e 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 t h e 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 t h e p a t i e n t s ' p e r s o n a l diaries.  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 t o 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 n o t e d by t h e n u r s e s on t h e m e d i c a t i o n r e c o r d . utilized.  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  T h e r e 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 , t h e n u l l h y p o t h e s i s was n o t r e j e c t e d . T h e r e 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 . Hypothesis Five The f i f t h h y p o t h e s i s was t h a t , T h e r e i s no m e a s u r a b l e 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 t i m e i n a sample o f burn p a t i e n t s r e c e i v i n g e x p o s u r e 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 diaries. 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 s e n s e 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 t i m e . measure was a p p l i e d .  No s t a t i s t i c a l  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 t h e 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 p o o r " w e l l - b e i n g throughout the data c o l l e c t i o n p e r i o d .  91 Hypothesis S i x The s i x t h h y p o t h e s i s was t h a t , T h e r e i s no c o r r e l a t i o n between t h e n u r s e s ' a s s e s s m e n t 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 t h e t r a i t a n x i e t y measured by t h e State-Trait Anxiety Inventories. The 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 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 c o r r e l a t e d w i t h t h e s c o r e s o f t h e n u r s e s ' a s s e s s m e n t o f p a t i e n t s ' t r a i t a n x i e t y on t h e 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  Patient 1 STAI Nurse  Patient 2 STAI Nurse  Patient 3 STAI Nurse  Patient 5 STAI Nurse  Patient 4 STAI Nurse  DAY 1  50  1  36  1  24  37  3  28  4  LAST DAY  40  1  39  1  25  37  2  28  3  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 Key: High A n x i e t y  Low A n x i e t y 20  STAI Nurse  -  1 not anxious A product-moment  the v a r i a b l e s .  30 2 fairly anxious  30  - 40  moderately anxious  40  -  4 highly anxious  80 extremely anxious  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 t o compare  At nine degrees o f freedom, t h e value o f r  was - 0.43.  When t h e 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 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 h e c o r r e l a t i o n was n o t significant.  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 n o t r e j e c t e d .  T h e r e was  I  92 an i n v e r s e c o r r e l a t i o n between t h e 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 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 and t h e n u r s e s ' a s s e s s m e n t 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 , T h e r e i s no c o r r e l a t i o n between t h e n u r s e s ' a s s e s s m e n t o f t h e p a t i e n t s ' s t a t e a n x i e t y and t h e s t a t e a n x i e t y measured by t h e State-Trait Anxiety Inventories. 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 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 h e s c o r e s o f t h e n u r s e s ' a s s e s s m e n t o f t h e p a t i e n t s ' state anxiety.  T a b l e 5.. l i s t s t h e 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  Patient 2 STAI Nurse  Patient 1 STAI Nurse  DAY 1 LAST DAY  Patient 3 STAI Nurse  Patient 5 STAI Nurse  Patient 4 STAI Nurse  '46  2  30  3  30  3  71  2  52  . 3  48  2  32  4  21  4  22  4  36  1  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 Key: High A n x i e t y  Low A n x i e t y STAI  20  Nurse  -  1 not anxious A product-moment  variables.  30 2 fairly anxious  s  30  moderately anxious  40  40 4 highly anxious  -  80 extremely anxious  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 t o compare t h e  A t n i n e d e g r e e s o f freedom, t h e 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 , 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 .  T h e r e was an  inverse  c o r r e l a t i o n between t h e 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 ' a s s e s s m e n t 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 n u r s e s 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 t h e S t a t e - T r a i t Anxiety Inventory.  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 t h e n u r s e a s s e s s m e n t 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 .  T h u s , the  clinical  a s s e s s m e n t 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  Inventory,  as compared w i t h t h e c l i n i c a l a s s e s s m e n t 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 developed  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 a s s e s s m e n t o f a n x i e t y . T h i s whole t o p i c i s a s t u d y i n i t s e l f .  Nursing a b i l i t y to assess  anxiety  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 a s s e s s m e n t 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 s t u d y .  P s y c h o l o g i c a l Phases o f Burn Care in 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 t h e burn i n j u r y varied markedly. a s m a l l sample was  Each p a t i e n t passed t h r o u g h  s i m i l a r "phases."  Although  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 f r o m 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 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 . f o l l o w i n g r e p o r t o f t h e f i n d i n g s w i l l be p r e s e n t e d p s y c h o l o g i c a l phases o f burn c a r e .  repeated  Therefore,  under v a r i o u s  the  94 D e p e r s o n a l i z a t i o n Phase In t h e 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 p a s s e d a phase i n which t h e y d i s e n g a g e d t h e m s e l v e s from t h e f a c t s o f t h e situation.  through r  The p a t i e n t s seemed t o f u n c t i o n as i f t h e 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 t h e f i r s t few d a y s , t h e p a t i e n t s were r a r e l y t r o u b l e d a b o u t t h e f u t u r e appearance, deformity or p o s s i b l e m a l f u n c t i o n o f a limb. c o n c e r n s l a y i n t h e 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 .  Their  They were most  a n x i o u s t o know a b o u t t h e 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 p r o m i n e n t s o u r c e o f a n x i e t y a t t h i s t i m e 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 g o i n g t o happen t o them c a u s e d 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 t h e 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 , t h e human  t r a f f i c i n t h e h a l l w a y and t h e 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 t o him and what t r e a t m e n t was t o come n e x t 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 . t h e day.  F o r the next week, she s l e p t a g r e a t d e a l d u r i n g  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  c o n f u s i o n when awake. appetite increased.  apparent  Then, she became more a l e r t , o r i e n t e d and her She e x p l a i n e d to. t h e 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 "soul." S h o r t l y a f t e r a d m i s s i o n t o h o s p i t a l , a l l t h e p a t i e n t s seemed t o have a need t o v e r b a l i z e , r e v i e w and a n a l y z e t h e e v e n t s s u r r o u n d i n g t h e 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 a b o u t 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 t h e 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 t h e 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 e m o t i o n a l 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 e m o t i o n a l 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 .  At 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 a b o u t 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 t h e 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 Schlictmann  substantiated this investigator's observation.  The  p r i n c i p a l f i n d i n g s o f Schlictmann's study concurred with the c o n c l u s i o n s found i n t h e 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 b r o u g h t on by burn i n j u r i e s .  P e r s o n s r e a c t e d to s t r e s s ,  first,  by m i n i m i z i n g t h e impact o f t h e 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 m o t i o n a l 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 recovery. 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 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 t h e burn u n i t , t h e n u r s e s ' n o t e s r e p o r t e d t h e 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 c o n c e r n e d 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 receiving.  was  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 n e x t day, t h e n u r s e s ' n o t e s  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 .  A t the b e g i n n i n g 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 , 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 become v e r y dependent on t h e n u r s i n g s t a f f . i n d e p e n d e n c e were e n c o u r a g e d ,  had  L a t e r , when s e l f - c a r e and  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 t h e 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 t h e 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 v e 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,  t h e " s t a t 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 i n d i c a t e d a low anxiety level.  