The Pain and Stress of Wound Treatment in

Patients With Burns

Dominic Upton, PhD, FBPsS, Jessica Morgan, BSc, Abbye Andrews, BSc, MBPsS, David B.
Lumenta, MD, Michael Giretzlehner, PhD, Lars P. Kamolz, PhD, MSc
An International Burn Specialist Perspective
Wounds. 2013;25(8):199-204.
Abstract and Introduction
Abstract
This study aimed to explore the views of burn specialists on the importance of reducing stress and
pain during wound treatment.
Methods. Burns specialists were invited to complete an online survey, consisting of 10 questions
about pain and stress in their patients.
Results. There were 141 respondents from 39 countries. Most were European (54.9%), and the
majority were surgeons (71.8%). Pain-free and stress-free dressing changes were viewed as important
overall ('very important:' 47.5% and 40.8%, respectively), although, in both cases, 11.3% did not
view either to be important. Respondents identified 7 benefits of simple, pain-free dressing removal,
although the focus was on clinical advantages rather than being patient-centered. Although most
acknowledged that pain is linked with stress, disagreement levels ranged from 21.9% to 25.3%.
Additionally, only 22.5% agreed that stress is related to wound healing.
Conclusion. In general, burn specialists recognized that pain can lead to stress and that it is
important to reduce stress and pain at dressing changes. Most also acknowledged that stress can
affect wound healing. However, these results suggest a need for research to further explore
perceptions about pain and stress, and how these perceptions can impact wound management
regimes.
Introduction
Burn injuries are one of the most devastating forms of individual trauma. However, with
advances in medical treatment techniques, the mortality rate for patients with burns has been
reduced in recent years.[1] Due to such progress, a person with burns over 80% of his total body
surface area (TBSA) now has a realistic chance of survival.[2] This reduction in patient mortality,
though positive, has implications about the challenges these individuals will face in their lives in
terms of long-term treatment, adjustment to daily life, and rehabilitation.[3] Consequently, burn
wounds have being compared to chronic illness, with a high incidence of physical and psychological
morbidity.[1,4]
Severe pain is one of the most significant components in the long-term suffering of burn
patients,[5] with continuous background pain experienced alongside intense pain during wound
treatment procedures. Often patients with burns must endure 1 or more painful procedures daily,
for weeks or months,[6] comprising wound cleansing, debridement, dressing changes, surgical
operations, and physical and occupational therapies.[79] The pain experienced during wound care
procedures has often been reported to be excruciating.[10,11]

Much research has been conducted within the chronic wound population on the
psychological effects of dressing-related pain, with stress being a common component.[1214]
Likewise, anxiety and depression are frequently reported to accompany the pain of burns, often
having a bidirectional relationship.[1516] Due to the emotional and physical trauma that patients with
major burns experience, high levels of distress and anxiety are common.[17] Additionally, stress and
anxiety are thought to be interlinked with pain, with anxiety increasing due to the anticipation of
pain, and the experience of anxiety also intensifying the perception of pain.[1819] This is cyclical in
that the intense pain often leads to anxiety in anticipation of upcoming pain, such as that
experienced with dressing change.[20] Due to the amplification of pain, by anxiety and stress levels,
for patients with burns, it is important that treatment methods simultaneously target both the
physical and psychological aspects of burn injuries.[1]
The consequences of pain, anxiety, and stress on wound healing provide further incentive to
ensure treatment protocols incorporate techniques that aim to reduce these experiences for patients
with burns as much as possible. It is known that pain can adversely affect the healing of a
wound[15,21] and can also have a negative impact on quality of life.[22] A study by McGuire et al[23]
found that in gastric bypass surgery patients, reports of postsurgical, high-intensity pain were
associated with longer healing times. Similarly, Woo and Sibbald[24] found that the mean pain scores
over a 4-week period for patients with leg or foot ulcers was significantly less (P < 0.041) for those
who achieved wound closure (mean pain score 1.67), than for those who did not (mean pain score
3.21).
In a way similar to pain, increased stress levels can also delay the healing process. [25,26]
Broadbent et al[27] explored the effects of stress levels on wound healing in patients who underwent a
laparoscopic cholecystectomy. It was found that those who received a psychological intervention
aimed at reducing stress, in addition to standard care, showed lower stress levels and enhanced
wound healing postsurgery compared to those who received standard care alone. Similar findings
have been reported in regard to individuals with burns. For example, Wisely et al [28] investigated the
effect of preexisting psychiatric disorders and psychological reactions to stress on the recovery of
burn survivors. It was reported that heightened psychological distress alone, without the presence of
a psychiatric disorder, had a significant delaying effect on the rate of recovery of burn wounds. This
finding highlights the importance of identifying and working with difficulties, such as stress and
anxiety, in light of the psychosocial and physical impact they may have on recovery.
The effect that both pain and stress have on wound healing makes it important for
professionals to reduce the pain and stress their patients experience during treatment, especially for
those whose burns require regular wound care procedures.
Despite the importance of pain and anxiety management in burn treatment regimes, Robert
et al[29] found it can be omitted during clinical assessments. The authors surveyed nursing directors at
64 burns centers. Of the burn teams, 19% (12 teams) did not assess anxiety at all during the
treatment of burn wounds, neither formally nor informally, despite its importance in the pain
experience of patients, and the subsequent healing of their wound.
However, it must be noted that many medical professionals are aware of the psychological
impacts of wounds upon patients. For example, Upton et al[30] surveyed health care professionals in
relation to patients with acute and chronic wounds. The majority of professionals believed that more
than half of their patients suffered from mood problems related to their condition. These problems
were most likely to include anxiety and feelings of helplessness, with chronic pain and discomfort of
the wound acting as potential contributory factors. Further research is needed to build upon the
knowledge of how important burn specialists perceive pain and stress to be, and how highly they
rate the need for pain- and stress-free management regimes for burn recovery.

