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March 2018 Article of the Month
This month's article selection is highlighted by John Ehman,
University of Pennsylvania Medical Center-Penn Presbyterian, Philadelphia PA.


Garimella, R., Koenig, H. G., Larson, D. L. and Hultman, C. S. "Of these, faith, hope, and love: assessing and providing for the psychosocial and spiritual needs of burn patients." Clinics in Plastic Surgery 44, no. 4 (October 2017): 893-902.


SUMMARY and COMMENT: The authors of this month's article -- a first-year medical student and three very experienced physicians -- recognize "the paucity of empirical research regarding the importance of psychosocial factors and spirituality after burn injury" [p. 893, abstract] and have sought to investigate "the relationship between spiritual involvement and stage of reconstruction…[as]…just 1 of countless questions warranting further study to better understand burn patients' spiritual and psychosocial needs" [p. 901]. The article should be of interest to chaplains, if not so much in terms of the findings, which are not dramatic, than for how it broaches issues of this particular population, presents a measure of religious involvement worth consideration, and shows the potential for subsequent research and clinical initiative. As more and more patients are surviving serious burn injuries, due to recent advances in medicine, chaplains in general may increasingly be involved with their care. The authors register their support of chaplains' work.

After a summary of the literature on psychosocial factors affecting burn injuries, and a fairly detailed review of the limited studies identified in spirituality & health (i.e., "6 small qualitative studies, 3 cross-sectional studies, and 2 prospective quantitative studies" [p. 896]), the authors line out how stages of recovery tend to fragment the kind of psychosocial needs that providers should address:

At the resuscitative stage, the main challenges include impaired communication, sleep disturbance, and pain. To provide for the needs of patients at this stage, in addition to sleep aid and pain management (pharmaceutical and nonpharmaceutical), it is imperative that patients' families are educated and put at ease about their loved one's condition. At the acute stage, patients should continue to be treated for pain and they should also be monitored for depression and other psychological symptoms so that appropriate counseling and/or medications may be provided. In the long-term rehabilitation stage of recovery, patients should continue to be monitored for psychological issues, especially anxiety and depression. Patients in this phase of recovery also likely experience social challenges related to changing roles, return to work, and body image. Burn patients in the long-term rehabilitation stage may benefit from outpatient, peer, and vocational counseling, social skills training, and support groups. [p. 896]
Against this backdrop, the authors state: "Although studies have reported that a majority of burn patients believe that addressing their spiritual needs should be an important part of their medical treatment, it is unclear exactly what resources are most desired or which spiritual benchmarks have the most unmet need" [p. 896]. So, "[t]o better allow clinicians to appreciate and address the spiritual needs of burn patients in the recovery process, the authors carried out a cross-sectional pilot investigation of the spiritual involvement of burn patients at various stages in their reconstruction" [pp. 897-898, italics added]. The study...
...enrolled 101 patients presenting to an outpatient burn clinic with a history of burn injury (enrollment rate: 99%). Patients were categorized as new (presenting in clinic for initial consultation for burn reconstruction), postoperative (presenting to clinic within 3 months of reconstructive surgery), or returning (presenting to clinic greater than 3 months after reconstructive surgery or have not yet had surgery). The authors surveyed patients for their level of spiritual involvement using the Belief into Action (BIAC) scale, a 10-question survey. [p. 898]
The complete BIAC measure is given in the article [--see pp. 897-898 and also Items of Related Interest §I, below] for examination -- an unusually helpful feature of this article -- along with tables of the survey results by question, comparing the three groups. Ultimately, the "findings do not illustrate meaningful differences in the overall spiritual involvement of patients in different stages of burn recovery" [p. 900] -- perhaps because of the cross-sectional design of data collection (as opposed to a longitudinal design that could have tracked individual patients' courses) -- but they do show "a few notable differences in spiritual involvement between the cohorts at the question level, which warrant further investigation" [p. 900]:
With P<.10 considered significant, postoperative patients are significantly more likely to rank God as their number 1 priority in life than are new patients. In addition, new and return patients spend significantly more time involved with meditation or prayer than recent postoperative patients. Finally, return patients are significantly more likely to conform their life to the teachings of their religious faith than are nonreligious post-operative patients. [p. 900]
The article concludes with a strong appeal: "Meeting patients' psychosocial and spiritual needs is especially important as the US health care system pivots toward value-based care. The economic advantage provided by improving quality-adjusted life years for recovering burn patients would likely more than justify increased expenditures on spiritual and psychosocial interventions, resources, and services" [p. 900]. Integral to the authors' encouragement of psychosocial and spiritual support for patients appears to be their high estimation of chaplains: "Burn patients widely use pastoral care (23% in 1 study), and chaplains and clinical pastoral education will likely continue to be an important resource for burn teams,"...[and]...[g]iven the role of inpatient religious services and chaplains in the care of severely burned patients, these resources should continue to be supported and expanded to improve accessibility" [pp. 896-897]. However, they note: "Whether or not utilization of such services improves outcomes is still unknown and merits further study" [p. 897]. The article is clearly written for physicians, but the latter point may be taken as a call to action by chaplain researchers.