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 . became l e s s i n h i b i t e d . ;  Moreover, h i s c o n v e r s a t i o n  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 t h e 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 of his recovery experience.  He seemed v e r y a c c e p t i n g o f h i s burn  injury  and t h e r e f o r e h i s e m o t i o n s 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 t h e burn u n i t , t h e f o u r t h p a t i e n t was a n x i o u s , t e n s e and r e g r e t f u l .  extremely  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  concern  was t h e 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 n o t knowing what was g o i n g  to happen t o 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 t o 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 a b o u t t h e 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 t h e f o u r t h p a t i e n t ; t h e n , h e r main concern, was t h e depth o f burn and t h e 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 n i g h t m a r e s about t h e i r a c c i d e n t .  D u r i n g t h e f i r s t week  o f h i s r e c o v e r y , t h e 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 t h e memory o f i t would f l a s h t h r o u g h h i s mind. h e l p f u l when he c o u l d t a l k about t h e n i g h t m a r e t o t h e n u r s e s .  I t was  They were  a b l e t o 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 during the night. 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 a b o u t t h e a c c i d e n t , but n o t n i g h t m a r e s . accident.  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 t h e  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 m o m e n t a r i l y d u r i n g t h e n i g h t .  These three 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 h i 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 t o 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 complain o f nightmares.  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 , " C l i n i c s o f N o r t h A m e r i c a 6 (December 1971), p. 625.  Nursing  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 s t u d y e x p r e s s e d  a  w i s h t o e s c a p e t h r 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 n i g h t m a r e s w h i c h involved v i v i d r e l i v i n g of the 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 , t h e 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 treatment.  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  t h e p r e d o m i n a n t f o r c e i n t h e burn p a t i e n t s ' l i v e s w i t h a p p e a r a n c e o f t h e burn wound as a p o s s i b l e s e c o n d a r y  force.  However, c o n c e r n a b o u t f u t u r e  a p p e a r a n c e 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 t h e r e a l i t y t e s t i n g p h a s e , t h e g r e a t e s t p o t e n t i a t e s 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 . 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  Therefore, these w i l l  experienced.  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 w o r s t p a i n i n donor s i t e s a f t e r  112 autografting.  However,  in t h i s study, the p a t i e n t s complained  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 d e b r i d e m e n t d u r i n g  of bathing.  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 . 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 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 r e a c h e d 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 D u r i n g t h e A c u t e Phase," p. 371. 2  I b i d . , p.  373.  99 a. to " p u t 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 w h i c h f e l t s e a r i n g and b u r n i n g on t h e surface, 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 b u r n s were exposed t o a i r , 3) t h e " 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 t h e 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 n o t s e e due t o 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 t o f e a r o f t h e unknown.  When he was a b l e  to 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 t h o u g h t . At t h i s t i m e , t h e p a i n became more d u l l . For 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 pain o f treatments was t h e w o r s t p a r t o f e a c h day.  He would be d e p r e s s e d  w o n d e r i n g how s e v e r e t h e p a i n would be. experienced  i n t h e burn b a t h .  i n the morning,  H i s day was c o l o u r e d by t h e p a i n  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 o v 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 t h e s e v e r i t y o f t h e 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 h e f i r s t week 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 .  However, t h e 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 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 during treatments.  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 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 began t o 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 treatments.  He dreaded  the treatment  f o r an hour b e f o r e i t t o o k 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 u n a b l e to c o n c e n t r a t e o r even  converse  99 b  with h i s wife.  However, when t h e n u r s e s t a l k e d t o him and d e s c r i b e d  his progress during treatments,  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 w h i c h he a l s o described vividly.  I t was t h e most p r e v a l e n t and p r e d o m i n a n t 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 t o be  a f r a i d o f t h e p a i n t h a t t h e 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 h e t r e a t m e n t s per se.  He w r o t e 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 h e 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 positively. Neither the f o u r t h or f i f t h p a t i e n t s described t h e i r pain experience i n any d e t a i l .  They d i d n o t 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 to review t h e i r pain  experience.  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 t o 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 . T h e 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  being  " 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 h e 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."  T h e s e two  p a t i e n t s were v e 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 analyzed t h e i r pain to the i n v e s t i g a t o r . The e f f e c t s o f t h e 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 patients. treatment  T h e i r emotional  s t a t u s and mood were d e p e n d e n t on t h e phase o f  t h a t was b e i n g a d m i n i s t e r e d .  more p a i n f u l than o t h e r s .  O b v i o u s l y , some t r e a t m e n t s  were  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  v  100 be p r e s e n t e d i n t h e sequence t h a t t h e y 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 , t h e p a t i e n t s e n j o y e d t h e burn b a t h ( o r w h i r l p o o l arm b a t h i n t h e c a s e 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 t h e c o l l a g e n and e x u d a t e 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, t h e 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 d e b r i d e m e n t o f dead t i s s u e d u r i n g t h e b a t h s and subsequent e x p o s u r e o f t h e burn wound as t h e most painful p a r t of the treatment.  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 t h e  burn b a t h s were t h e w o r s t p a r t o f t h e 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 h y s i c a l l y and e m o t i o n a l l y .  painful  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 t h e more h i s wounds were d e b r i d e d , t h e f a s t e r t h e y 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 d e b r i d e m e n t d u r i n g h i s arm b a t h s 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 t h e d r e s s i n g s were a l l o w e d t o soak o f f . D u r i n g t h e 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 , t h e t h i r d p a t i e n t found t h e 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  to a c o o l h a l l w a y from a warm room t o a warm b a t h 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 bath. t i m e had been a l l o w e d to soak and r e l a x i n t h e b a t h .  They a l l w i s h e d more  101 The Compresses The " s t a t 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 d r a m a t i c a l l y f o r most o f t h e p a t i e n t s when compress t r e a t m e n t i n i t i a t e d i n preparation f o r skin grafting. not o n l y e x t r e m e l y  rose was  The d r e s s i n g changes were  p a i n f u l , b u t they .were a l s o c a r r i e d on t h r o u g h o u t  the n i g h t , thereby d i s t u r b i n g sleep. 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 tolerable.  The p a t i e n t f e l t h i s body a d j u s t t o t h e b e a r a b l e p a i n .  pain experienced  The  seemed t o depend on w h i c h n u r s e 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 r e a c h e d was v e r y important  i n his opinion.  