burns 40 (2014) 17–29

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

Review

Adult burn survivors’ personal experiences of

rehabilitation: An integrative review

R. Kornhaber a,b,*, A. Wilson c,d, M.Z. Abu-Qamar e, L. McLean f,g,h

a
Severe Burns Injury Unit, Royal North Shore Hospital, Sydney, NSW, Australia
b
The University of Adelaide, School of Nursing, South Australia, Australia
c
School of Medicine, Flinders University, Bedford Park, South Australia, Australia
d
Prince of Wales Clinical School, The University of New South Wales, Sydney, NSW, Australia
e
Department of Adult Health Nursing, Faculty of Nursing, Mútah University, Mútah, Jordan
f
Westmead Psychotherapy Program, Discipline of Psychiatry, Sydney Medical School, University of Sydney, Australia
g
Consultation-Liaison Psychiatry, Royal North Shore Hospital, Sydney, NSW, Australia
h
Sydney West and Greater Southern Psychiatry Training Network, WSLHD, Sydney, NSW, Australia

article info abstract

Article history: Burn rehabilitation is a lengthy process associated with physical and psychosocial pro-
Accepted 2 August 2013 blems. As a critical area in burn care, the aim was to systematically synthesise the literature
focussing on personal perceptions and experiences of adult burn survivors’ rehabilitation
Keywords: and to identify factors that influence their rehabilitation. Studies were identified through an
Integrative review electronic search using the databases: PubMed, CINAHL, EMBASE, Scopus, PsycINFO and
Qualitative research Trove of peer reviewed research published between 2002 and 2012 limited to English-
Burn rehabilitation language research with search terms developed to reflect burn rehabilitation. From the
378 papers identified, 14 research papers met the inclusion criteria. Across all studies, there
were 184 participants conducted in eight different countries. The reported mean age was 41
years with a mean total body surface area (TBSA) burn of 34% and the length of stay ranging
from one day to 68 months. Significant factors identified as influential in burn rehabilitation
were the impact of support, coping and acceptance, the importance of work, physical
changes and limitations. This review suggests there is a necessity for appropriate knowl-
edge and education based programmes for burn survivors with consideration given to the
timing and delivery of education to facilitate the rehabilitation journey.
# 2013 Elsevier Ltd and ISBI. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.1. Review process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.2. Literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

* Corresponding author at: PO Box 758 Lane Cove 1595, NSW, Australia. Tel.: +61 2 9452 4554.
E-mail address: rachel.kornhaber@adelaide.edu.au (R. Kornhaber).
0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved.
http://dx.doi.org/10.1016/j.burns.2013.08.003
18 burns 40 (2014) 17–29

2.3. Inclusion criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

2.4. Data extraction and synthesis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.1. Study characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2. The influence of support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.1. Family and friends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
3.2.2. Professional support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.2.3. Peer support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3.3. Coping and acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.4. The importance of work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.5. Physical changes and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.5.1. Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.5.2. Altered physical appearance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.5.3. Physical limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.1. Limitations and strength of evidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2. Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2.1. Accredited burns rehabilitation education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2.2. Development of a multimedia education based programme directed towards adherence to burn therapy and
continuum of burn care.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2.3. Provision of services that mutually engage health professionals, employers and survivor in the process of
transition home and returning to work . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
4.2.4. Development of an inpatient clinician based formalised burn peer support program . . . . . . . . . . . . . . 28
5. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

