Research Term paper 2
Checklist for Term paper 2
This checklist is designed to elaborate on the key points of the term paper.
General:
o No page limit but strictly follow the APA style (font size, spacing, citation, paragraph
structures, etc).
o Submit Term Paper 2 in Turnitin
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Data Collection:
o What type of data do you plan to acquire to answer your research question? (Qualitative
or quantitative or Mixed?) and Why you choose that type of data?
What kinds of instruments or materials will you use (observations, surveys,
interviews, case studies, focus groups, experiments, documents, media,
database searches, etc.)
Identify the sources information that you need to answer the research question
(journals, books, internet resources, government documents, people, etc).
If you plan to use mixed methods, will they be sequential, concurrent, or
transformative? and Why?
o List the kinds of data/information that you plan to collect (e.g. testimonials, statistics,
business/government reports, other research data, audio/video recordings, etc.). Also,
consider two or three alternative ways you could gather data/information for this
research.
o If you plan to use research participants,
where will they come from (e.g from a list of employees of a factory, students of
a university, Manages/supervisors, etc? )
How will they be sampled (e.g. random sampling, stratified sampling, purposeful
sampling?)
How many participants will you require? (your sample size) and how you decided
the number?
o If you are not using research participants,
who will you use as the target audience of your data? Who would most benefit
from your research, and why?
o If your research topic is related to events that develop in time.
Explain how would you acquire a snapshot of data (a data at a particular point in
time) relevant to your research question. Within the snapshot, the data become
effectively stationary.
Consider the evolution of data with time. How would you acquire the time series
data relevant to your research question?
o What ethical issues will your research project present? (You dont need to explain how
will you address it)
o What biases might you bring to the research and how will you address that bias?
Analysis of (stationary) data:
o What method will you choose to analyze the stationary data that you plan to collect (e.g.
descriptive analysis, variance analysis, etc)?
o Has this method of data analysis you choose been applied in similar situations by other
authors? If yes (most likely Yes to all of you unless you developed a new methodology),
Include references and illustrations from the literature to show the advantages
and disadvantages of the method.
o Attach a worked-out example of the application of the method using simulated or
previously published data (Optional).
o How will you validate your findings/conclusions?
Testing Hypothesis
o State your hypotheses ( the null hypothesis ONLY).
o Explain whether your hypotheses will be tested using a frequentist or Bayesian approach,
and justify the choice.
o Have similar hypotheses been tested by other authors?
If yes, include references and illustrations from the literature.
o Attach a worked-out example of hypothesis testing using simulated or previously published
data (Optional).
o How will you validate your findings/conclusions?
Analysis and forecasting of time series
o What method will you choose to analyze and forecast the time series data that you plan to
collect? (Simple Index Number, Composite Index Number, Weighted Composite Price Index, etc)
o Have these methods of data analysis and forecasting been applied in similar situations by
other authors?
If yes, include references and illustrations from the literature to show their
advantages and disadvantages.
o Attach worked-out examples of analysis and forecasting using simulated or previously
published data (Optional).
o How will you validate your findings/conclusions?
Time Tabel and Budget Plan
o Show the time table for major activities on weekly or monthly basis.
o Show your budget plan for research related expenses. Bachelor in Science (Nursing) (BSc (Cur))
Research Proposal
A QUALITATIVE RESEARCH STUDY INVESTIGATING
NURSES PERCEPTIONS AND EXPERIENCES OF
PROVIDING PSYCHOLOGICAL CARE TO BURNS
PATIENTS DURING THE RECOVERY PHASE.
2
Work Declaration
I ________________hereby declare that the work in this Research Proposal is
entirely my own work, except where stated. Research was gathered using online
databases and printed texts and all work referenced is included in a reference list.
No help was sought from an external professional agency and there was no use of
other students past work and has not been submitted as an exercise for
assessment at this or any other University.