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 p a i n o f t h e compress t r e a t m e n t ,  anxious  reaction to the  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 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 f r o m t h e 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 . o f a n x i e t y and e m o t i o n a l of treatment  His state  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 to the type  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 d e m o n s t r a t e d unusual 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 .  control throughout h i s 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 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  pain experience.  Although  stress and t h e  he d i d s t a t e t h a t d e b r i d e m e n t i n t h e 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 patient d i d not  o v e r t l y express 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 n o t have e x t e n s i v e compress t r e a t m e n t . 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 h e same  When  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 anxiety.  p a i n and  pre-treatment  The o n l y t i m e 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 painful. 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 course of recovery.  R e a l i z i n g t h a t compress t r e a t m e n t  and  s u b s e q u e n t 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 d e p r e s s e d and w i t h d r a w n . refused analgesics.  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  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 t h e 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  lady  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 . Surgical  Pinning  The i n s e r t i o n o f K-wires and s u b s e q u e n t s u s p e n s i o n o f an  extremity  (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 these p a t i e n t s .  Fear o f t h e 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 expressed t h e i r f e a r of the pain with a n t i c i p a t i o n of 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 a b o u t to be removed.  At t h e s e  times,  t h e " s t a t 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 i e s r o s e toward elevated anxiety.  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 e n s u e d .  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 t h e most r e a c t i o n i n r e l a t i o n to pain expected The p a t i e n t s c o m p l a i n e d  exaggerated  versus actual pain.  o f o n l y a d u l l ache when t h e i r limbs were  103 in 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  nerves."  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 these p a t i e n t s .  One p a t i e n t t h o u g h t t h a t he would f e e l b e t t e r ,  more day t o day improvement and f e e l l e s s p a i n .  see  Another p a t i e n t  reported that pain did lessen considerably a f t e r skin g r a f t i n g .  However,  donor a r e a p a i n was  lifted  now more p r o m i n e n t .  Regardless,  his s p i r i t s  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 r e a l i s t i c a l l y very p a i n f u l .  and  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  that  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 t h a n the d o n o r s i t e . T h e r e was no p a i n when the g r a f t s were r o l l e d ( t o remove e x u d a t e 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. f e l t comfortable  now."  "waiting  He was  He f e l t t h a t h i s r e c o v e r y was  "home f r e e . "  "downhill  a l l the  T h i s phase o f h i s r e c o v e r y was  a  period."  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 a bearable  he  w i t h t h i s ache because he had been t h r o u g h the w o r s t o f  his pain experience. way  One p a t i e n t s t a t e d  was  t h r o b b i n g ache a r o u n d 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 a p p e a r a n c e o f the g r a f t s .  A f t e r he was  informed  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 v e r y d e p r e s s e d and a n g r y a t t h e s t a f f . a b i l i t y o f the new g r a f t s 'to  take.  1  M o r e o v e r , he w o r r i e d a b o u t t h e  104 Frequent r o l l i n g of the g r a f t s , e s p e c i a l l y during the 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 t h e  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, t h e p a t i e n t s a d j u s t e d o v e r time t o t h e o n g o i n g stresses of their situation.  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 t h e 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 " t h e w a i t i n g period."  Time seemed t o pass s l o w l y a t t h i s s t a g e as compared t o t h e  previous stages.  E m o t i o n a l t r e n d s were seen i n most o f t h e p a t i e n t s .  Philosophizing Toward the end 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 , t h e 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 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 .  this  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 t h e 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 n u r s e s and s t a t e d t h a t h i s a n t a g o n i s m must have been a phase he was through.  going  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 t h e 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 t h r o u g h 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 t o t h i s e x p e r i e n c e as h i s "burn in r e l a t i o n to his t o t a l l i f e .  space"  E v e r y p a r t o f " l i f e has a space and  t h i s burn s p a c e " 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 s t o p p e d 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 accident. 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 t h i n g c o u l d be a g r e a t p r o b l e m 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 o u t so e a s i l y .  L i f e c a n n o t be r e p l a c e d . " The f i f t h p a t i e n t began t o r e a l i z e t h e magnitude o f human s u f f e r i n g when p e o p 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 t h e 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 t o p l a g u e t h e s e p a t i e n t s during the l a t t e r stages of recovery. a l l were n u r s e d i n p r i v a t e rooms.  E x c e p t f o r one p a t i e n t ,  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 e n v i r o n m e n t 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 w i s h e d t h a t t h e n u r s e s had time t o 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 t o c o n v e r s e w i t h o t h e r patients.  H i s sense o f c o n f i n e m e n t was overwhelming.  He seemed t o  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 , c o m p l a i n e d 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 t h e t r a c t i o n on h i s K-wires i n o r d e r t o walk t o t h e bathroom.  T h i s gave him a s e n s e o f m a s t e r y o v e r a s m a l l  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 n o t e 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 t h e e i g h t bed 'porch.'  The s e c o n d , t h i r d and f o u r t h p a t i e n t s became  at t h e end 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 . to one a n o t h e r immensely and r e c o v e r y .  roomates  They seemed t o e n j o y t a l k i n g  as t h e y r e v i e w e d each o t h e r ' s c o u r s e o f t r e a t m e n t  A 'men's c l u b  atmosphere  1  was p r e v a l e n t .  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  A l l wished t h e y  sooner.  A l t h o u g h she was n u r s e d i n t h e 'women's p o r c h , ' t h e f i f t h p a t i e n t a l s o spoke o f a s e n s e o f i s o l a t i o n . from t h e o u t s i d e l i f e . "  She s t a t e d t h a t she f e l t " c u t o f f  A c t i v i t y i n t h i s open ward n e v e r c e a s e d .  There  seemed t o be t o o much s e n s o r y s t i m u l a t i o n . S e n s o r y 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 recovery o f t h i s  burn p a t i e n t . Antagonism and Empathy The i m p o r t a n c e o f i n t e r p e r s o n a l dynamics are  paramount.  between p a t i e n t and n u r s e  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 , t h e 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 , n u r s e s 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 n u r s e has s p e n t more t i m e 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  Young^  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 t h e n u r s e has a v a i l a b l e t o spend w i t h t h e burn p a t i e n t and t h e q u a l i t y o f t h e 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  114  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 t h e S e v e r e l y Burned P a t i e n t , " H e a r t and Lung 2 (September/October 1973) p.706. 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 t o t h e f i r s t patient's r e l a t i o n s h i p with his nurses. have enough time t o t a l k t o him.  He f e l t t h a t t h e n u r s e s d i d n o t  However, he c o m p l a i n e d t h a t t h e y were  always "coming i n and d o i n g s o m e t h i n g . "  Obviously, the q u a l i t y o f time  and t h e q u a n t i t y o f t i m e f r o m t h i s p a t i e n t ' s p e r s p e c t i v e was  important.  He b e l i e v e d t h a t t h e 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 g e t a l o n g w i t h t h e n u r s e t h a t day, he s u f f e r e d more p a i n during the treatment.  When s e l f - c a r e and i n d e p e n d e n c e were e n c o u r a g e d ,  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 and 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.  As t h e day o f d i s c h a r g e a p p r o a c h e d , 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 t h e n u r s e s .  