1. Introduction 2. Methods

Since antiquity, the trauma of a severe burn has beset
humankind with poor outcomes and survival rates. The loss
of both function and independence, can be physically limiting,
requiring aggressive rehabilitation to improve functionality
and quality of life. Accordingly, rehabilitation is a critical
element in the recovery of those who sustain severe burn
injuries. Primarily, the importance of an early and rigorous
focus on regaining physical and emotional independence
remains critical. Consequently, identification of specific
rehabilitation needs is a key priority for those with severe
burns to facilitate the restoration of their independence.
However, the progression to a rehabilitation facility is often
delayed due to the rehabilitation facility’s inability to manage
burn wounds [1]. Moreover, there are increasing concerns
related to complications with burn wound care requiring
unplanned readmissions to burn units [2,3]. Despite the extent
of both the physical and psychological trauma endured, the
growing body of literature concerning burn rehabilitation is
based mainly on research relating to complications of severe
burns and largely of a quantitative nature. However, there is
dearth of literature that explores the personal perceptions and
experiences of adults’ rehabilitation after a severe burn.
Therefore this integrative review aims to illuminate the
personal perceptions and experiences of rehabilitation as
experienced by adult burn survivors through voice and
narrative and to understand the factors that influence burn
rehabilitation. The integration of burn survivors’ perspectives
offers a means of reaffirming burn rehabilitation.
2.1. Review process
The framework guiding this integrative review is based on
Whittemore and Knafl’s [4] five stages: problem identification,
literature search, data evaluation, data analysis and presen-
tation (Fig. 1).
2.2. Literature search
A systematic search was conducted of PubMed, EMBASE,
CINAHL, PsychINFO, Scopus and grey literature using the
Trove database. Boolean connectors AND, OR and NOT were
used to combine search terms as burn, rehabilitation,
perception and experiences. In addition, the references of
potential papers retrieved were examined to identify any
additional papers.
2.3. Inclusion criteria
The search criteria for this integrative review incorporated
peer reviewed reports of original research, reviews of litera-
ture and dissertations published in the English language
within the last 10 years that described through the means of
voice and narrative, personal perspectives or experience of
adults’ rehabilitation following severe burn injuries. The 10
year range between 2002 and 2012 was chosen due to the
advancements made in the area of burn care in the last decade
resulting in an increased need for inpatient rehabilitation [5].
 burns 40 (2014) 17–29
Fig. 1 – Flow diagram: literature review.
Papers that addressed self-emollition or focused on psychiat-
ric disorder in burn rehabilitation were excluded as the
requirements of this cohort of patients necessitate specific
needs [6].
2.4. Data extraction and synthesis
A total of 17 papers were summarised and systematically
synthesised. During the data extraction process, three papers
were further excluded because the full review found that they
did not focus on the rehabilitation process. On completion of
the full review, 14 papers met the final criteria for inclusion
(Table 1). Findings were compiled then arranged to identify
themes and relationships. Papers reviewed for inclusion were
not assessed for methodological quality and all findings
describing adults’ personal perceptions and experiences of
burn rehabilitation integrated.
3. Results
3.1. Study characteristics
The review incorporated a broad perspective on adults’
perceptions and experiences of burn rehabilitation addressing
peer support [7–9], adherence to therapy [10], the return to
work [8,11], psychosocial implications [12], quality of life
19
[13,14], adaption and coping [15–17] and regaining indepen-
dence and the reintegration into society [9,18–20]. Of the
included 14 papers, there were 184 participants involved in
studies conducted across eight different countries including
Australia [20], Brazil [12–14,19], China [17], United States of
America [7,9], Norway [15,18], Sweden [8,16], Germany [10] and
the United Kingdom [11]. Among the studies that reported the
participants’ age and TBSA, the mean age was 41 years with a
mean TBSA burned of 34%. The ages ranged from 18 to 74 years
of age with only one study that did not specify the ages only
stating that participants were of working age [11]. Of the
studies that reported the TBSA burned, the range was wide
varying between 1% and 98%. Most studies specified the time
period after the initial injury with participants interviewed
once discharged that ranged from five months to 50 years.
Three studies reported if participants sustained a significant
facial burn [7,19,20]. All but one study [11] stated the number of
males to females with men sustaining significantly more
burns than women. Only four studies reported the length of
stay during hospitalisation [8,16–18] ranging from one day to
68 months (5 years). Surprisingly, only five studies reported
the marital status of participants [8–10,19,20] and only four
addressed the issue of return to work [8,9,11,20]. However, it
must be noted that the integrative review by Gonçalves et al.’s
[12] included 45 studies of which most studies were descriptive
and qualitative and incorporated Williams et al.’s [9] study in
their integrative review in which religion was addressed. As
the integrative review in the current study also included the
study by Williams et al.’s [9] study, statements that attributed
to religion from Gonçalves et al.’s [12] were referenced to
Williams et al. [9] to avoid duplication or misrepresentation of
the data. The 14 studies were synthesised and their findings
were categorised into four themes: the influence of support,
coping and acceptance, the importance of work and physical
changes and limitations.
3.2. The influence of support
Support was identified in all 14 papers reviewed and organised
into three categories: support provided by family and friends,
professional and peer support.
3.2.1. Family and friends
Social and physical support from family, friends and signifi-
cant others was an important factor found in this review of the
literature. One of Rossi et al.’s [14] participants indicated that
family support provided a better quality of life that facilitated
with coping:
I think that my strong will to continue comes from my
family. I think that this support from my family, my
husband, the companionship, everything helps me [14].
Moi et al.’s [15] study also found that family and friends
gave burn survivors the motivation necessary to recover:
I just feel, she [his wife] had belief in me all the time, always
saying: ‘Oh no, you’re so stubborn, you’ll get going again.’
From day 1 she said that; she had belief in me all the time,
and she was right [15].
 20
Table 1 – Summary of included studies.

Author/s, year Design Purpose Sample and study Data collection Method of analysis Significant finding/ Significance to
and country population method s and outcome burn rehabilitation
Badger and Royse Qualitative To explore burn survivors’ Purposive sample of 30 adult Face to face Semi Thematic analysis Burn peer support The importance of the
(2010) (USA) descriptive study perceptions of the value of burn survivors; M/F 19/11; mean structured interviews provided a sense of development of peer
peer support in participants’ age 41, range 19–71 years; mean belonging, affiliation support resources in
psychosocial rehabilitation TBSA 60%, range 25–93%; 17 and gave hope and coordination with
reported facial burns. Sustained confidence to burn burn professionals to
burn on average 14 years prior survivors facilitate
with a range of 2–50 years psychological
rehabilitation
Ciofi-Silva, Rossi, Qualitative To describe the changes Purposive sample of 44 adult Face to face semi Thematic analysis and Burn injury had a high Relatives and health