In a personal communication to our Network, the authors have related that they plan to expand upon their original cross-sectional statistical work with added data and analyses, to explore predictors of BIAC scores. They also intend to track some of their study cohorts long term, through repeated BIAC surveys. As their research continues, our Network will look to report on developments.


Suggestions for Use of the Article for Student Discussion: 

This month's article works as much as brief review of the literature as it does a presentation of a study, and that offers a good bit of flexibility for discussion with students. The provision of the Belief into Action scale and the question-by-question comparative analysis should be most interesting to students focused on research, and the results implicitly bring up the value and limits of a cross-sectional methodology. Consideration of the study design naturally dovetails with the subject of patients' needs at three stages of recovery, and that should be of broad interest to students and connect with the rich overviews of psychosocial and spiritual dynamics in the paper's opening sections. While the article raises awareness specifically about burn injuries, students who have not cared for burn patients could be asked to muse about how it might enlighten their perspective on populations more generally. For instance, are they cognizant of how their pastoral care occurs at a particular point-in-time in relation to stages of a patient's experience of illness/injury experience? Does it help them to think about psychosocial & spiritual dynamics as having practical effects on a course of physical healing? Are there other patient conditions that cause disfigurement and risk stigma? Do students sense connections between patients' physical appearance and their sense of hopefulness/hopelessness? A CPE educator could help students find wide relevance in articles like this one, but nevertheless caution against overgeneralizing beyond the scope and aim of a specific study. Finally, what do students see as the relationship between the work of chaplains and the responsibility of physicians to take into account psychosocial and spiritual needs?


Related Items of Interest:

I.  For more on the Belief into Action (BIAC) scale, see:

Koenig, H. G., Wang, Z., Al Zaben, F. and Adi, A. "Belief into Action scale: a comprehensive and sensitive measure of religious involvement." Religions 6, no. 3 (2015): 1006-1016. [(Abstract:) We describe here a new measure of religious commitment, the Belief into Action (BIAC) scale. This measure was designed to be a comprehensive and sensitive measure of religious involvement that could discriminate individuals across the religious spectrum, and avoid the problem of ceiling effects that have haunted the study of highly-religious populations. Many scales assess religious beliefs, where assent to belief is often widespread, subjective, and a superficial assessment of religious commitment. While people may say they believe, what does that mean in terms of action? This 10-item scale seeks to convert simple belief into action, where action is assessed in terms of what individuals say is most important in their lives, how they spend their time, and where they put their financial resources. We summarize here the psychometric characteristics of the BIAC in two very different populations: stressed female caregivers in Southern California and North Carolina, and college students attending three universities in Mainland China. We conclude that the BIAC is a sensitive, reliable, and valid measure of religious commitment in these two samples, and encourage research in other population groups using this scale to determine its psychometric properties more generally.] [The article is available freely online from the journal.]