He s t a t e d t h a t h i s a n t a g o n i s m 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 n o t comment about h i s r e l a t i o n s h i p w i t h t h e staff.  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 t h e n u r s e s as  ' a n g e l s 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 t h e 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 n u r s e s 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 . T h e s e 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 d e b r i d e m e n t o f t h e wound.  The n u r s e s who t a l k e d t o 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 t h e 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  n u r s e 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, t h e 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 t h e same f e a r .  108 When h i s s k i n g r a f t s d i d n o t ' t a k e , ' t h e 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 h e 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 d e a l o f a n g e r  against the s t a f f a t t h i s time.  However, when i t was a p p a r e n t t h a t t h e  new r e p l a c e m e n t g r a f t s were h e a l t h y , he p r a i s e d t h e s t a f f h i g h l y . A t no time d i d t h e 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  looked forward to t a l k i n g to "those good-looking nurses." Discharge Anxiety In t h r e e c a s e s , t h 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. 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 t h e appearance o f t h e s c a r t i s s u e and t h e s o c i a l a c c e p t a n c e o f t h e 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 t h e 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 t h e s e c u r i t y o f t h e 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 t h e " o u t s i d e w o r l d " and t h e p o s s i b i l i t y o f another i n j u r y . to wear t h e J o b s t  Moreover, t h e f a c t t h a t he would have  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 h e a p p e a r a n c e o f h i s s c a r s t o o t h e r p e o p l e , especially his girlfriend.  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 h e second p a t i e n t ' s " s t a t e " s c o r e on 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 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 '  n o t e s r e p o r t e d t h a t he a p p e a r e d 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 h e a p p e a r a n c e 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 t h e purpose  109 (Hi  and a p p e a r a n c e o f t h e 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 a b o u t t h e  g l o v e o r t h e a p p e a r a n c e 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 h e r wounds, t h e f i f t h p a t i e n t r e f e r r e d t o t h e 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 a p p e a r a n c e o f t h e 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  that concerns  a b o u t 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 t h e burn s c a r s were p r e v a l e n t a t t h e time o f discharge.  The n e c e s s i t y o f w e a r i n g an e l a s t i c g l o v e f o r a y e a r was a  threatening forecast.  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  with  t h e 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 h e r 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 h e s e c u r i t y o f t h e h o s p i t a l and e n t e r t h e e n v i r o n m e n t 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 p r e d o m i n a n t i n t h e i r t h o u g h t s  was, " w i l l p e o p l e t u r n away when t h e y see t h e 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 Findings The c o n c e p t o f t h e 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 r e s p o n s e 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 study.  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 d e f e n s e mechanisms were c a l l e d i n t o p l a y .  which  Therefore, 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 t h e r e p o r t o f t h e 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 .  D e f e n s e mechanisms employed  by t h e p a t i e n t t o r e d u c e 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 f r o m t h e 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 .  no  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 unconscious  and  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 a b o u t 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 s e c u r i t y and s e l f - e s t e e m . p a t i e n t ' s sense o f f r e e d o m . on t h i n g s and  of  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 He i s now f o r c e d t o assume a dependent r o l e  people.  Disfigurement  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 t i m e .  The sudden change i n body image a l s o  produces a d i s t o r t i o n of 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 , a n g e r 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 , t h e 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  a n g e r and h o s t i l i t y toward t h e n u r s e s 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 t h e s i t u a t i o n by r e f e r r i n g t o t h e m s e l v e s 'animal' 115  terminology.  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 C o n c e p t s 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., 1 9 7 0 ) , 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 C o n c e p t s and t h e C r i t i c a l l y 111 (Englewood C l i f f s : P r e n t i c e - H a l 1 I n c . , 1 9 7 6 ) , p. 78.  1 1 7  Ibid.,  p.83.  Patient  in  11 o Roberts  a l s o n o t e d 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  condition.  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 in his environment. therapy,  and p a s s i v e l y a c c e p t s  events  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  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  difficulty  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 e n d e a v o r s i n t h e d i s t a n t f u t u r e . 119 Roberts  a l s o n o t e d 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 once whole body has been r e n d e r e d burns w h i c h s e r v e as a c o n s t a n t  w i l l i s o l a t e him s o c i a l l y . imperfect.  his g i r l f r i e n d to h i s s c a r s .  A l l he sees a r e the  reminder of his imperfection.  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  The ugly  As  c o n c e r n e d about the r e a c t i o n o f  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 a b o u t the a p p e a r a n c e o f her l e g s .  This patient,,  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 t o p i c o f the e f f e c t o f the burns on her e m o t i o n a l s t a t u s .  away f r o m the "Threats  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 s o m e t h i n g o r someone o t h e r t h a n t h e 1 ?D patient himself." 118 R o b e r t s , B e h a v i o r a l C o n c e p t s and the C r i t i c a l l y 111 P a t i e n t , p. 83. 119 " I b i d . , p.  84.  I b i d . , p.  85.  y  1 2 0  Combs and Snygg  n o t e d t h a t p a t i e n t s who a n a l y z e the  events  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 t h e a c c i d e n t from the r e l a t i o n t h e y p e r c e i v e between the a c c i d e n t and 121 themselves.  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 t h e  events  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 o u t  a r e l a t i o n s h i p between t h e m s e l v e s  and t h e f a t e o f t h e i r i n j u r y .  analysis  This  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 .  Lone!iness 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  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 .  disfigurement  Both t y p e s o f p a i n  w h i c h 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 , c a u s e w i t h d r a w a l  and f o c u s a t t e n t i o n on t h e 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 study expressed, to h e l p them l o o k w i t h i n t h e m s e l v e s in l i f e .  seemed  and p h i l o s o p h i z e a b o u t t h e i r "space"  "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 others." 121  R o b e r  1 2 3  t s , _Bj^hayior^^  P  '  8 8  1 2 2  I b i d . , p.  142.  1 2 3  C 1 a r k M o u s t a k a s , 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 . , 1 9 6 1 ) , 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 o v e r w h e l m i n g . 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 n u r s e s 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 t h e slow p r o g r e s s o f h i s r e c o v e r y . outside l i f e . "  The f i f t h p a t i e n t f e l t " c u t o f f from t h 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 t o t h e s t a f f and o t h e r p a t i e n t s on t h e burn u n i t , l o n e l i n e s s made them f e e l as i f t h e y were i n a n o t h e r world. 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 . " Although  h i s h e a r i n g i s n o t i m p a i r e d , a burn p a t i e n t c a n 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 . or happenings w i t h i n h i s environment. reference.  He was unable t o p e r c e i v e changes He had no v i s u a l frame o f  A t f i r s t , he heard sounds b u t d i d n o t 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 j u d g e time on t h e b a s i s o f t h e human t r a f f i c i n t h e c o r r i d o r and t h e a u t o m o b i l e  t r a f f i c outside.  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 t o h i s burns.  