burns 40 (2014) 17–29

Dantas, Costa, descriptive study experienced of Brazilian
Echevarria- and descriptive burn survivors during their
Guanilo and Ciol statistics rehabilitation and to
(2010) (Brazil) investigate associations
between changes in work
and the percentage of TBSA
and the anatomy burned
Costa, Rossi, Ethnographic study To interpret the meanings of
Lopes and based on modern quality of life of people
Cioffi (2008) hermeneutics undergoing burn
(Brazil) rehabilitation based on
participants’ own
experiences, conceptions
and values
Dahl, Wickman Qualitative To explore burn patients’
and Wengstrom descriptive study experiences of adapting to
(2012) (Sweden) life after burn injury to
acquire a deeper
understanding of important
issues for patients during
and after a burn injury
burn survivors; M/F 24/20; mean
age 38, range 18–71 years; 50%
(22) <20% TBSA and 50% (22)
>20% TBSA. Discharged from
hospital between 6 months to 1
year prior. Marital status: 65.2%
were married. 59% reported
changes in their work status
Purposive sample of 19 adults
who had sustained burns; M/F
12/7; age range 18–50 years (11
relatives of the participants
present at the time of the data
collection also took part)
Purposive sample of 12 adult
who had sustained burns; M/F 8/
4; mean age 50, range 19–74
years; mean TBSA 11%, range 2–
40%, mean LOS 16.4 days, range
8–45 days. Sustained burn
between 6 and 12 months prior
structured interviews descriptive analyses; impact on professionals are key
Chi-square test participants’ lives in components in the
(P < 0.05) particular in relation rehabilitation process
to their work status
and financial status
Direct observation and Thematic analysis Quality of life altered Family support, work,
semi structured due to physical and independence and
interviews psychological social integration are
limitations experience key concepts in the
by a severe burn injury rehabilitation journey
Face to face interviews Qualitative content Patients with severe Necessity of support
analysis using Kvale’s burns require more to assist burn
three step method for information about and survivors to confront
structuring analysis involvement with and cope with altered
their rehabilitation bodily sensations and
plan appearance early in
the burn rehabilitation
period
Author/s, year Design Purpose Sample and study Data collection Method of Significant Significance to burn
and country population method analysis finding/s rehabilitation

Gonçalves, Echevarrı́a- Integrative literature Identify the biopsychological Publications between January Pubmed, Latin Evidence level ranking Mental health prior to Complexity of burn
Guanilo, de Carvalho, review factors that influence the 1987 to January 2007; studies American and from level I to VII. injury, ineffective rehabilitation requiring
Miasso and Rossi rehabilitation of burn related to burn rehabilitation of Caribbean Health Studies classified as coping strategies and a multidisciplinary
(2011) (Brazil) survivors adults related to biological, Sciences Literature quantitative, qualitative lack of social support approach both physical
psychological and sociocultural (LILACS) and Scielo and reviews were factors influencing and psychosocial
themes in English, Portuguese between October 2007 the burn rehabilitation
and Spanish and January 2008 process
Mackey, Diba, McKeown, Qualitative To explore burn survivors Purposive sample of 23 adults of Face to face semi Matrix analysis Employment prospects The rehabilitation of
Booth, Gilbert and descriptive study experiences and perceptions working age; TBSA range of 10– structured interviews methodology developed after a severe burn is burn survivors’ back
Dheansa (2008) (UK) of returning to work after 25%. Excluded self-inflicted the Qualitative Research related to their pre into the workforce has

burns 40 (2014) 17–29

discharge burns
Moi and Gjengedal Husserlian To explore and describe the Purposive sample of 14 adults
(2008) (Norway) phenomenological experience of quality of life who survived a major burn
study after a major burn injury injury; M/F 11/3; mean age 46,
range 19–74 years; mean TBSA
33%, range 7.5–62%, mean full
thickness burn 27%, range 3–
62%. Burn sustained on average
14 months after injury with a
range of 5–35 months
Unit at the National injury status, benefits for burn
Centre for Social employment factors, survivors, their families
research (not described) physical and and the community
psychological issues
related to burn injury
and the management of
burn injury and the
socieo-economic
background
20 open, unstructured, Thematic analysis using Accidental burn injuries Education and
in-depth interviews Giorgi’s and the subsequent information is critical in
phenomenological hospitalisation were life preparing burn
method using data changing events that survivors and their
analysis software NVivo altered participants’ families for the long
perception of life with rehabilitation journey
the necessity to accept ahead
what could not be
changed and make
efforts to change what
was changeable

21
 22
Author/s, year Design Purpose Sample and study Data collection Method of analysis Findings Significance to
and country population method burn rehabilitation