II.  A few recent studies of burn survivors not included in the analysis by Garimella et al.:

[Added 3/6/19]: Abrams, T. E., Ratnapradipa, D., Tillewein, H. and Lloyd, A. A. "Resiliency in burn recovery: a qualitative analysis." Social Work in Health Care 57, no. 9 (2018): 774-793. [This is a phenomenological study involving face-to-face interviews with 8 adults being treated at a primarily rural burn center in the US. Injuries ranged between 20% and 98% of total body surface area, and were suffered 1 to 22 years ago. Themes of resilient protective factors contributing to post-burn health and recovery included resourcefulness, achievement motivation, optimism, empathy, and spirituality. The authors address spirituality briefly: "Spirituality, or the belief in a higher power, provided a sense of stability and meaning for participants as they faced the uncertainties of burn recovery. All eight participants attributed their survival to a higher power," and "There was a shared ability within the sample to recognize a higher power and to not take life for granted" (p. 786). Two examples are given with quotes from participants.]

Dekel, B. and van Niekerk, A. "Women's recovery, negotiation of appearance, and social reintegration following a burn." Burns (2018): online ahead of print, January 30, 2018; 9pp. [This qualitative study analyzed in-depth interviews of seven women in South Africa (a country with a high rate of burns and significant concentrations among women). Among the findings, the authors discuss the role of religion: "The women in this study frequently drew their strength from their spiritual beliefs and religious support, which provided them with an experience of acceptance. Resiliency studies have indeed indicated religion as an overall buffer to life stress. Religious or spiritual relationships act as lifelines for resilience, provide ties to a religious community and enable the experience of a personal relationship with a divine power. Such belief systems and relationships may foster feelings of comfort and support to those dealing with a trauma. Psychospiritual growth may therefore, contribute to survivor resilience because it offers believers the possibility of a worldview that can enable positive meaning or emotions such as joy, gratitude and hope, in the midst of a major life challenge. This is thus accomplished through those values or teachings that promote the acceptance of the individual regardless of community or society views of physical or psychological flaws. Religious beliefs and practices may therefore, promote for many the experience of a forgiving and accepting worldview that can both allow a survivor to endure a trauma and give meaning to the related difficult burn experience. Meaning, in turn, may provide a sense of purpose and direction that enhances hope and the perseverance required to withstand the personal and social challenges imposed by burns, which might be the key to recovery." (MS p. 7)]

Jibeen, T., Mahfooz, M. and Fatima, S. "Spiritual transcendence and psychological adjustment: the moderating role of personality in burn patients." Journal of Religion and Health (2017): online ahead of print, August 30, 2017; 16pp. [This study of 98 burn patients in three hospitals in Lahore, Pakistan, used the Spiritual Transcendence Index. "[C]orrelations between spiritual transcendence, psychological distress, and positive change were calculated. The correlation analysis indicated that spiritual transcendence was negatively associated with psychological distress, but positively with positive change. This suggests that level of spiritual transcendence in burn patients is likely to protect them from negative consequences of burn trauma, such as distress, and is more likely to promote post-traumatic growth in terms of positive change, which, in turn, may lead to successful adaptation to the consequences of the burn incident." (MS p. 10) The personality traits of neuroticism and extraversion "played a moderating role in the relationship between spiritual transcendence and positive change, and spiritual transcendence and distress in burn patients." (MS p. 1, abstract) "Overall the results indicate that patients' personality traits such as high levels of extraversion and low levels of neuroticism interacting with high spiritually transcendent beliefs result in better psychological adjustment in terms of low psychological distress and more positive adaptation to change. Hence, extravert and neurotic personality traits of patients moderate the effects of spiritual transcendence on their psychological distress. The findings have implications for clinicians for rehabilitation strategies, and suggest putting greater emphasis on spirituality regarding how to improve the psychological adjustment of patients." (MS p. 12)]