Moreover,  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 t h e C a r e o f t h e P a t i e n t E x p e r i e n c i n g S e n s o r y D e p r i v a t i o n , " Advanced C o n c e p t s i n C l i n i c a l N u r s i n g , e d . 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 w i t h d r a w i n t o s l e e p . " P e r c e p t u a l monotony may c a u s e 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 e n v i r o n m e n t .  The  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  fifth  admission.  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 n v i r o n m e n t , 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 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. s l e e p i n g helped pass the time.  I t was t h i s p a t i e n t who  f r o m an o v e r w h e l m i n g s e n s e o f boredom, i s o l a t i o n and 127 Roberts behavior  He s a i d t h a t  s u f f e r e d t h e most  loneliness.  n o t e d 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  i s boredom, i n a c t i v i t y and s l e e p .  stimulation.  unable to  S l e e p o f f e r s i t s own  At l e a s t i n s l e e p the p a t i e n t can dream.  Sleep also  pass the time w h i c h , t o the p a t i e n t , seems t o s t a n d s t i l l . s l e e p i s an a c c e p t a b l e way Defense Mechanisms  helps  Furthermore,  t o w i t h d r a w from one's monotonous e n v i r o n m e n t . " 190  According  to Lazarus,  "Defenses are 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 1 2 5  R o b e r t s , Behavioral  1 2 6  I b i d . , p.  280.  1 2 7  I b i d . , p.  286.  1 2 8  C o n c e p t s i n t h e C r i t i c a l l y 111 P a t i e n t , p.  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 (New Y o r k : M c G r a w - H i l l , 1 9 6 6 ) , p. Zbb.  Process  of 279  115 threat.  In t h i s way,  o r an i n t e r n a l  harm i s not a n t i c i p a t e d , e i t h e r f r o m an  external  source."  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 conscious  awareness i n the e n d e a v o r t o r e s o l v e e m o t i o n a l c o n f l i c t and  allay anxiety. process  I t i s a normal c o p i n g b e h a v i o r by w h i c h the  i s brought about.  Therefore, 129  adaptive  d e n i a l s e r v e s to d e c r e a s e the  individual's anxiety 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  fully  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 . 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 . s k i l l f u l l y steered conversation  One p a t i e n t c l e a r l y  Another patient  away f r o m 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  care,  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 grafting.  In both p a t i e n t s , d e n i a l may  provoking  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 .  d e n i a l may anxiety.  have m i n i m i z e d the  anxiety Furthermore,  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 o v e r w h e l m i n g  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 s p o n s e 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 p e r s o n does not have the e x p e c t e d r e s p e c t f o r him. 131 expresses h o s t i l i t y . "  R a t h e r than f e e l a n x i o u s ,  he f e e l s a n d / o r  129 Roberts, Behavioral 1 3 0  131  I b i d . , p.  192.  I b i d . , p.  201.  C o n c e p t s i n the C r i t i c a l l y 111 P a t i e n t , p.  182.  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 o n t o someone i n his 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 a n g e r 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 n u r s e s 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 t h e  n u r s e s d i s l i k e d him and were ' a g a i n s t ' him. been a d m i n i s t e r e d administered treatment.  I f a p a i n f u l treatment  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  the treatment,  had  who  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 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 a n g e r 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 e r , he  p r o j e c t e d t h e 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 staff.  the  The e x p r e s s i o n o f " a n g e r r e v e a l s a s e n s e o f f r u s t r a t i o n i n 132  attempting  t o a c h i e v e a goal t h a t has been  obstructed."  H o s t i l i t y and a n g e r 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 t h e vagueness and p o w e r l e s s n e s s o f a n x i e t y .  Threats to the  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. anxiety. 133 ways.  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  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 r e s p o n d i n abnormal  Roberts,  B e h a v i o r a l C o n c e p t s and the C r i t i c a l l y 111 P a t i e n t , p.  I b i d . , p. 209 ,  203.  117 Discharge Anxiety 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 . 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,  They had the  p a t i e n t s r e a l i z e d t h e y were a b o u t 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 surroundings.  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 e n v i r o n m e n t ,  they  had r e g a r d e d t h e 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 abrupt t e r m i n a t i o n of t h i s emotional attachment to t h e i r e n v i r o n m e n t and t h e s t a f f a p p e a r e d 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 t h e " o u t s i d e w o r l d " and d r e a d e d t h e p o s s i b i l i t y of another i n j u r y .  He and t h e o t h e r p a t i e n t s w o r r i e d about  t h e r e s p o n s e 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 t h e 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 t h e 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 isolation. 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 t h e 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 e m o t i o n a l t u r m o i l d u r i n g hospitalization.  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 a b o u t  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 revealing.  The i m p l i c a t i o n s f o r t h e n u r s e i n r e d u c i n g t h e e f f e c t s o f  treatment s t r e s s are s u b s t a n t i a l .  118  Chapter 5 SUMMARY RECOMMENDATIONS CONCLUSIONS Summary The p r i m a r y p u r p o s e o f t h e s t u d y was  to 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 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 and p s y c h o l o g i c a l burn p a t i e n t s .  support  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  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  anxiety producing  information  about  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 The i n s t r u c t i o n a l program a l l o w e d  study.  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 e m o t i o n s 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 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  care.  interventions  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  statistical  measurements. S i n c e a d e s c r i p t i v e a p p r o a c h was s e l e c t e d , i t was  not the s o l e  purpose o f the study to c o n v i n c i n g l y demonstrate that the 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 r e d u c e a n x i e t y due to t h e e f f e c t s o f treatment 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  behavior  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 with i t s all-encompassing Nevertheless,  p a i n t h a t dominated the s i t u a t i o n .  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 p r o d u c e d 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 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 patients. (  However, i t a p p e a r s t h a t t h e r e i s no m e a s u r a b l e 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 t h e  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 . M o r e o v e r , t h e r e was no m e a s u r a b l e i n c r e a s e i n the hours o f s l e e p and no m e a s u r a b l e d e c r e a s e i n e x p r e s s e d time.  S l e e p and m e d i c a t i o n  d u r i n g the recovery p e r i o d .  need f o r m e d i c a t i o n o v e r u n i t  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 Extraneous  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 t h e 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  during  valid  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 t h e 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  of  the e f f e c t i v e n e s s o f t h e 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 treatment 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 w h i c h 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 t h e p l a n n e d v i s i t s w i t h t h e patients.  Furthermore,  t h e s e p a t i e n t s were u n a n i m o u s l y i n f a v o u r o f t h e  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 ' a s s e s s m e n t 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 somewhat i n v e r s e l y r e l a t e d .  This suggested  was  t h a t t h e nurse c a r i n g f o r t h e  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  validity.  120 T h e r e were many a n x i e t y p r o d u c i n g as p e r c e i v e d by t h e p a t i e n t s . w i t h burn t r e a t m e n t  stressors during h o s p i t a l i z a t i o n  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  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 .  Since  these  p a t i e n t s ' l i v e s a t t h i s t i m e r e v o l v e d a r o u n d t h e i r burn i n j u r y and t h e p e o p l 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 t o be  expected.  