Moi, Vindenes Husserlian To describe the body of
and Gjengedal phenomenological people who had survived a
(2008) (Norway) study severe burn injury and
understand the essence of
participants ‘lived
experience’
Na (2008) Hermeneutic To understand how burn
(Australia) inquiry: dissertation survivors view their
participation and re-
engagement in activities
after a burn injury
Purposive sample of 14 adults 20 face to face open, Thematic analysis An altered and The facilitation of
who survived a major burn in-depth interviews (9 using Giorgi’s demanding bodily social support is
injury; M/F 11/3; mean age participants were phenomenological awareness that critical in the
46.2; mean TBSA 32.6%, mean interviewed once, 4 method using data revealed both rehabilitation after a
full thickness burn 26.8%; participants analysis software limitations and severe burn injury
mean LOS 50.6 days. Burn interviewed twice and NVivo potentials for burn
sustained on average 14 1 participant survivors
months prior. 50% participants interviewed 3 times)
unemployed
Purposive sample of 5 adults The Occupational Thematic analysis The use of cognitive The importance of
rehabilitating from burn Performance History behavioural therapy social and
injuries; M/F 2/3; mean age 47, Interview-II (OPHI-II) during burn professional support
range 32–61 years; mean TBSA utilised as a guide in rehabilitation to assist to facilitate adaption
16.4%, range 6–30%; 2 reported conducting face to patients in reframing and adjustment in
facial burns. Burns sustained face interviews their experiences and burn survivors’
on average 16 months prior modifying everyday lives
with a range of 2–54 months. misconception in
Marital status: 4 married and 1 relation to pain and
divorced social stigma