Royse, D. and Badger, K. "Near-death experiences, posttraumatic growth, and life satisfaction among burn survivors." Social Work in Health Care 56, no. 3 (2017): 155-168. [This research out of the University of Kentucky (Lexington) involved 92 burn survivors. While no significant differences were found in reported life satisfaction between NDErs and non-NDErs, "participants who indicated their religion was a source of support or comfort reported a higher level of life satisfaction and PTG." Moreover, the authors note: "...NDErs found more comfort in religion than Non-NDErs. Given the strong association of spirituality with NDEs and their potential to aid in recovery, discussing these topics with burn survivors could be beneficial." "Social workers, chaplains, and other burn team members who provide psychosocial or spiritual support can be instrumental in assisting burn survivors as they seek to make sense of their burn events." (--see p. 164)]

Zamanzadeh, V., Valizadeh, L., Lotfi, M., Salehi, F. and Khalili, A. "The main concern of burn survivors in Iran." Iranian Journal of Nursing and Midwifery Research 21, no. 4 (July-August 2016): 410-416. [Among the findings of this qualitative study analyzing unstructured interviews of 17 burn survivors in Iran was a theme of spiritual threat: "The incessant psychological pressure on the burn victims in the course of new life, markedly different from the one prior to burns, and the harsh conditions of the new life caused them to feel so desperate and helpless that they began to doubt the existence of God or His mercy." (n.p.) In the words of one participant, "When I looked at myself, I thought, at first, that there was no God." (loc. cit.)]


III.  Intentionally self-injurious burning is certainly a special case of burn injury. The following older study by two chaplains at Children's Hospital Medical Center of Akron (Akron, OH) and Miami Valley Hospital (Dayton, OH) gives thoughtful insight.

Grossoehme, D. H. and Springer, L. S. "Images of God used by self-injurious burn patients." Burns 25, no. 5 (August 1999): 443-448. [(Abstract:) Suicide by burning and other forms of self-injurious behaviors which involve burning are sometimes considered to have religious overtones. The ritual death of widows upon their husband's funeral pyre is closely associated with Hindu beliefs. Buddhists have used self-immolation as a form of protest. The Judaeo-Christian traditions have imagery of fire as cleansing and purifying; there is also secular imagery associating fire with images of condemnation and evil. Previous studies have described religiosity as a common theme among survivors. The present study describes the ways in which persons who inflicted self-injurious behaviors through burning, including attempted suicide, imagine the Divinity and use religious language to give meaning to their experience.]


IV.  Chaplains may be interested the following two poster presentations from the 2006 annual meeting of the American Burn Association, previously noted on our Network site:

Hallman, H H.; Honari, S., Heimbach, D. M., Klein, M. B., Engrav, L. H. and Gibran, N. S. "Burns and Clinical Pastoral Education: Is there a standard of care?" Journal of Burn Care and Research 27, no. 2, Supplement (March 2006): S153. [The lead author, Rev. Holly Hallman, was a CPE resident at the University of Washington Burn Center at Harborview Medical Center (Seattle, WA) at the time of the research in 2004, and the project was pursued through a multidisciplinary team that included a nurse and four physicians. Forty-three hospitals were identified with both burn centers and CPE programs, and questionnaires were mailed to CPE Supervisors and students and to Nurse Managers. The number of respondents was relatively small, but in the hospitals represented there did not appear to be "spiritual care available during wound care, wound rounds or in the operating room," and "[b]urn education, overview of burn care and orientation to the burn unit were not significant" [--from the abstract]. The poster itself is available on line to the Research Network as a PowerPoint file or a PDF file.]