Signed: __________________________
Print Name:__________________________
Date: _____________
3
Table of Contents
1. Title Page……i
2. Acknowledgements…………ii
3. Work Declaration……..iii
4. Table of Contents…….iv
5. Abstract.1
Chapter 1
6. Identifying the Research Issue…..7
7. Literature Review….8
1.2.1 Psychological Implications…9
1.2.2 Interventions….11
1.2.3 Nursing Role….13
1.2.4 Conclusion…14
8. Research Question…15
9. Aims and Objectives.15
Chapter 2
10. Research Methodology…16
11. Design/Proposed Method..16
12. Population Sample……..17
13. Data collection…18
14. Data Analysis.19
16. Pilot Study…….19
17. Robustness….20
18. Ethical Consideration….20
2.8.1 Beneficence and Non-maleficence..20
4
2.8.2 Autonomy21
2.8.3 Justice.21
Chapter 3
20. Proposed Outcome.22
21. Limitations.22
22. Dissemination22
23 Time Scale…..23
24. Resources23
25. Reference List..38
Appendices
Appendix I Table 1
Appendix II Letter to Ethics Committee
Appendix III Letter to Director of Nursing
Appendix IV Letter to Clinical Nurse Managers
Appendix V Letter of Invitation
Appendix VI Consent
Appendix VII Sample Interview
Appendix VIII Colaizzis Seven Step Process to Data Analysis
Appendix IX Time Scale
5
Abstract
Research Question: What are nurses perceptions and experiences of providing
psychological care to burn victims?
Background: Burn injuries are a common traumatic experience which can set an
enormous amount of stress and strain on an individuals psychological state. Due
to the improvements in emergency services and burn treatment in the past century
more and more burn survivors are required to make psychosocial adjustments to
cope with their new body image (Lawrence et al. 2006, Klein et al. 2007, Ullrich et
al. 2009).
There are known support groups to aid this adjustment post hospitalization
however literature demonstrates the lack of research into the psychological care
provided by nurses during the patients recovery period in hospital. Thus the
research question What are nurses perceptions and experience of providing
psychological care for burn victims? was developed.
Aim of this study: This study aims to explore nurses perceptions and
experiences of providing psychological care in order to identify areas of
psychological care which can be improved or developed to enhance quality of
practice.
Methods: The research method chosen and best suited to this study is descriptive
qualitative research. The proposed method for data collection is open-ended semi-
structured interviews which will be audio taped to maintain accurate accounts of
information given.
Sample: The researcher intends to use 6-8 registered nurses who fit the outlined
criteria chosen through purposive sampling. It is proposed that that the clinical
nurse manager (CNM) of the chosen burns unit will distribute letters of invitation
and consent forms to registered staff nurses in the unit.
Data Analysis: The researcher proposes to make use of Colaizzis (1978) data
analysis approach following the transcription of audio recorded information.
Findings: It is hoped that the outcome of this study raises awareness of the need
for psychological care in the recovery period of burn injuries and with the
knowledge gained from nurses experiences and perceptions improve standard
and quality of psychological care in burn units.
6
A Qualitative Research Study Investigating Nurses
Perceptions and Experiences of Providing Psychological Care
to Burns Patients During the Recovery Phase.
Chapter 1
1.1 Identifying the Research Issue of Interest:
From the literature accessed it is evident that the psychological needs of
burn victims is a vital part of their recovery following their injury, however there is
little research carried out regarding the extent or format of care necessary. For
example Bernstein (1976) is one of many researchers who investigated the idea of
burn victims who had suffered large total body surface area (TBSA) injuries, in
visible locations of the body and concluded that these victims are thought to have
decreased self-esteem and value of their role in society. Bernstein discusses
significance of attractiveness in society, and concludes that burn survivors have to
come to terms with their new body image and re-establish personal worth following
their injury. Although Bernstein recognises the psychological needs of burn
patients in terms of what they must overcome such as new body image, how we
can support these challenges and patients is not discussed. Studies in the US and
Canada (Holaday & Yarbrough 1996) and in Europe (Van Loey et al. 2001) reveal
that patients are not often psychologically assessed and/or provided with
psychological care in burn units. One clear finding from studies previously carried
out is that a minority of burn victims report significant psychological issues due to
their injuries as it is not usually assessed or discussed while hospitalised
(Fauerbach et al. 1999, Tebble et al. 2004, Fauerbach et al. 2005, Hulbert-
Williams et al. 2008). Thus, the researcher identified and selected this issue as it is
not only an area of personal interest, but also as it is an area identified in the
literature review which has only been given attention in recent decades and has
not yet been looked at in depth. This issue is often overlooked when trying to care
for the acute burn victim however it can prove to be a more serious psychological
issue further along the line if not cared for effectively throughout the recovery
phase (Ullrich et al. 2009). The majority of literature in relation to burn injuries
7
focuses on the acute physical care of the injury (Williams 2009 & Rowley-Conwy
2010). However from the literature review, which was carried out corresponding to
the psychological effects of burn injuries, it was found that, following assessment,
many burn victims suffer psychological harm post recovery in burn units. As a
result the researcher wishes to identify the current psychological care being
provided by registered nurses and gain an insight into their opinions and
experiences of the subject. Therefore by carrying out research looking at the role
the nurse plays in caring for burn victims psychological state during the recovery
phase, we may begin making the necessary adjustments to the care already in
place; which may be in need of reassessment and remodelling in order to provide
the best holistic care and in turn psychological care possible for burn victims.