burns 40 (2014) 17–29

Oster, Kildal and Qualitative To explore the burn injured Purposive sample of 39 who Face to face semi Qualitative content Barriers returning to The importance of a
Ekselius (2010) descriptive study persons’ perception of had previously sustained a structured interviews analysis work were perceived return to work
(Sweden) facilitators or barriers to burn injury; M/F 29/10, mean as: cessation of pain coordinator early in
returning to work after a age at time of injury 39.7 years, medication, Primary the rehabilitation
severe burn injury range 19–61 years; mean TBSA healthcare facility’s process focusing on
29%, range 1.5–80%, mean full lack of knowledge, a capabilities not
thickness burn 19.9%, range 0– lack of psychological impairments
64%; mean LOS 29 days, range support and a lack of
1–230 days. Sustained burn on individualised
average 4.6 prior rehabilitation plans.
Facilitators returning
to work were
perceived as: the
individual
characteristics of own
ability to take action,
goals for
rehabilitation,
determination and
ability to adjust.
Assistance with
modified work or
change of work place
was also perceived as
a facilitator
Author/s, year Design Purpose
and country
Ripper, Renneberg, Qualitative To investigate the specific
Landmann, descriptive study problems and impairments
Weigel and that patients wearing
Germann (2009) pressure garments confront,
(Germany) and the supportive aspects
or resources that help
patients to continue with
therapy
Rossi, Costa, Dantas, Qualitative To explore the cultural
Ciofi-Silva and Lopes descriptive study meaning and dimensions of
(2009) (Brazil) the quality of life of Brazilian
burn patients
Williams, Davey and Qualitative To explore burn survivors’
Klock-Powell descriptive study adaption to a severe burn
(2003) (USA) injury.
Research question:
1. How did the participants
in this study experience the
process of recovery from a
severe burn injury?
2. What personal and
environmental factors
appeared to influence the
survivors’ recovery process?
Wu, Zhai and Liu Descriptive To describe the differences
(2009) (China) phenomenological in coping strategies that
study affect psychological and
physical rehabilitation in
Chinese burn patients
Sample and study
population
Randomised selection 21
(method of randomisation
not described); M/F 13/8,
mean age 42 years, mean
TBSA 19.8%; average time
since injury 1 year and 5
months, range 5 months to 4
years and 2 months; marital
status: 71% in relationship,
19% single and 10% widowed
Purposive sample of 19 burn
survivors and 11 relatives (7
wives, 1 husband, 2 mothers
and 1 sister-in-law); M/F 12/
7; age range 20–50 years;
mean TBSA 33%, range 1–
68%; 8 reported facial burns.
Sustained burn
approximately 6 months
prior
Purposive sample of 8 adult
burn survivors; M/F 4/4;
mean age at time of injury
29.6 years; mean age at time
of interview 41.75 years;
mean age at time of injury
29.63 years; 2 of the
participants were African
American, 3 Latino heritage
and 3 Caucasian. Marital
status: 3 married, 1 widow 4
single
Purposive sample of 8 adult
burn survivors; M/F 6/2;
mean age 39, range 22–54
years; mean TBSA 67%, range
30–98%. LOS ranged from 4 to
68 months
Data collection Method of analysis Findings Significance
method to issue
Face to face semi structured Content analysis using Adherence to pressure Education and social
interviews MAXQDA garment therapy was support facilitates
related to education and with adherence to
resources available burn therapy
Direct observation and face to Thematic analysis The importance of The importance of
face semi structured returning to their pre socio-cultural
interviews injury status including dimensions for burn
independence, mobility, survivors undergoing
employment resuming rehabilitation
interpersonal relations
and leisure activities
burns 40 (2014) 17–29
Face to face semi structured Thematic analysis The primary themes that The importance of
interviews emerged encompassed burn professionals’
losses, gains, adaption role in facilitating
and coping with change burn survivors’
and relationships with adjustment and the
others transition to regain
their lives
Face to face Semi structured Case study analysis Optimistic personality, Social support is a
interviews positive coping styles and critical element to the
social support were vital burn rehabilitation
to the rehabilitation process
process
23
24 burns 40 (2014) 17–29
Both Badger and Royse [7] plus Ciofi-Silva et al. [19] also
noted that their participants encountered difficult and
insensitive experiences with family members and friends
after their burn injury. Ciofi-Silva et al. [19] stated that several
participants experienced adverse changes in their relation-
ships related to a breakdown in their marriage. Badger and
Royse [7] described a shift and a loss of relationships
particularly with friends:
A great many of people that I spent a lot of time with before
I was burned have since disappeared. . .. I knew that if I
talked about it, it would help me understand. I needed
somebody to stop long enough to listen. And people didn’t
want to hear it [7].
Na’s [20] study highlighted negative experiences with
relatives and friends of participants after their injury and
also demonstrated in contrast, how total strangers assisted:
People, (a) couple of strangers . . . put on meals and pick up
the kids and do things . . . people we barely know . . . just
come in and helped [20].
3.2.2. Professional support
Identified in the literature, was the lack of or limited
knowledge and education afforded to burn survivors by
healthcare professionals concerning therapy and wound care
[8,10,16]. A participant in Dahl et al.’s [16] study demonstrate
this lack of education, information and assistance:
Information is important about treatment and medication
and what is going to happen, I did not get any informa-
tion. . .there is always a lack of information. . .for those who
work here everything is self-evident [16].
The transition from the burns unit to either a district
hospital or home identified insecurities and negative
experiences as the primary responsibility for care was
handed over to the burn survivor and their families.
Participants in Moi et al.’s [15] study revealed that after
discharge from the burns centre, participants experienced
wound breakdown and a restriction in their mobility that
were a significant source of stress. Na [20] highlighted the
importance of feeling secure and familiar with the treating
health professionals. In the absence of familiarity, the
perception of a potential threat was evident with this
particular participant:
I didn’t really feel like he understood me or what I’ve been
through . . . I sort of broke down . . . ‘cause he just sort of put
a couple of dressings on me and sent me on my way [20].
A lack of educational support from burns personnel
facilitated non-adherent behaviours as demonstrated in
Ripper et al.’s [10] study with participants displaying little
knowledge of why they should adhere to burn therapies:
It hurt terribly and I had no idea why I should wear it – they
just told me that I should [10].
For example I didn’t know in the summer: ‘‘Do I need to put
sun protection underneath?’’ [Underneath burn compres-
sion garments] [10].
In fact, 57% of participants in Ripper et al.’s [10] study
identified a lack of education concerning the purpose of
pressure garment therapy contributed to non-adherent
behaviours. However as a participant of Dahl et al.’s [16]