The a t t i t u d e s , a c t i o n s and s t a t e m e n t s 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 w h i c h 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  t h 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 r t h e r m o r e , t h e p a t i e n t s passed t h r o u g h recovery period.  s i m i l a r phases d u r i n g t h e  T r e n d s 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 t o t h e small number o f p a t i e n t s in the 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 h e 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 n o t 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 n u r s e s p e c i a l i s t remains u n r e s o l v e d . p a t i e n t ' s emotional  Nevertheless,  the approach t o a  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 n u r s e who does n o t 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 to p a i n .  stress leading  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 t o  121 cope w i t h t h e 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 m a j o r e m o t i o n a l 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 r s e s 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 t o enhance t h e i r u n d e r s t a n d i n g  of  the p s y c h o l o g y o f t h e burn p a t i e n t and p h a s e s he may be e x p e c t e d t o p a s s through.  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  and b e h a v i o r a l  d e f e n s e mechanisms  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 c o p e 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 t h e n u r s e 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 h e burn b a t h t o h e l p t h e 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 d e b r i d e m e n t and accompanying p a i n . p e r s o n , engaged i n c o n v e r s a t i o n  As one p a t i e n t s u g g e s t e d , a  w i t h him d u r i n g t h e b a t h , would  provide  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 f o r m e r 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 a s k e d t o 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 f o r m e r p a t i e n t may  b o o s t t h e m o r a l e 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 c a n 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 t h e 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 t h e p a t i e n t s ' s e n s e 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 t o 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 h r o u g h 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 t h e same situation.  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 t h e p a t i e n t s themselves.  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 suggestions to  enhance t h e 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 v e r y 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 d j u s t m e n t t o t h e burn i n j u r y and i t s , . c o n s e q u e n c e s . 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 s t u d y sample i s needed t o c o n f i r m t h e 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 to the t a r g e t p o p u l a t i o n has not been a t t e m p t e d . S i n c e i t was recommended t h a t a n u r s e , n o t 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 t o 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 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 . An e x p e r i m e n t a l s t u d y c o u l d compare t h e 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 versus a n o n - s p e c i a l i s t nurse i n order 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 t h e p u r p o s e . 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 t h e e m o t i o n a l 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 t h e 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 i m p o r t a n c e 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 p r o b l e m s , 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 face a f t e r discharge 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 e m o t i o n a l 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 . apparent  problems I t was  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 t h e  l e s s s e v e r e l y burned p a t i e n t .  M o r e o v e r , no i n f o r m a t i o n a b o u t the  e f f e c t s o f t h e n e c e s s i t y o f w e a r i n g t h e J o b s t * * - e l a s t i c garment f o r 7  approximately  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 t h e burn i n j u r y and great anxiety during h o s p i t a l i z a t i o n . Planned nursing 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 t h e e f f e c t s o f t r e a t m e n t  Since a  p e r s o n who  stress.  has been burned c o n f r o n t s m u l t i p l e s t r e s s e s and  profound  s u f f e r i n g , p s y c h o l o g i c a l s u p p o r t , e x p l a n a t i o n and r e a s s u r a n c e  from f a m i l y  and s t a f f members a r e paramount i n t h e t o t a l c a r e o f t h i s i n d i v i d u a l .  124  BIBLIOGRAPHY BOOKS A b d e l l a h , Faye, and L e v i n e , Eugene. 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"Passage T h r o u g h H o s p i t a l i z a t i o n o f S e v e r e l y Burned I s o l a t e d School Age C h i l d r e n . " Communicating N u r s i n g R e s e a r c h . B o u l d e r : Western I n t e r s t a t e Commission f o r H i g h e r E d u c a t i o n , 1975: 181-197. L a i n g , James. 844-845.  " R e g i o n a l Burns C e n t r e . " N u r s i n g Times (May 29,  1975):  L a r s o n , Duane; and G a s t o n , R i t a . " C u r r e n t Trends i n t h e Care o f Burned P a t i e n t s . " American J o u r n a l o f N u r s i n g 67 ( F e b r u a r y 1967):319-327. L a z a r u s , R i c h a r d ; Deese, James; and O s i e r , S o n i a . "The E f f e c t s o f P s y c h o l o g i c a l S t r e s s Upon P e r f o r m a n c e . " P s y c h o l o g i c a l B u l l e t i n 49 (1952):293-317. Le Shan, Lawrence. "The World o f t h e P a t i e n t i n Severe P a i n o f Long D u r a t i o n . " J o u r n a l o f C h r o n i c D i s e a s e s 17 ( F e b r u a r y 1964):119-126. L e v i , L e n n a r t . " S t r e s s and D i s t r e s s i n Response to P s y c h o s o c i a l S t i m u l i . " Supplement No.528 t o A c t a Medica S c a n d i n a v i c a 191 (1972). L e w i s , S.R.; G o o l i s h i a n , H a r o l d ; Wolf, C l i f t o n ; L y n c h , J o h n ; and B l o c k e r , T.G. " 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):323-332M a r t i n , B a r c l a y . "The Assessment o f A n x i e t y By P h y s i o l o g i c a l B e h a v i o r a l Measures." P s y c h o l o g y B u l l e t i n 58 (1961 ):234-255. M a r t u z a , V i c t o r R.; and K a l l s t r o m , • D a l e . " V a l i d i t y 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 . " P s y c h o l o g i c a l R e p o r t s 35 (August 1974):363-3661 M c C a f f e r y , Margo; and Moss, Fay. " 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):1224-1227. McGranahan, B e t t y G. " N u r s i n g Care o f t h e Burned P a t i e n t . " 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):787-793. Meyers, M.E. "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 to S t r e s s . " N u r s i n g R e s e a r c h 13 ( S p r i n g 1964):126-131. M i n c k l e y , B a r b a r a . "The M u l t i p h a s i c Human-to-Human M o n i t o r - N u r s i n g O b s e r v a t i o n i n t h e I.C.U." N u r s i n g C l i n i c s o f N o r t h America 3 (March 1968):33-35. M i n c k l e y , B a r b a r a . " E x p e r t N u r s i n g Care For Burned P a t i e n t s . " J o u r n a l o f N u r s i n g 70 (September 1970):1888-1893.  American  Moss, Fay T.; and Meyer, B u r t o n . "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 R e s e a r c h 15 ( F a l l 1966):303-306. N e s s e l r o a d e , John; and C a b l e , Dana. "Sometimes, It's O.K. t o F a c t o r D i f f e r e n t i a t e S c o r e s - The S e p a r a t i o n o f S t a t e and T r a i t A n x i e t y . " M u l t i v a r i a t e B e h a v i o r a l R e s e a r c h 9 ( J u l y 1974):273-282.  131 N i e l d , M a r g a r e t Ann. "The E f f e c t o f H e a l t h T e a c h i n g on t h e A n x i e t y L e v e l o f P a t i e n t s w i t h C h r o n i c O b s t r u c t i v e Lung D i s e a s e . " N u r s i n g R e s e a r c h 20 (November/December 1971):537-541. Noyes, R u s s e l l ; A n d r e a s e n , N. J . ; and H a r t f o r d , C.E. "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 e v e r e Burns." P s y c h o s o m a t i c s X I I (November/December 1971 ):416-422. O ' M a l l e y , Peggy. " S e p t i c Shock i n a Burn P a t i e n t . " ( J a n u a r y 1976):39-43.  