Hospitals, staff, nurses and most importantly burn victims may all benefit from
further research and training in this area of care.
1.2 Literature Review:
There have been many studies carried out related to burn injuries, most of
which focus on the physical implications of burns, however this literature review
will concentrate on some of the psychological and social implications and nurses
perspectives regarding these issues. The literature collected and analysed in this
review were accessed from online databases including CINAHL, PsycINFO,
PsycARTICLES, Academic Search Premier, PubMed and Ovid. Only English
language papers with full texts available were reviewed. All studies accessed were
international studies as there were no Irish studies found in relation to this topic.
There were over 40 articles accessed however not all were completely relevant
and as a result not included in this review. No set timeframe was decided upon yet
the most valuable studies came under the parameter of 1990-2010. A variety of
research studies were accessed most of which were found to use qualitative
research methods in their studies. No printed texts were used in this literature
review as texts available were more suitable to care of physical burn injury.
From the literature several key topics were identified and discussed
however, due to word constraints only the most relevant topics will be chosen to
be discussed in detail while others may only be mentioned in this section. These
chosen themes include psychological implications, interventions and the nursing
role.
8
With the increased survival rate of burn patients comes psychological
complications. Burn injuries include both losses and gains in relation to:
functioning, identity, roles, lifestyles and relationships (Williams et al. 2003 & Moi
et al. 2008); which poses major stress on patients. Burns force victims to try to
come to terms with new bodily appearances, how others react to this new
appearance, and coping with physical limitations. These new life stressors create
many psychosocial complications for patients (Patterson et al. 1993). There are
three stages of physiological recovery and patients psychological needs vary at
each stage (Wiechman & Patterson 2004).
1.2.1 Psychological Implications:
Burn victims are at high risk of developing various psychological issues
which can vary from person to person. These issues include anxiety, grief, sleep
disturbances, post-traumatic stress disorder (PTSD), depression and stress. Three
central psychological disturbances were recognised as the most commonly
witnessed including depression, anxiety and PTSD. As stated by Lawrence et al.
(2006) depression is the most common disorder on follow-up among burn victims.
Moi et al. (2008) undertook a qualitative, longitudinal, phenomenological
research study to gain an understanding of the lived experience of a burn victim.
This was done through 20 open, in-depth interviews during 2005-2006, on average
14 months post injury. The study was carried out in Norway where 14 participants,
most of which were men, were selected to participate in the study. The participants
discussed both physical and psychological disturbances as part of their experience
with burn injury. The psychological effects identified by the participants, such as
isolation, social withdrawal and feelings of stigmatisation, are predisposing factors
of depression. Anxiety is another very common issue following, injury of any kind
and hospitalisation. Hulbert-Williams et al. (2008) implies that sufferers of larger
burns experience greater levels of anxiety when compared to those who have
smaller burns. In contrast Tebble et al. (2004) argues that burn injuries no matter
what size can have psychological implications for the patient.
A qualitative, experimental study was carried out by Hulbert-Williams et al.