study revealed, health professionals facilitated by means of
providing support through positive feedback that strength-
ened self-confidence:
The physiotherapist gave me handles so that I could
exercise my fingers when I was watching television and
support so that I could start walking, I took the handles
with me out in the corridor instead, there were 110 steps
from the front door to my room and I practiced with the
handles at the same time; in this way I pushed myself a
little more [16].
3.2.3. Peer support
Peer support enhanced the recovery and empowered burn
survivors. One paper in particular focussed on burn survivors’
perception of peer support [7]. Participants from Badger and
Royse’s [7] study reported that their lives had changed by the
acquisition of hope for the future and an added perspective as
a result of burn survivor peer support:
Visualize a future. Seeing someone who is happy, doing
things allows burn survivors to rebuild lives. People can tell
you [that you can rebuild your life] but you can’t see it
without a real example [7].
Oster et al.’s [8] also echoes Badger and Royse’s [7] findings
demonstrating how speaking with other burn survivors is an
empowering action:
When you meet someone who really knows what you’re
going through, you can discuss things in a different way [8].
Evident in several papers reviewed, was the credibility that
peer support brought to burn rehabilitation. Health profes-
sionals have the knowledge and expertise to treat and manage
burn injuries. However, they lack actual experiences that can
only come from those who experience being burnt:
Credibility that comes from burn survivors. It is okay to ask
questions. There is trust because the information comes
from someone other than a health professional [7].
Peer support was a means for burn survivors to give
support to other burn survivors. Williams et al. [9] and
Badger and Royse [7] found that survivors engaging in peer
support experienced a significant positive change in their
attitude providing comfort by engaging with others survi-
vors:
It made me address my issues. Helping others forces one to
grow and heal [7].
 burns 40 (2014) 17–29
3.3. Coping and acceptance
Much of the reviewed literature focused on the psychological
impact of a burn injury. However, a common theme isolated
among the literature reviewed, was the notion of coping and
acceptance. Coping strategies were identified as influential in
the rehabilitation journey. Accepting the unchangeable was
often difficult as portrayed by a participant in Moi and
Gjengedal’s [18] study:
I take one day at the time. I keep to the time horizon they
[the burn unit staff] have given me, one and a half to two
years, and this I can manage. But if next year they tell me
that I have to continue [treatment], I do not know how I will
react [18].
Common to all papers, pain was a prime example of the
reality of burn rehabilitation. However, coping often required a
specific mind set as demonstrated by a participant from Dahl
et al.’s [16] study:
You learn to live with the pain. . .you can’t do anything
about pain. . .the body has to heal and there is no other way
out. . .you support and adapt to pain. . .and you say to
yourself that this is going to be good. . .not expect the pain
to disappear completely [16].
Depression and anxiety were found to negatively influence
patients’ ability to cope. Wu et al. [17] found that a prolonged
hospitalisation facilitated ‘endless negative thoughts’ [17] that
affected patients’ physical and psychological well-being.
While Williams et al. [9] found depression and feelings of
intense anger were universal among the participants of their
study:
I would say my first year there was a lot anger, emotionally,
a lot of ‘‘what ifs’’ [9].
Goncalves et al. [12] identified that patients with a
greater TBSA burned or experienced burns to their hands
and face experienced an increased likelihood of developing
depression. Furthermore, TBSA burned was identified as a
primary indicator for poor adjustment and quality of life.
Additionally, the mental health status prior to the injury
was reported to be associated with poor rehabilitation
outcomes [12]. Surprisingly, Dahl et al. [16] found that
patients with minor burns also experienced psychological
issues six to eight months after discharge. In fact, patients
with minor burns and short hospital admissions seemed to
experience traumatic memories of the injury making coping
difficult [16].
Four papers [9,13,14,19] focused on spirituality and religion
as a coping mechanism that provided strength and support.
However, religion and spirituality was also used as a form of
rationalising that made the process of acceptance difficult as
the participant from Williams et al.’s [9] study found:
Before the accident I always felt that it was every man’s
obligation to be compassionate. . . that we were, indeed,
responsible for our brothers. Immediately after the
25
accident, it was almost like, ‘‘God I’ve given you everything
and you’ve taken everything away from me’’ [9].
Common to seven papers [12–14,16–18,20] was to compare
oneself with others or to reframe the experience claiming that
it could have been worse. This coping strategy offered burn
survivors a form of comfort and compensation [13] that
assisted with coping and acceptance of the burn injury:
I’m lucky that I did not get any hot water in my face. . .and
then it could be much worse. . .when I see other people who
have cancer and everything with that. . .I’m grateful. . . [16].
3.4. The importance of work
Participants in five papers reported returning to work as a
significant rehabilitation goal [8,11,14,16,19]. These authors
have clearly demonstrated how the participants’ have
experienced disruptions, difficulties and financial implica-
tions concerning limitations that encompassed: a leave of
absence, forced retirement, difficulties with adapting to the
work environment, poor performance, loss of job, change of
employment and difficulties in attaining new employment.
The following narratives illustrate the experiences of voca-
tional changes as reported by burn survivors:
I had an extra job working as an electrician. I have already
resumed this activity at home, fixing things to test my
limits and preparing myself to resume activities at the
sugar cane mill. I know that it will not be possible to resume
the activities I had before the accident happened, because I
can’t stay in the sun for a long time, my skin is very
sensitive to sun exposure, hot weather and also to air
conditioning [14].
The limitations experienced returning to work included
burns to the hands and upper limbs, hypertrophic scarring and
contractures, pain, skin hypersensitivity, ongoing psychologi-
cal issues, difficulties with reintegration into the work force
and reaction of others to a severe burn injury [8,14,19].
Additionally, Ciofi-Silva et al. [19] claimed that 68.7% of their
participants that sustained burns to upper limbs, reported
some form of change in their vocation compared to those who
sustained burns on other areas of their anatomy. However on
the contrary, some participants in Mackey et al. [11] study
experienced no change in their work as a consequence of their
burn injury. Both Mackey et al. [11] and Oster et al. [8] in
particular, focused on the participants’ perception of barriers
and facilitators of returning to work after a significant burn
injury. The individual characteristics of burn survivors such as