N u r s i n g '76 6  P r u i t t , B a s i l A.; and M o n c r i e f , J o h n . " C u r r e n t T r e n d s i n Burn R e s e a r c h . " J o u r n a l o f S u r g i c a l R e s e a r c h 7 ( J u l y 1967):332-347. R e i t e r , Henry. " R e l a t i o n s h i p s Among Four Measures o f A n x i e t y . " P s y c h o l o g i c a l R e p o r t s 28 (June 1971):761-762. R o s e n f i e l d , S.R. " N u r s i n g C a r e S t u d y : Burns." N u r s i n g Times 69 ( O c t o b e r 4, 1973):1289-1291. Rottkamp, B a r b a r a . "A B e h a v i o r M o d i f i c a t i o n Approach t o N u r s i n g T h e r a p e u t i c s i n Body P o s i t i o n i n g o f S p i n a l - C o r d I n j u r e d P a t i e n t s . " N u r s i n g R e s e a r c h 25 (May/June 1976):181-186. S a y l o r , Dennis. "Understanding P r e - S u r g i c a l A n x i e t y . " Journal 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 22 ( O c t o b e r 1975):624-636. S c h a f e r , D o n a l d . " H y p n o s i s Use on a Burn U n i t . " 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 H y p n o s i s 23 ( J a n u a r y 1975):1-13. S c h l i c h t m a n n , K a t h r y n A. " A d a p 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 R e s e a r c h 18 ( J u l y / A u g u s t 1969):379. S c h m i t t , F l o r e n c e ; and W o o l d r i d g e , Powhatan. " P s y c h o l o g i c a l P r e p a r a t i o n o f S u r g i c a l P a t i e n t s . " N u r s i n g R e s e a r c h 22 ( M a r c h / A p r i l 1973):108-116. S h e d l e t s k y , R a l p h ; and E n d l e r , Norman. " A n x i e t y : The S t a t e - T r a i t Model and t h e I n t e r a c t i o n Model." J o u r n a l o f P e r s o n a l i t y 42 (December 1974):511-527. Shor, R o n a l d E. " P h y s i o l o g i c a l E f f e c t s o f P a i n f u l S t i m u l a t i o n Under H y p n o t i c A n a l g e s i a Under C o n d i t i o n s D e s i g n e d t o M i n i m i z e A n x i e t y . " 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 H y p n o s i s 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 O u t l o o k 22 (September 1974): 560-566. Weisz, A l f r e d . " 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 . " T r e a t m e n t 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):52-57W 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 . " C l i n i c s o f N o r t h America 6 (December 1971):616-638. W i l l i a m s , B a r b a r a . " L i f e s t y l e s o f S e v e r e l y Burned Men. 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.  "Handling Anxiety."  Nursing  Nursing Research  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 S e n s o r y 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 , e d . 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 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):802-808.  ADDITIONAL SOURCES J o h n s o n , J e a n 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 h e P a t i e n t ' s P o s t - O p e r a t i v e C o u r s e . " ( 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.) J o h n s o n , Jean E. " C o g n i t i v e C o n t r o l o f t h e Emotional Component o f t h e P a 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. T e 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 R e s e a r c h 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 a g r 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 t h e Burn U n i t o f t h e Vancouver G e n e r a l H o s p i t a l by B a r b a r a 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 t h e p u r p o s e o f t h i s s t u d y i s t o a c q u i r e knowledge a b o u t 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 treatment s t r e s s . I understand that p a r t i c i p a t i o n i n t h i s study i n v o l v e s answering t h e 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 k e e p i n g 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 t h e 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 w i t h d r a w from t h e s t u d y a t any time.  Signature  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  MODERATELY SO,  VERY MUCH SO  ©  SOMEWHAT  ®  NOT AT ALL  DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each statement 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.  ©  ®  ©  ® . ®  ©  3. I am tense  ©  ®  ®  ®  4. I am regretful  ©  ®  ®  ®  ©  ®  ®  ®  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  ©  ®  ®  ©  ©  ®  ®  ©  18. I feel over-excited and "rattled"  ©  ®  ®  ©  19. I feel joyful  ©  ®  ®  ®  ..... © Spielberger  ®  ®  ®  1. I feel calm  ..  :  :  2. I feel secure  ;  5. I feel at ease  •.  17. I am worried  .  20. I feel pleasant S p e c i a l p e r 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 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  135*_  STAI FORM X-2  NAME  DATE  ALMOST NEVER  SOMETIMES  OFTEN  ALMOST ALWAYS  DIRECTIONS: A number of statements which people have used to describe themselves are given below. Read each statement 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.  ©  ®  ®  ®  22. I tire quickly  ©  ©  ®  ©  23. I feel like crying  ©  ®  ®  ©  24. I wish I could be as happy as others seem to be  ©  ®  ®  ©  ®  ®  ©  ©  ®  ®  ©  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  ©  ®  ®  ©  ©  ®  ®  ©  21. I feel pleasant  ..  25. I am losing out on things because I can't make up my mind soon enough.... 26. I feel rested  ;  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 Consulting Psychologists Press. 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  Patient Teaching Audio-Visual Presentation  '^  " E x p l a i n i n g Your Burn C a r e "  PART I: ORIENTATION TO THE  BURN UNIT  We'd l i k e & to inform receive. t o you and  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 you o f some o f the t r e a t m e n t s you w i l l 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 answer any q u e s t i o n s .  The Burn U n i t o f the V a n c o u v e r 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 Paviiion.  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 t h e p o r c h when y o u do n o t 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 f o r w a r d i n y o u r i n d e p e n d e n c e 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 n u r s e s a r e a s s i g n e d t o a l l o f t h e p a t i e n t s here.  T h e r e 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 n u r s e s w e a r i n g 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 t a k e n t o h e l p p r e v e n t t h e 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 o u r p a t i e n t s from c o n t a c t i n g further infection.  138  When t h e n u r 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 t h e w a l l i n t h e 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 t h e 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 workers.  T h e s e 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 questions.  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 t h e e x t e n t of 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 h e a l 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 of t h e s k i n and p r o d u c e s a " b l i s t e r b u r n . " A second d e g r e e 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 d e g r e e burn i n v o l v e s c o m p l e t e d e s t r u c t i o n o f t h e f i r s t two l a y e r s o f t h e s k i n and p e n e t r a t e s t h e f a t t y t i s s u e b e n e a t h .  Various pain medicines 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 , y o u 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 healing takes place.  Your burn a r e a s may be c o v e r e d by bandages or d r e s s i n g s - u s u a l l y wet c o m p r e s s e s . The n u r s e 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 a r e a w i l l be e x p o s e d .  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 , o i n t m e n t s 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 o r remove any dead s k i n , and c l e a n s e the a r e a well before applying f r e s h dressings.  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 h o u r s . 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.  T h e r e 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 t o m a i n t a i n good movement i n t h e 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 o i n t m e n t i s a p p l i e d t o 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 t o t h e l e g s a f t e r h e a l i n g has t a k e n p l a c e . They a r e a p p l i e d whenever y o u a r e w a l k i n g t o p r o v i d e s u p p o r t t o t h e newly healed 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 v e r 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 y o u a r e encouraged t o d r i n k i t d a i l y .  Feel f r e e t o a s k 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 y o u 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 y o u w i t h t h e b e 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 s h 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 t h e most common t r e a t m e n t s on t h e u n i t i s t h e 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 y o 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 m e d i c a l s o l u t i o n added. I t i s n o t 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 t h e n u r s e s move y o u 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 h e b a t h . You w i l l s t a y on t h i s metal cot 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 n u r s e w i l l d e b r i d e t h e 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 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 t h e 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 t h e o p p o s i t e way t o which you were put i n . The n u r s e w i l l d r y you e n t i r e l y and c o v e r you with a flannel sheet.  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 t h e y 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 t h e most common t r e a t m e n t s on t h e 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 t o 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 w a t e r . The water may be an orange c o l o u r due t o a m e d i c a l s o l u t i o n added t o t h e w a t e r . I t i s n o t 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 h e t r e a t m e n t l a s t s 20 m i n u t e s .  The n u r s e w i l l d e b r i d e o r remove t h e 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 t h e w a t e r 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 t h e 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 are re-applied.  