(2008), investigating anxiety levels related to burn injuries in the United Kingdom
(UK). In total 60 participants were recruited for the study 30 of which had no injury,
used as a control group. Results showed greater levels of anxiety in those with
9
burn injuries and even higher in those who were injured in the previous three
years. This study concluded that burn victims require more than just physical
medical treatment in overcoming the trauma of suffering a burn and require a role
in therapeutic technologies to relieve general anxiety and other psychological
implications experienced by burn victims.
Tebble et al. (2004) lead a prospective, longitudinal qualitative research
study in order to examine the psychological impact of facial injuries and influence
of scarring characteristics on self-consciousness and anxiety levels. Self-report
questionnaires were given to those presenting to the accident and emergency
(A&E) unit in a UK based hospital. A collective 63 people participated in the study
with a criteria limited to those with a visible wound larger than 1.5cm in length. The
Derriford Appearance Scale (DAS-59) (Carr et al. 2000) using only two
subheadings for this study and the State trait Anxiety Inventory (STAI)
(Spielberger 1970) were put into practice for this study. Factors identified as
impacting on self-consciousness were then studied using the state anxiety results;
this found that anxiety and social self-consciousness did not decrease six months
after the injury. Living arrangements displayed mixed results, thus reflecting an
indication of support to be made available based on individual needs. This study
concludes with mention to further training to relevant staff and additional research
into cognitive behavioural and social skills workshops for affected patients.
The American Psychiatric Association (1994) characterise PTSD by three
symptoms; re-experiencing (upsetting thoughts of the traumatic event), avoidance
(suppression of trauma related stimuli), hyper arousal (i.e. unable to sleep or
anxiety).
A cohort longitudinal research study which explored the investigated the
impact PTSD following a severe burn injury was carried out by Fauerbach et al.
(1999). This study was completed in the United States (US) making use of 86
participants. Many tools were utilised in order to assess the levels of distress
experienced some, of which include the Davidson Trauma Scale (DTS), the Beck
Depression Inventory (BDI; Beck et al. 1961) and the Satisfaction with Appearance
Scale (SWAP; Lawrence et al. 1998). This study recognises that those identified
as suffering from PTSD experience a pessimistic outlook; high levels of
depression symptoms and greater level of body image dissatisfaction (BID).
10
Findings suggest that personal traits and characteristics may be a vital variable
that contributes to level of post burn adjustments. Nightmares and intrusive
thoughts related to the traumatic incident in the first four weeks of hospitalisation
can be indicative of acute stress disorder and lead to PTSD (American Psychiatric
Association 2005). All members of the multidisciplinary team (MDT) in burns units
recognise that the patients psychological state affects their physical recovery thus
acknowledge its importance (Klein; 2009). It is part of the nurses role in burns
units to psychologically assess, intervene and support burn victims. It is vital that
nurses make use of the Zung depression scale (Zung 1965) in order to avoid over
prescribing anti-depressants when a burn patient may only be acting rationally to
the situation as opposed to being depressed. Klein (2009) states by identifying the
patients previous coping strategies for stressful situations may give an insight into
how the patient will cope with their new injury. Assessing, identifying and treating
psychological issues following traumatic burn injuries is an integral nursing role
which contributes to the physical recovery of the patient. According to Fauerbach
et al. (2005) psychological needs and issues delayed the rate of recovery of both
physical and psychosocial health and function.
1.2.2 Interventions:
From the available literature it is evident that there are both psychological
and social implications post burn injuries, however there is a clear need for further
research into the psychological care available, the effectiveness of this care and
explore and expand additional care interventions.