The present study aimed to explore clinicians' views about pain and stress in their patients
with burns. In particular, this research aimed to investigate how clinicians perceive the relationship
between pain and stress, and how important they consider reducing pain and stress during
treatment. Additionally, this research aimed to look at beliefs about how stress affects wound
healing.
Methods
A voluntary, cross-sectional survey was created by the Austria Burn Treatment, Research,
and Prevention Study Group, a scientific, nonprofit medical organization, in conjunction with
experts originating from various other strands of the burn community. The 10 survey questions
related to pain of wound treatment, stress of wound treatment, stress-pain relationship, or stress
impairing wound healing. The questions were either open-ended or had a 7-point Likert scale
answering system, in which a rating of 1 indicated "not important" or "agree totally," and a rating of
7 represented "very important" or "disagree totally," depending on the question. Additionally, 4
questions were included to gain demographic information on the respondent related to profession,
staff grade, country, and city.
An email invitation was sent to 1000 burn specialists worldwide, which included a direct link
to the survey. The list of email contacts was created using the contact information available on the
internet for burn centers, as well as the corresponding email addresses provided in all publications
from 2008 to 2011 of the Burns journal (Elsevier Science Ltd for the International Society for Burn
Injuries). The personal information of the respondents was not collected, and no incentives to
complete the survey were offered. In an attempt to guarantee the avoidance of duplicate
submissions, JQuarks 4 Surveys (IP-TECH, La Marsa, Tunisia) was chosen to host the
questionnaire, as the system does not allow for more than 1 entry from the same participant
computer IP address.
Throughout the completion of the questionnaire, respondents were able to check and
change any answers previously submitted, with the questionnaire located on a single scrolling web
page. The time taken for completion was not recorded, and once the respondent had submitted their
answers it was automatically logged in a MySQL-Database (Oracle, San Francisco, CA). The website
was checked on a daily basis for technical difficulties.
Results
Respondents
A total of 141 respondents (response rate of 14.2%) from 39 countries completed the online
questionnaire over a 6-week period. Out of the total sample, 72.3% were surgeons (n = 102), 5.7%
were anesthetists/intensivists (n = 8), and 14.2% were nursing staff (n = 20), with 7.8% falling into
the 'other' category (n = 11) of emergency physicians, physical therapists, or unknown. Respondents
were from a variety of countries, including Europe (57.5%), Australia and New Zealand (17.7%),
North America (12.8%), Asia (9.2%), South America (1.4%), and Africa (0.7%), with 0.7% not
specifying country of origin.
Importance of Pain-free, Stress-free Dressing Changes
Medical professionals were asked to rate the importance of pain-free dressing changes using
one of 3 options: essential, desirable, or neutral. Of the 141 respondents, 53.9% expressed that painfree dressing changes were "essential," and 44% felt they were "desirable." Only 1.4% of
respondents indicated a "neutral" opinion, and 0.7% did not answer. When the same question was
asked slightly differently, using a scale from "very important" to "not important," 47.5% of
respondents expressed it was "very important" that dressing changes are pain-free. However, 11.3%