a positive outlook, adaption, motivation and having set
rehabilitation goals, social support, were influential in
facilitating the return to work process:
It’s not like I remember having any problems with training, I
had goals and once I’ve made up my mind about it, then I can
also do it, it doesn’t matter how much outside influence
there is. . .You can get care and support and everything but if
you don’t have the will yourself you don’t get any further [8].
26 burns 40 (2014) 17–29
However, significant barriers experienced in returning to
work were reported as a lack of psychological assistance, fear
of the workplace coupled with physical impairments, no
specific rehabilitation plan or individualised training and the
wait for reconstructive surgery [8,11]. Additionally, Oster et al.
[8] identified that a lack of primary care concerning health
professionals limited knowledge of wound care had a negative
impact on wound healing that unduly delayed the return to
work:
The first district nurse I saw, she was like this, I mean,
almost just standing there with her mouth hanging open
and saying, ‘‘My god, it’s really a lot,’’ and so on. . .Yes, it
was strange; you don’t feel secure, because it was as if she
(district nurse) was unsure, she’d had more education than
I have. . .if she didn’t know what to do then, well, it would be
difficult. So I had to explain what she should do. Well you
can’t put it on tight, you have to use Vaseline first and then
put the dressing on, otherwise they’ll stick [8].
3.5. Physical changes and limitations
Evident in each article reviewed was the physical and
emotional trauma experienced. Most of the papers reviewed
addressed the physical changes and limitations experienced.
Pain, altered physical appearance, burn wound and scarring
and physical limitations were identified as problematic areas.
3.5.1. Pain
The ongoing physical pain was identified as a significant factor
that negatively affected burn survivors’ rehabilitation in 10 of
the papers reviewed. Williams et al. [9] highlighted that
participants experience and perceive pain in different ways.
Pain according to Moi and Gjengedal [18], has the potential to
alter burn survivors’ perspectives on life. One participant in
Mackey et al.’s [11] study stated that pain was a primary reason
for not returning to work. While Dahl et al. [16] participants
stated that they continued to experience pain and altered
sensations that include heat, itching, smarting pain, cold and
pricking pain with Moi et al.’s [15] findings also concurring
with Dahl et al. [16]. Ripper et al.’s [10] study revealed that pain
was a significant factor in non-adherence to pressure garment
therapy with almost half of the participants referring to the
pain as a difficulty while wearing the pressure garments.
Furthermore, half of the participants experienced altered
sensations with more than a third, mentioning burn itch as a
major concern.
Issues with pain medications and withdrawal were
reported by Dahl et al. [16], Na [20], and Oster et al. [8].
Difficulties experienced included withdrawal symptoms,
reduction and the cessation of pain medications. Four
participants in Oster et al.’s [8] study experienced withdrawal
symptoms stating that it was essential to cease taking pain
killers prior to returning to work, however they did not know
how to do so. These participants experienced increased pain
upon a reduction of medication and felt unprepared empha-
sising the importance of education and support. A participant
in Na’s [20] study revealed that pain medication interfered
with rehabilitation, limiting their functioning more so than
the burn injury itself claiming ‘‘I feel that those tablets had
actually dragged me down probably for lot longer than what I
even really realised’’ [20]. Another participant experienced
difficulties with taking strong pain killers and endured the
pain to be able to live a normal life:
I don’t want to be on strong pain killers all my life . . . I’d
much rather endure the pain and try and function as
normal as possible [20].
Managing the physical pain is a challenge for burn
survivors. Williams et al. [9] and Oster et al. [8] both reported
difficulties with managing burn pain. A participant from
Williams et al.’s [9] study was made to debride devitilised skin
off their body after premature discharge from hospital:
The physical therapist had said you have to debride
yourself so uh. . .but I didn’t know what to really debride
with, so I finally took a razor blade and I would just cut the
adhesions that would start. . .looking back, I don’t know
how I did it [9].
3.5.2. Altered physical appearance
The literature reviewed described an altered physical appear-
ance as variations in the colour of grafted skin and donor sites
in an assortment of colours, shades and textures with thick,
raised scars with some experiencing facial disfigurement.
Participants of Moi et al.’s [15] study perceived their bodies as
unfamiliar. Looking at oneself was a difficult experience that
constantly remind them of their trauma experienced: ‘‘this
body, this thing with the arm, it is like I am reminded of it a
hundred, 200, 300 times a day’’ [15] and also conveyed by
another participant in Moi et al.’s [15] study by this powerful
statement:
I was not very pretty before [the accident], but I was a
normal person and suddenly you see a person in the mirror,
without hair and with an ugly face, and you think, ‘That is
not me!’ Even though I knew it was me I saw in the mirror, I
refused to admit it was me. It was painful, indescribable.
Me, like that.
Feelings of stigmatisation through stares or finger pointing
were felt as experienced by a participant in Rossi et al.’s [14]
study ‘‘I am a tourist attraction. I need to stop in the street to
tell people about the accident’’ [14]. Moi et al. [15] and Na’s [20]
study also reported participants feeling vulnerable in public
areas due to their altered appearance and the potential for
interaction with strangers. However other studies reviewed,
portrayed a positive experience of an altered appearance
stating that the visible scars were ‘‘a bit like tattoos. . .they just
tell a better story’’ [11] and ‘‘Friends tell me it is not that bad
after all and that the glove I am wearing is really cool’’ [10].
3.5.3. Physical limitations
Barriers and challenges experienced by burn survivors,
encompassed loss of physical functioning, scarring, amputa-
tions, difficulty with walking and performing activities of daily
living [9,11–13,16,18,20] issues with pain [8,9,11,12,15,16,20]
adherence to pressure garment therapy [10] challenges
 burns 40 (2014) 17–29
experienced with employment and returning to work
[8,11,14,16,19] burn wounds and infections [8,12,18,20].
The scars that developed as a result of the burn created
physical limitations by means of restricting movement:
I feel that they [the scars] will pull me even more
downwards. Yes, the strings go all the way down, and on
this side they are very thick and tight [15].
until I found out how to dress and close that zipper – that
was a real battle [10].
However, despite the physical limitations experienced, the
studies reviewed illuminated how some burn survivors
perceived small steps as a significant turning point in their
rehabilitation:
My best moment was when I managed some steps with the
walking frame from the bed – I moved! That’s when I
started to see things in a brighter perspective [15].
Even the smallest achievement gave some form of