Blakeney et al. (2005) produced a qualitative study which examines the
efficiency of a short-term and intensive social skills training program as an
intervention to improve psychosocial adjustment. The researcher chose a
prospective randomised experiment which included one intervention group and a
control group both consisting of 32 participants who suffered from a burn injury two
years prior to the study and were identified as having a form of psychosocial
difficulties (elevated behavioural issues or diminished competence). This study
was aimed at adolescents aged between 12 and 17 with a mean age of 14. 175
adolescents were contacted by mail and follow-up phone calls, both parents and
teens were sent written explanations of the study along with consent and assent
forms, of these 103 responded, and were then assessed using the Child
11
Behaviour Checklist (CBCL) which was completed by a parent or guardian and
from this the final 64 participants were selected. The intervention was carried out
in a residential work shop format over several days. A curriculum was followed
which made use of didactic material, audiovisual aides and experiential exercise
(e.g. role playing), goals and assignments for practicing specific skills during life-
activities were also set throughout the workshops. In contrast the control group
only received usual treatment and follow-up appointments regarding surgeries and
only received psychological/psychiatric attention upon request. One year following
the intervention it was found that those who received the intervention work shops
became less withdrawn and had fewer somatic complaints, whereas there was no
significant change in the control groups. Although this study was carried out using
adolescents it can be applied to adults as the curriculum followed by the
intervention group was developed by Changing Faces a non profit organisation in
the UK who reported success in using the curriculum with adults.
A retrospective qualitative study was lead by Muangman et al. (2005), to
investigate the importance of both physical and psychosocial variables that predict
survival in patients with large burn injuries, looking at social support in particular.
For the purpose of this literature review only the psychosocial factors will be
discussed. Patients were selected based on the percentage of total body surface
area (TBSA) affected by the burn only those with 60% TBSA burns were
selected to participate. Patients with social support were those who had family and
friends present during there time in the intensive care unit (ICU). 36 patients were
selected following a careful assessment of medical notes, and then categorised
into two groups, survivors and non-survivors. It was found that there was a greater
social support in the survivor category, 81% of the survivor group had some form
of social support compared to that of the non-survivor group where only 35% had
social support. It is evident that those without any social support from family or
friends are at higher risk of complications, thus the nursing staff and
multidisciplinary team should be aware of those with little support and in turn
provide the necessary positive support required and find ways to decrease anxiety
and stress levels the patient may be experiencing.
Fauerbach et al. (2002a) completed a study where two coping strategies
were compared (venting emotions and mental disengagement) when coping with
body disfigurement following a burn injury. Findings of this study were
12
hypothesized and ultimately found that the use of one coping method were less
likely to portray symptoms of depression where as a use of both strategies were
more likely to display symptoms of depression. Following this study Fauerbach et
al. (2002b) continued this work with a further study into the relationship of
ambivalent coping to depression symptoms and adjustment. The study used a
prospective longitudinal design to investigate the effect of acute post burn coping
strategies on depression and health related quality of life (HRQOL). This study
was conducted using 76 adult burn patients admitted to a regional burn unit in the
United States. Recruitment was carried out over two and a half years where of 715
burn patients only 286 met the criteria and agreed to participate. The exclusion
criteria included early transfer or discharge against medical advice, those who died
before discharge and a mini mental state exam (MMSE) score of less than 23/30.
The inclusion criteria were purposefully broad and included two specifications; the
patient must be 18 years or older and meet the criteria of severe burn injuries
(American Burn Association 1984). Data was gathered within the first 72 hours of
admission three tools were used in order to facilitate the collection of data these
include the COPE scale (Carver et al. 1989), the Beck Depression Inventory (BDI)
(Beck et al. 1961) and the SF-36 (Ware et al. 1993). The BDI was again
administered one week post discharge, and then the BDI and SF-36
readministered two months later. Results suggest that those who used both
emotion venting and mental disengagement had both larger TBSA and TBSA-FT
(full thickness) than those who used one or none of these coping methods. The
use of both coping methods was however associated with greater symptoms of
depression (see Appendix I) and symptoms decreased or stabilised with frequent
use of either mental disengagement or venting emotions. This study portrays
limitations including selfreports, which is subject to variances and bias, future
studies my benefit from third party informants and/or work evaluations. Also this
study was carried out up to 2 months post discharge; it remains unknown whether
the effects remain consistent beyond this point.
It is evident from these studies that psychological interventions or coping
strategies enhance patient recovery following burn injuries. Suppression has
proven to be neutral or even beneficial, particularly in coping with pain in which
distraction, imagery and other suppression techniques have proven effective
(McCaul & Mallot 1984, as cited by Fauerbach et al. 2002b, p.394). It may profit
13
burn patients if we systematically examine their preferences and goals for
suppressing or processing coping as well as their efficiency and frequency to do
so. It is vital that individual difference in cognitive behaviour and motivation are
taken into account when considering coping strategies which may be most
beneficial for the patient at hand.
