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THE USE OF NON-PHARMACOLOGICAL NURSING INTERVENTIONS IN THE MANAGEMENT OF BURNS PAIN

DAWN WESTLAKE

(2012)

Dissertation submitted in part fulfilment of the requirements for the degree of BSc (Honours) Adult Nursing at the University of the West of England.

I certify that this is my own unaided work.

Signed:

ACKNOWLEDGEMENTS

I would like to thank my wonderful fianc Bob who has selflessly and patiently supported me throughout my studies. His invaluable guidance, abundance of encouragement and unconditional love has been an inspiration.

CONTENTS Title page Acknowledgement Contents Abstract Chapter 1: Introduction 1.1 Research Questions 1 2 3 5 6 8 9 9 11 12 13 13

Chapter 2: Method 2.1 2.2 2.3 Search strategy Limitations Critique framework

Chapter 3: Critical Review 3.1 Do all adult burns patients experience unsatisfactory levels of pain relief during routine wound care procedures? 3.2 Are non-pharmacological interventions such as virtual reality and hypnosis effective at reducing procedural pain experienced by adult burns patients? 3.3 Does the use of virtual reality and hypnosis result in reduced medication consumption for pain relief by adult burns patients? Chapter 4: Discussion 4.1 Do all adult burns patients experience unsatisfactory levels of pain relief during routine wound care procedures?

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4.2

Are non-pharmacological interventions such as virtual reality and hypnosis effective at reducing procedural pain experienced by adult burns patients?

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4.3

Does the use of virtual reality and hypnosis result in reduced medication consumption for pain relief by adult burns patients?

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4.4

Recommendations for future practice

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Reference List Appendix A Search Strategy and Keyword Searches Appendix B Critiquing Framework Appendix C Research Summary Tables

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ABSTRACT

The multifaceted nature of burns injury pain makes it challenging to treat. Often adult burns patients experience uncontrolled pain during wound-care despite pharmacological interventions. Although opiates remain the mainstay in the treatment of burns pain they are often not affective or appropriate therefore additional nursing interventions are needed to improve pain management.

The best available evidence has found that non-pharmacological interventions such as virtual reality and hypnosis have been successful at distracting patients away from painful stimulus, resulting in significantly reduce pain levels during routine wound-care procedure such as debridement and dressing changes.

Therefore non-pharmacological interventions are an important adjuvant to drug treatment, with the most effective pain management protocols using a flexible approach, tailored to the individual patient needs, which incorporates both pharmacological and non-pharmacological methods alongside regular pain assessment.

However, more research is needed before well founded evidence based decisions for the incorporation of such interventions into nursing practice can be made. This should include evaluating the nursing role within pain management processes, the types of intervention and their suitability to individual patients and the feasibility and cost of incorporating into clinical practice.

CHAPTER 1 INTRODUCTION The management of burn injury pain has been widely reported as a clinical problem for many years, with procedural pain in particular, described as the most intense and most likely type of burn pain to be undertreated (Perry et al, 1981; Perry, 1984; Choiniere et al, 1989; Byers et al, 2001). Seminal research by Choiniere et al (1989) found that most patients being treated with burns reported excruciating pain during wound-care, despite aggressive use of opioid pain management. These findings are still being reported in contemporary research with burns patients reporting pain severity at its greatest during therapeutic procedures, describing procedural pain as psychologically scaring and the worst pain imaginable (Tengvall et al, 2010; Yuxiang et al, 2011;). Therefore as nurses whose role it is to provide this essential wound-care it is imperative that we continue to challenge our clinical practice to gain a better understanding of its influence on our patients experience, to improve our standard of care thus minimising the negative impact of uncontrolled pain. This is critical as research continues to make significant correlations between the severity of pain experienced during hospitalisation and the amount of post-discharge mental and physical dysfunction (Ptacek et al, 1995;Patterson et al, 2006). Summer et al (2007) report that inadequate pain control has been found to increase the incidence of long term sensory problems such as chronic pain, with Dauber et al (2002) estimating that chronic pain is a problem for approximately 54% of burns survivors. Richarson and Mustard (2009) also highlight the negative consequences of poor pain control, explaining that the fear and anxiety induced by a bad acute pain experience can result in debilitating psychological conditions such as depression and posttraumatic stress disorder.

Despite pain management guidelines and protocols, the ever changing multifaceted nature of burn injury pain makes its management very challenging, especially as modern burn care involves the repetitive performance of painful and anxiety provoking procedures; such as wound-care, debridement and dressing changes which create additional treatment related pain (Summer et al, 2007; Sharar et al , 2008). Atchison et al (1986) describe these procedures as more painful than the burn injury itself resulting in the administration of increasing amounts of opiates, which Hanafiah et al (2008) explain can exacerbated the problem further with patients rapidly gaining tolerance to opioids, necessitating increasing doses, therefore increasing side effects, and potentially leading to opioid induced hyperalgesia which Wilder-Smith and Arendt-Neilson (2006) caution may complicate analgesic therapy making further management difficult. This was a phenomenon which I experienced during an elective placement in a specialist burns unit, in which whilst assisting with the care of patients I found myself in the paradoxical position of directly inflicting pain during wound-care procedures, whilst also being the provider of pain relief. A dilemma exacerbated by patients continuing to experience pain despite analgesia being administered according to pain management protocols. This made me question if pharmacological interventions alone were sufficient to provide pain relief in these complex patients, and inquire if effectiveness of pain management. non-pharmacological nursing interventions could be incorporated into practice to improve the