accomplishment as with this participants perception stating
‘‘there were times when if they moved it one micrometre that
was cause for celebration’’ [9].
4. Discussion
4.1. Limitations and strength of evidence
This integrative review is limited by the small number of
original papers that were identified for evaluation. Two
studies used the same cohort of participants further limiting
the pool of research that is incorporated into the integrative
review [14,15,18,13]. The incorporation of primarily qualita-
tive studies may be viewed as a limitation. However, the
importance of methodological congruence within the
review requires consideration. The participants incorporat-
ed into the integrative review consisted of mainly men.
However, this is consistent with other findings that report
men to have a higher incidence of burn injury than women
due to occupational risk factors leaving them prone to
industrial accidents [21,22]. Despite this diversity in burn
injury and age, the papers reviewed did describe the
subjective perceptions and experiences that were compara-
ble with each other. Whilst informative, the issues raised
may limit the applicability and transferability of the
synthesised results to other fields of rehabilitation. Addi-
tionally, the generalizability is also limited by the inclusion
of papers from mainly developed countries whereby the
incidence and occurrence of severe burns is considerably
higher in underdeveloped countries [23]. Several studies
included in the review were conducted in languages other
than English with the narratives translated into English.
However, this process may have led to the meaning and
context of the narratives being lost. Notwithstanding these
limitations, conclusions can be made about the perceptions
and experiences that influence burn rehabilitation.
27
4.2. Recommendations
4.2.1. Accredited burns rehabilitation education
This integrative review highlights a lack of clinician based
burn rehabilitation education that is insufficient evidenced by
the inadequacies experienced by burn survivors concerning
the management of burn injuries during rehabilitation. The
development of an accredited burn rehabilitation training
program would allow health professionals with the necessary
knowledge and training to be confident and competent in
managing burn patients in the rehabilitation and community
settings. As with the Australian Emergency Management of
Severe Burns course (EMSB), a burn rehabilitation course
should require all participants to successful complete the
course with an examinable component to ensure that those
working in the area of burn rehabilitation are competent
clinicians. Given the resource of each healthcare service and
community, the challenge of delivering education would need
to be met in a specific manner.
4.2.2. Development of a multimedia education based
programme directed towards adherence to burn therapy and
continuum of burn care.
The development of a multimedia education based program
would provide those with severe burns greater knowledge and
understanding of their injury. Multimedia programs have
been shown to not only increase patients’ confidence and
reinforce critical elements of burn care [24], they have been
reported to significantly improve the knowledge base of
patients that in turn reduces anxiety and enhances adherent
behaviours [25,26]. A multimedia package could contain such
products as a DVD, CD, still images, animation, traditional text
or interactive media directed at ongoing burn care and
therapy. Given that the integrative review identified that
patients would like more information concerning their injury
and sequelae, this raises questions of the timing and delivery
of education and information. Utilising a multimedia format
could overcome some of these issues experienced during burn
rehabilitation. Additionally, using DVDs and CDs to provide
survivors with information on their burn care and therapy
would facilitate those who have poor literacy skills.
4.2.3. Provision of services that mutually engage health
professionals, employers and survivor in the process of
transition home and returning to work
Improved integration between the burn units and the
rehabilitation/community setting may improve the patient’s
experience and facilitate for a smooth transition period during
an often disruptive period. This could be achieved by
purposeful collaboration between the acute and rehabilita-
tion/community services whereby the rehabilitation/commu-
nity nurses responsible for the care of the patient, come to the
burns unit and engage with both the patient and the
multidisciplinary burn team and partake in burn care
practices. Further to this, the specialist burn nurses and allied
health personnel should follow up with the patient at regular
set intervals to monitor issues as wound breakdown, scarring
and contracture development as this may reduce the
incidence of unplanned readmissions and functional compli-
cations. Given the importance of psychosocial recovery, this
28 burns 40 (2014) 17–29
should also be regularly followed throughout the recovery and
rehabilitation process by relevant clinicians and teams
(nurses, social workers, psychologists, psychiatrist, and
general practitioners). Finally, to facilitate the return to work,
liaising with employers early in the rehabilitation process may
provide for better communication and understanding be-
tween the employee and employer. This could assist with
providing both the employee and employer with the necessary
support and resources to enable burn survivors to return to the
workplace environment.
4.2.4. Development of an inpatient clinician based formalised
burn peer support program
A formalised inpatient burn peer support program cham-
pioned by volunteers based on the fundamental premise of a
shared experience has the capacity to engage burn survivors
providing hope, reassurance [27,7] and facilitate their psycho-
social adjustment [27,7,28,29]. Speaking to another burn
survivor is often a key aspect in the rehabilitation of those
with severe burn injuries [28]. It has been reported that an
encounter with a burn survivor is a meaningful experience for
a person who is rehabilitating from a severe burn injury [28].
Burn survivors would be selected following a comprehensive
recruitment, screening and training process to ensure appro-
priateness. A network based on this structure could provide
burn survivors and in particular those in remote access
locations, with the necessary peer support needed to endure
the rehabilitation journey.
5. Conclusion
Ongoing educative support to the health professionals, burn
survivors and their families remains an important element in
burn rehabilitation. There is a necessity for appropriate
knowledge and education based programmes for burn
survivors with consideration given to the timing and delivery
of education to facilitate the rehabilitation journey. Research
that explores the broad understanding of burn survivors’
experiences and perceptions of both the physical and
psychosocial rehabilitation following a burn injury is essen-
tial in that it suggests and informs a multidisciplinary
approach leading to possible education and research devel-
opment.
Conflict of interest
The authors declare that they have no conflicts of interest;
such as employment, consultancies, stock ownership, hono-
raria, paid expert testimony, patent applications/registrations,
grants or other funding.
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