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 t o e n j 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 of skin t i s s u e , the skin i s not able 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 h e a l t h y n o n - b u r n a r e a o f y o 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 t h e 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 a r e a . 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 area i s l e f t exposed.  Because d r a i n a g e and pus accumulate under t h e g r a f t , t h e n u r s e 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 t o remove t h i s d r a i n a g e . When t h e 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 n o t 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 t i m e . Your d o c t o r w i l l d i s c u s s t h e a p p r o x i m a t e l e n g t h o f time.  The donor a r e a from w h i c h t h e s k i n comes, i s exposed t o t h e a i r . I t d e v e l o p s a d r y 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 i m p o r t a n t t h a t y o u do n o t s c r a t c h t h i s a r e a .  The d o n o r 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 of 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 t h e 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 f r o m m o u l d a b l e p l a s t i c and may require frequent adjustment.  These a r e p r e s c r i b e d to maintain the 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 t h e 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 d u r i n g t r e a t m e n t and e x e r c i s e .  except  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 functional position.  150  PART V I : 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 l i m b . T h e s e p i n s a r e screws p l a c e d through t h e bone and a r e thus h e l d i n p l a c e .  T h e s e 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 l i m b position during healing.  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 h e p i n s do n o t 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 n u r s e 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 o i n t m e n t . 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.  B.  Evaluation of the informative component:  Yes  1.  Do you understand why you are on " i s o l a t i o n " ?  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 periodically?  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 f o r you to exercise often?  7.  Do you know why e l a s t i c stockings are applied on your healing legs?  8.  Do you understand why good n u t r i t i o n i s important?  No  Evaluation of the support component: Please rate the f o l l o w i n g questions on t h i s scale 1 very helpful  2 helpful  3 uncertain  4 not helpful  5 useless  How helpful did you f i n d the t a p e - s l i d e program?  1 2  3  4  5  How helpful did you f i n d our discussion of the t a p e - s l i d e program?  1 2  3  4  5  153 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -  C.  Evaluation of the Burn Bath component: 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?  Yes  No  Evaluation of the support component: Please rate the following questions on t h i s scale 1 very helpful  2 helpful  3 uncertain  4 not helpful  5 useless  How helpful d i d you f i n d the t a p e - s l i d e program?  1 2  3  4  5  How helpful did you f i n d our d i s c u s s i o n of the t a p e - s l i d e program?  1 2  3  4  5  154 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -  E.  F.  Evaluation of the Arm Bath component 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?  Yes  No  Evaluation of the support component: Please rate the f o l l o w i n g questions on t h i s s c a l e . 1 very helpful  2 helpful  3 uncertain  4 not helpful  How helpful did you f i n d the t a p e - s l i d e program?  1  How helpful did you f i n d our discussion of the t a p e - s l i d e program?  1 2  2  5 useless 3  4  5  3  4  5  155  INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -  Evaluation of the Skin Grafting component:  H.  Yes  1.  Do you understand why skin g r a f t i n g i s necessary?  2.  Do you understand why the nurse must r o l l each g r a f t with a " Q - t i p " frequently?  3.  Do you understand why you must remain in one p o s i t i o n for a period of time?  4.  Do you understand why you must not scratch an i t c h y donor area?  No  Evaluation of the support component: Please rate the f o l l o w i n g questions on t h i s s c a l e . 1 very helpful  2 helpful  3 uncertain  4 not helpful  5 useless  How helpful did you f i n d the t a p e - s l i d e program?  1 2  3 4  5  How helpful did you f i n d our discussion of the t a p e - s l i d e program?  1 2  3  5  4  156 INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -  I.  J.  Evaluation of the S p l i n t i n g component: 1.  Do you understand why you must wear s p l i n t s ?  2.  Do you understand why exercise i s important when the s p l i n t i s removed from your hand or leg?  Yes  No  Evaluation of the support component: Please rate the following questions on t h i s s c a l e : 1 very helpful  2 helpful  3 uncertain  4 not helpful  5 useless  How helpful did you f i n d the t a p e - s l i d e program?  1 2  3  4  5  How helpful did you f i n d our discussion of the t a p e - s l i d e program?  1 2  3  4  5  157*~ INTERVIEW FORMAT FOR EVALUATION OF THE INSTRUCTIONAL PROGRAM CONTINUED -  K.  L.  Evaluation of the Surgical Pinning component: 1.  Do you understand why pinning i s necessary?  2.  Do you understand why frequent, cleansing of the p i n s i t e s are necessary?  3.  Do you believe t h a t , although the pins look p a i n f u l , they do not r e a l l y hurt?  Yes  No  Evaluation of the support component: Please rate the following questions on t h i s s c a l e . 1 very helpful  2 helpful  3 uncertain  4 not helpful  5 useless  How helpful did you f i n d the t a p e - s l i d e program?  1 2  3  4  5  How helpful did you f i n d our discussion of the t a p e - s l i d e program?  1 2  3  4  5  1571)  APPENDIX E  Key:  u^= awake  a> asleep =  sleeping p i l l pain p i l l nursing task  SLEEP RECORD Room  Name  Date  Day 1  1900  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:  2000  2100  2200  2300  2400  0100  0200  0300  0400 0500  0600  0700  158b  APPENDIX F  Key:  (Tj) = request (&)= given )= time  (  159a  MEDICATION RECORD Room Analgesic Day  Day  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:  ize?^ Evng.  Night  Day  1 1  "  Sedative Evng.  Night  Sleeping P i l l Evng.  Night  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  not anxious 2.  2  fairly anxious  3  moderately anxious  4  highly anxious  5  extremely anxious  Under 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 , would y o u 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  not anxious  fairly anxious  moderately anxious  4  highly anxious  5  extremely anxious  160b  APPENDIX H  161  YOUR DAILY DIARY  The purpose of your diary i s to keep a d a i l y account of your reactions to your treatments. Your f e e l i n g s and concerns are important to nurses. Although your diary w i l l be c o n f i d e n t i a l during your hospital s t a y , the researcher hopes to accumulate s i m i l a r comments and concerns common in a l l patients in t h i s study. This w i l l help give the nursing and medical s t a f f i n s i g h t into the concerns of burn patients during t h e i r recovery. INSTRUCTIONS: 1. Try to enter comments into your diary at the same time of day, every day, a f t e r your treatments - - perhaps from 4-6 p.m. 2. Try to think of 5 p o s s i b l e responses 1 strongly agree  2 agree  3 uncertain  4 disagree  5 disagree strongly  6 does not 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, describing how you f e l t during the day with regard to that particular topic.  DAILY DIARY 1. I found the dressings painful but t o l e r a b l e today. 1 strongly agree Comments:  2 agree  3 uncertain  4 disagree  5 disagree strongly  6 does not apply  162 2. The p a i n does n o t seem as s e v e r e 1 strongly agree  2 .agree.  3 uncertain  today. 4 disagree  •  5 strongly disagree  6 .does n o t apply  5 strongly disagree  6 does n o t apply  Comments:  3. .1 was a f r a i d o f my t r e a t m e n t s t o d a y . 1 2 3 4 strongly agree uncertain disagree agree 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  \  strongly  2  agree  . uncertain 3  4  disagree  agree  today. 5  6  strongly  does n o t  disagree  apply  5 strongly disagree  6 does n o t apply  Comments:  I slept well l a s t night. 1 2 3 strongly agree uncertain agree Comments:  4 disagree  I was a n x i o u s t o d a y . 1 2 3 strongly agree uncertain agree  164 4 disagree  5 strongly disagree  6 does not apply  Comments:  I,am  c o n c e r n e d a b o u t 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 strongly agree Comments:  2 agree  3 uncertain  4 disagree  5 strongly disagree  6 does not apply  165 8. I am c o n c e r n e d 1 strongly agree  a b o u t my f a m i l y .  2 agree  3 uncertain  4 disagree  5 strongly disagree  6 does n o t apply  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 strongly agree Comments:  2 agree  3 uncertain  4 disagree  5 strongly disagree  6 does n o t apply  166 10. I feel discouraged today because I can see no improvement. 1 strongly agree  2 agree  3 uncertain  4 disagree  5 strongly disagree  6  does not apply  Comments:  11. I/f my general sense of w e l l - b e i n g could be rated on a s c a l e , with (1) being "poor" and (5) being " g r e a t ! " , today I am: 1 poor Comments:  2 fair  3 average  4 good  5 great!  

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