considered it "not important." Similar findings were obtained for the question of how important it is
that dressing changes are stress-free, with 40.8% of respondents rating this as "very important," and
11.3% considering it "not important."
Potential Effects of Easy-to-Use, Painless Dressing Removal Products
When asked to identify the changes that could be brought about by an easy-to-use, pain-free
dressing removal product, respondents referred to 7 main areas. These included less pain relief,
effective treatment and quicker dressing change, reduced healing time and movement from inpatient
to outpatient, reduced pain, reduced stress, increased patient compliance, and cost implications
(Table 1).
Effects of Pain and Stress
Overall, 71.8% of respondents generally agreed that pain from patients' wounds caused the
patient stress, with 48.6% of respondents "totally agreeing." However, an overall 23.2% generally
disagreed, with 10.6% "totally disagreeing."
Similarly, when asked if higher wound pain correlated with higher levels of stress in patients,
72.5% generally agreed, with 47.9% "agreeing totally." In disagreement were 22.5% of respondents,
with 12% "disagreeing totally."
When asked if pain associated specifically with wound dressing caused patients stress, 67.5%
generally agreed, 40.8% of whom "agreed totally." Although this still represents the majority, the
agreement levels were reduced compared to responses to the previous 2 questions. Additionally,
25.3% disagreed with this, with 9.9% "totally disagreeing." Thus, more people disagreed with the
statement that pain at wound dressing caused stress than with the idea that pain in general was
related to stress.
Similar results were found for the question of whether or not pain associated with a wound
management regime caused stress, with 40.1% "totally agreeing" that it did.
Finally, when respondents were asked their opinions on whether or not stress impairs
wound healing, an overall 66.9% generally agreed that it does, with 22.5% "agreeing totally."
However, 20.3% generally disagreed, with 4.9% "disagreeing totally." An additional 10.6% of
respondents selected the middle value on the Likert scale, neither agreeing nor disagreeing with the
statement.
Discussion
The majority of the health care professionals surveyed (97.9%) indicated that pain-free
dressing changes were either "essential" (53.9%) or "desirable" (44%). However, when asked a very
similar question about the importance of pain-free dressing changes using a different scale, only
77.7% expressed that it was important (with 47.5% responding "very important"). Considering that
97.9% of respondents selected "essential" or "desirable" to the first question, it is surprising that
20.4% then went on to select low importance levels in this subsequent question, with 11.3%
expressing that pain-free dressing change is "not important." Almost identical figures were found in
relation to the importance of stress-free dressing changes, with the majority expressing this was
important, but a proportion of professionals expressing low or no importance.
Nevertheless, most specialists who responded to the survey believed dressing changes
should be painless and stress-free, although it is possible that some consider this to be the "ideal"
rather than an important factor. Additionally, they may rate the importance of pain-free dressing in
terms of a "comfort factor," and not in relation to the effect on the outcome and well-being of the
patient.

In terms of the possible effects of using easy-to-use, pain-free dressing removal products,
the health care professionals identified 7 areas. Clinical and practical benefits were highly cited, such
as reduced need for pain relief, efficiency of treatment with quicker dressing change, reduced healing
time, and quicker progress from inpatient to outpatient. In contrast, more patient-centered benefits,
such as reduced pain and stress, were referred to less frequently. This suggests that medical
professionals face a challenge in juggling departmental demands with patient needs, which may
affect which issues they prioritize as important. Since almost half of respondents expressed that
pain- and stress- free dressing changes are "very important," it may seem surprising that patientcentered benefits were not referred to frequently. However, it is important to note that the question
asked about changes in care practices, and different findings may have been reported if the question
asked about the general benefits of easy-to-use, pain-free dressing removal products.
In a similar study, Selig et al[31] explored the views of 121 clinicians from 39 countries, about
the 'ideal' properties of wound dressings. The clinicians referred to nonadhesion, absorbency, and
antimicrobial activity as key factors which would contribute to the ideal dressing. They also reported
that it would be beneficial if the dressing was easy to remove, leading to reduced pain at dressing
change. This shows some consideration of minimizing pain in ideal practice, although no dressings
were known to exist at the time of the study that incorporated all of those factors.
Another area explored in this research was that of medical professionals' views on the role of
pain and stress and their patients' experiences of these. It is known that there is a cyclical
relationship between pain and stress and anxiety, with pain causing anticipatory anxiety, and anxiety
lowering the pain threshold.[1820] Taking this relationship into consideration, it is surprising that
overall disagreement responses ranged from 21.9%-25.3% for statements relating to wound pain,
wound dressing, dressing removal, and wound-management regime causing patient stress. However,
the majority of respondents did agree that stress could be caused from wound pain, wound dressing,
dressing removal, and wound-management regime, and that wound pain and stress levels are
positively correlated with one another (72.5% overall). This demonstrates that most burn specialists
acknowledge the effect pain can have on patient stress levels, although some may not fully recognize
how pain and stress are linked.
While the majority of the medical professionals thought it was important that dressing
changes did not cause stress for their patients (73.9%), only 22.5% totally agreed that stress impairs
wound healing, with 4.9% totally disagreeing, and 10.6% selecting the middle value. The number of
respondents who disagreed with the statement, or who were unsure, is surprising, considering that
stress is reported to be directly associated with the healing of wounds.[2527] An important message to
come from this research is that some burn specialists believe pain and stress do not influence wound
healing. Whilst most acknowledge that patients experience stress in relation to pain, they may not
fully understand the implications of this stress. This highlights the need for further education of
specialists in relation to pain, stress, and wound healing in the burn population.
Conclusion
The findings of this study indicate that, in general, burn specialists acknowledge the
importance of pain- and stress- free dressing changes, agree that pain associated with wounds and
wound treatment does cause stress, and believe that stress impairs wound healing. Despite this
general agreement however, there were relatively high percentages of respondents who 'disagreed
totally', or believed that pain- and stress-free dressing changes were "not important." Additionally,
when considering the benefits of using an easy and pain-free dressing removal product, clinical and
practical implications were referred to most frequently, with patient-centered outcomes considered
less often. These findings suggest a need for additional research and education about the role of pain
and stress for patients with burns.

Research needs to further explore the views of burn specialists in relation to the importance of painand stress-free wound treatments, and the consequences that both stress and pain can have on the
patient. In particular, research needs to investigate how these opinions affect wound management
regimes for people with burns.
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http://www.medscape.com/viewarticle/809923_1