1.1: Research Questions The three questions to be explored and addressed within this review are:

1. Do all adult burns patients experience unsatisfactory levels of pain relief during routine wound care procedures?

2. Are non-pharmacological interventions such as virtual reality and hypnosis effective at reducing procedural pain experienced by adult burns patients?

3. Does the use of virtual reality and hypnosis result in reduced medication consumption for pain relief by adult burns patients?

CHAPTER 2 METHOD A literature search is the means of locating and identifying the most up to date and relevant material to provide the reader with current theoretical and scientific knowledge about a particular problem (Parahoo,1997; Burns and Grove,2007). A skill which Hek and Moule (2006) state is essential for healthcare practitioners to develop in order to become research literate as the ability to search literature effectively is essential to retrieve the best evidence available to inform evidence based practice. The purpose of this chapter is to outline and justify the methodology used to identify and retrieve the relevant information necessary, to perform a systematic review of the literature. It will detail the search strategy used including keywords, inclusion and exclusion criteria. Problems and limitations encountered during the search process will be discussed and formulation of the critiquing framework used to analyse the literature explained.

2.1: Search Strategy As Hek and Langton (2000) consider that a systematic approach is most likely to generate a review that will be beneficial in informing practice, it was necessary to identify a structured way to generate the appropriate and relevant information. Following Hek and Moule (2006) Steps to Undertaking a Literature Search, background reading on the subject was performed in order to identify appropriate key words necessary to methodically and thoroughly search bibliographical databases. Computer databases were used as they offer quick and easy access to substantial quantity of information compared to manual searches, and provide the latest evidence compared to books, which

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Younger (2004) explains are often out of date by the time they reach the shelf. Ely and Scott (2007) classify keyword searches as the most common method of identifying literature; however Younger (2004) advises that careful consideration is needed to select terms that will generate the data being sought, with the success of the search being dependent on choosing the appropriate words or terms developed within the search strategy. To ensure that any relevant literature was not missed alternate keywords and terms with similar meanings or different spellings were included. For example; burn injury and thermal injury or opiates and narcotics. This was necessary as it was discovered from background reading that the majority of research about burns had been performed in America and therefore the American database CINAHL was included in the list of databases to be searched (See appendix A). This would be considered appropriate as Burns and Grove (2007) advocate that an important aspect of the search strategy is to identify relevant research sources, and should include selecting appropriate databases. Therefore AMED, ASSIA, BNI, CINAHL, Cochrane Library, EMBASE, HMIC, MEDLINE were selected as Walliman and Appleton (2009) recognise these database to be of use in health and social care studies. Also due to the psychological components of pain it was felt appropriate to include PsycInfo, for its coverage of the psychological aspects of illness and treatment (See appendix A). An initial search was performed via the university library electronic catalogue database, using the key word Burn*. Truncation was used in order to ensure that all variations of the word were included, such as; burn, burns, burnt and burned. This generated an overwhelming amount of literature (835,054),therefore in order to constrain the search to ensure that only the most relevant literature was retrieved, keywords were combined using Boolean operators of AND,OR and NOT as recommended by Polit, Beck and Hugler (2001). Aveyard (2007) also

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suggests that setting an inclusion and exclusion criteria can assist in keeping searches focused to ensure that you are not side-tracked by literature irrelevant to your topic. Therefore further searches were limited by content type, subject terms, language and publication date (See appendix A). Other techniques that proved useful were searching thorough specialist journals such as Burns and Journal of Burn Care Research, and subsequently Snowballing through the reference lists for key articles, particularly literature reviews, to find further references until saturation was reached. Using this technique facilitated the identification of seminal works that were missed by the date limitations set within the exclusion criteria.

2.2 Limitations The literature search highlighted a shortage of UK based research on the topic therefore the inclusion criteria had to be changed to include countries outside the UK. This meant that careful consideration would need to be given to any differences within health care systems and possible cultural diversities which may limit the transferability of findings. Renowned research on the pain experienced by burns patients was conducted in Canada in the late 1980s into the 1990s (Choiniere et al, 1998, Choiniere et al 1990, Choiniere et al, 1991, Choiniere et al, 1994). These were cited in numerous research papers and literature reviews thus considered to be seminal pieces of research. However these studies focused on different aspects of burns injury pain, and therefore did not meet the inclusion criteria and as a consequence were not included in the critical review, but were used to educate and inform discussion. When searching the literature for procedural pain the majority of contemporary research was undertaken on children, therefore could not

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be included as the research questions were targeted at adult burns patients. However, studies where the sample contained both adults and children, providing the mean age was over eighteen and no correlations were found between reduction in pain ratings and patient variables such as age, they were included.