1.2.3 Nursing Role:
Burn care requires close multidisciplinary team (MDT) alliance for optimal
patient outcome, at the centre of any MDT there is the nurse, coordinator of
patient care. Not only does burn care require a large amount of knowledge
regarding physical effects of burns but also demands rehabilitative and
psychosocial skills (Greenfield 2010). Rehabilitation for burn victims begin from the
day of admission for a number of years following discharge, with aim of restoring
full function or as near as possible to the patients pre-burn state. In addition to this
rehabilitation, care for the patients psychological and social well-being should also
be managed. This can be achieved through continued nursing input with both
patient and family and ensure continuous communication with both is maintained
(Williams 2009).
A prospective, longitudinal quantitative research study was carried out by
Wikehult et al. (2008) which assessed negative emotional experiences during burn
care in aim of improving the development of optimal nursing for these patients.
The study was carried out in a large Swedish hospital responsible for caring for
those with severe burn injuries. The admission criteria was based on the
recommendations American Burn Associations (ABA) including; total body surface
area (TBSA) burned and TBSA with full thickness burn (TBSA-FT). A total of 42
patients participated in the study, all of which were above the age of 18 at time of
injury. This study examined psychiatric morbidity along with physical,
psychological and social well-being. Over all this study found low ratings of
negative emotional experiences which are an encouraging discovery for burn care
nursing. Patients with severe burns are often greatly dependent on nurses and
nursing interventions in the burns unit. Nurses should be aware of the negative
experiences encountered by their patients, particularly the feeling of powerless
which was found to be the most commonly rated experience. Patients reported
feeling most powerless when unable to make decisions regarding daily care, this
14
should be acknowledged by nursing staff and patient empowerment should always
be encouraged. It is also the nurses duty in burn care to assess and observe both
verbal and non-verbal signals of emotional distress and reduce these feelings to
avoid PTSD in the future. These findings coincide with those found by Moi et al.
(2008).
Nurses have a pivotal role in burn care particularly through the rehabilitation
phase where most social and psychological issues come to light. It is crucial that
all nurses be aware of this, it is a vulnerable time for burn victims where they rely
on healthcare staff for emotional support and encouragement. As nurses are
present with the majority of the day and spend much of their time with the patients,
they are relied upon to observe and assess any new issues such as depression or
PTSD which may be oncoming. Nurses assess, plan, implement and evaluate
physical and psychosocial needs on a daily basis in order to provide an optimal
level of holistic care (Baker et al. 2007).
1.2.4 Conclusion:
The aim of this literature review is to acknowledge the psychosocial
implications of burn injuries on the victims lives which are often overlooked by
nursing staff and other health care professionals. This review identifies the key
psychological implications post burn injuries, discusses possible interventions
previously studied and used by healthcare professionals and patients (Wiechman
& Patterson 2004), and also takes a look at the nursing role in relation to
psychological needs which proves to be a vital role for burn victims (Baker et al.
2007 & Williams 2009). Although the nursing role is identified as an important part
of the patients care, no literature has been found in relation to psychological care
for burn patients from a nurses perspective, thus the researcher has chosen to
carry out this study from a nursing point of view rather than a patient.
1.3 Research Question:
What are Nurses perceptions and experiences of providing psychological care
for burn victims?
From review of the available literature it is evident that more emphasis should
be related to the patients psychological state while hospitalised following a burn
injury. It is one of nurses roles to provide optimal care for all patients in a holistic
15
manner. Thus the researcher proposes a study to investigate nurses perceptions
and experiences of providing psychological care to burn patients.
1.4 Aims and Objectives:
This study aims to explore nurses perceptions and experiences of
delivering psychological care to burn victims in order to gain an understanding of
the care currently in place. This study also intends to highlight areas within this
field which may be in need of assessment, improvement and/or complete
development, and in turn improve standards and quality of patients psychological
care.
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Chapter 2
2.1 Methodology:
2.1.1 Introduction:
There is an absence of both Irish and international research into the area of
psychological care provided by nurses for burn victims, and to address this