Snedeker, A. A., Yowler, C. J. and Fratianne, R. B. "The impact of guided imagery on pain and anxiety levels of burn patients." Journal of Burn Care and Research 27, no. 2, Supplement (March 2006): S151. [This is a brief report of a poster presentation describes research at the MetroHealth Medical Center/Case Western Reserve University (Cleveland, OH,) where Fr. Art Snedeker (chaplain) led an intervention to help burn patients manage pain and anxiety. (Abstract:) Introduction: Guided imagery uses various relaxation techniques, such as rhythmic breathing and visualization of a relaxing and pleasurable experience, to minimize the anxiety of a stressful situation. We have used guided imagery for 5 years as an adjunctive therapy in the control of pain and anxiety associated with inpatient burn care. A prospective study was completed to determine the efficacy of this technique in our patients. Methods: During his initial visits, our burn chaplain would introduce the concept of visual imagery to inpatients in our burn center. If patients requested instruction in the technique, prospective data was collected. Using the Likert Visual Analogue Scale, data were collected on pain and anxiety levels before and after each guided imagery session. These sessions were usually held immediately prior to wound care and dressing changes. All data was obtained within 5 minutes of starting and finishing the session. Results: Significant decreases were noted in anxiety levels with the use of guided imagery. On the 1-10 scale of the Likert Scale, mean anxiety levels decreased from 6.8 to 3.3 (p<0.05) while pain levels decreased from 5.7 to 3.9 (NS). Conclusions: Guided imagery is a useful adjunct in control of the anxiety that accompanies inpatient burn care. Future studies need to determine how long the effect lasts and the optimal timing and number of sessions required for optimal anxiety relief."]


V.  The following recent articles -- a study out of Southern Illinois University (Abrams, et al.) and a review out of the University of Western Australia (Martin, et al.) -- address broader issues of burn survivors.

Abrams, T. E., Ogletree, R. J., Ratnapradipa, D. and Neumeister, M. W. "Adult survivors' lived experience of burns and post-burn health: A qualitative analysis." Burns 42, no. 1 (February 2016): 152-162. [(Abstract:) INTRODUCTION: The individual implications of major burns are likely to affect the full spectrum of patients' physical, emotional, psychological, social, environmental, spiritual and vocational health. Yet, not all of the post-burn health implications are inevitably negative. Utilizing a qualitative approach, this heuristic phenomenological study explores the experiences and perceptions early (ages 18-35) and midlife (ages 36-64) adults providing insight for how participants perceived their burns in relationship to their post-burn health. METHODS: Participants were interviewed using semi-structured interview questions framed around seven domains of health. Interview recordings were transcribed verbatim then coded line by line, identifying dominant categories related to health. Categories were analyzed identifying shared themes among the study sample. RESULTS: Participants were Caucasian, seven males and one female. Mean age at time of interviews was 54.38 and 42.38 at time of burns. Mean time since burns occurred was 9.38 years with a minimum of (20%) total body surface area (TBSA) burns. Qualitative content analysis rendered three emergent health-related categories and associated themes that represented shared meanings within the participant sample. The category of "Physical Health" reflected the theme physical limitations, pain and sensitivity to temperature. Within the category of "Intellectual Health" were themes of insight, goal setting and self-efficacy, optimism and humor and within "Emotional Health" were the themes empathy and gratitude. CONCLUSIONS: By exploring subjective experiences and perceptions of health shared through dialog with experienced burned persons, there are opportunities to develop a more complete picture of how holistic health may be affected by major burns that in turn could support future long-term rehabilitative trajectories of early and midlife adult burn patients.]

Martin, L., Byrnes, M., McGarry, S., Rea, S. and Wood, F. "Posttraumatic growth after burn in adults: an integrative literature review." Burns 43, no. 3 (May 2017): 459-470. [(Abstract:) Posttraumatic growth after burn is a relatively new area of study with only a small number of studies that have examined this phenomenon. It is important to understand the presentation of posttraumatic growth and coping in burn survivors, how it changes over time and the components which influence growth so that we can understand how to promote posttraumatic growth in burn survivors. The aim of this review was to assess these three parameters. Studies were identified through multiple databases with specific search terms to identify posttraumatic growth after burn. From the 813 articles found, 57 were identified as potentially useful, and 8 as eligible for review; three qualitative, one mixed methods, two quantitative, one discussion paper and part of a review which assessed all psychosocial outcomes. Growth presented as realising personal strength, reprioritising, spirituality, humanity, changed relationships, and compassion and altruism. Styles of coping included feelings of gratefulness and downward comparison, humour and planning. Suddenness of the event, and the severity and location of injury might affect the amount of growth experienced. Overall function, quality of life, social support and optimism, hope and new opportunities are influences on growth after burn, all of which have the potential for improvement through targeted intervention strategies. Further research is indicated in many areas related to growth, intervention and measurement.]



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