2.3 Critiquing Framework All readers of research should use a systematic framework to appraise research papers, necessary to determine the quality of the research evidence and demonstrate how relevant and applicable the results are (Walliman and Appleton, 2009). Many such frameworks are available from the Critical Appraisal Skills Programme (CASP) which includes appraisal tools developed to critique qualitative research, randomised control trials, cohort studies and case control studies, and therefore would have been appropriate to use. However as the studies chosen to analyse in-depth within this review contained both qualitative and quantative research, to facilitate ease of comparison a critiquing framework that appraised both qualitative and quantative studies alongside each other was sought. Valente (2003) provides a framework that mentions both approaches in some sections, for example method, but refers solely to quantative in others, such as analysis (Cauldwell et al, 2005). This framework was attractive as it offered examples of written critique alongside each question. However as this framework is heavily biased towards quantative it was necessary to adapt it to include questions that could be used to thoroughly appraise qualitative research. For this purpose questions from Hek and Moules (2006) Critical Appraisal Framework were incorporated to provide balance and included several ethical issues that were lacking in Valente (2003). This is considered appropriate by Cauldwell et al (2005) who argue that using a framework which addresses both quantative and qualitative research within one list

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of questions, assists the novice student of nursing and health-related research. CHAPTER 3 CRITICAL REVIEW OF THE LITERATURE The purpose of this chapter is to critically analyse and evaluate the literature selected to answer the research questions posed in Chapter 1. A critical review was undertaken using the critical appraisal framework developed in Chapter 2, and aided by summary tables designed to compare and contrast each study (Appendix C). For clarity and to facilitate ease of reading, this chapter has been organised into sub-sections which reflect each research question.

3.1: Do all adult burns patients experience unsatisfactory levels of pain relief during routine wound care procedures? The research papers selected to answer this question were conducted by Yuxiang et al (2011), Tengvall et al (2010), Carrougher et al (2003) and Byers et al (2001). Each paper aims to study the same phenomenon; the burns patients experience of pain. Two papers use a qualitative approach and two papers a quantative approach. Selecting papers utilising differing approaches was intended to address the argument that quantative research is limited in researching meaning and experience, and that qualitative research can be biased, subjective, lacking in reliability, validity and generalisability (Parahoo, 2006). Each paper provides a concise abstract, clearly describing the phenomenon of interest. Yuxiang et al (2011) and Tengvall et al (2010) both identify that pain after burns is a major clinical problem with research continuing to report that burn pain remains untreated. They explain the purpose of their studies are to describe burns patients experiences in order to acquire a deeper understanding of how patients cope with the experience, and to identify factors responsible for

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undertreated pain. This demonstrates the importance of the research in context of improving clinical practice, thus providing significance, as the results will be used to establish effective pain management guidelines or recommendations (LoBiondo-Wood and Haber, 2006). These qualitative studies both use phenomenology as a research approach, a philosophical theory exploring how humans experience consciousness, originally conceived by the German philosopher Husserl in the early 20th century (Parahoo, 2006). Yuxiang et al (2011) justifies this method by explaining that since this approach is designed to discover, describe and understand the lived experience of individuals, it was appropriate as their study described patients experiences and expectations in relation to burn pain management. Carrougher et al (2003) and Byers et al (2001) both propose to examine burns patients experiences and patient satisfaction by comparing self-reports of pain against patients acceptable levels of pain and treatment analgesic goals. Byers et al (2001) also aims to explore the relationship of contextual factors and interventions to pain and anxiety. Carrougher et al (2003) hypothesise that patient satisfaction with pain management plans would be highest amongst patients who were experiencing the least pain and also amongst patients whose experiences most closely matched their treatment analgesic goals. This hypothesis gives a clear directional statement of the anticipated relationship between two variables to be tested empirically (Valente, 2003). It was specific enough to understand what the variables are and whom the researcher will be studying, predicting an outcome directly related to the research problem, using a deductive approach appropriate to quantative studies (Hek and Moule, 2006). However neither study offers a rationale for their chosen research methodology, although Byers et al (2001) does state that a prospective, descriptive design was used. Prospective surveys are undertaken to ascertain the thoughts, feelings and attitudes of people about a service or product at the point in which they receive it, therefore this would be

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deemed appropriate. It also has the advantage of being undertaken in real time, therefore not requiring the person to remember the event, hence eliminating recall bias. In contrast to the study by Tengvall et al (2010) in which patients were interviewed six to twelve months post burn. Each paper includes a literature review which provides a rational and direction for the research, supported by relevant and current evidence cited from previous research. However no search strategy was offered detailing named databases or keywords used. This may have been as a result of conflicting opinion among qualitative researchers regarding the performance of a literature review at the onset of a study. Cormack (2000) argue that consulting literature before collecting data might unduly influence the researchers conceptualisation of the phenomena under study, whilst Polit, Beck and Hungler (2001) consider that a brief literature review may offer guidance, including that of identifying any biases from previous studies. The literature was critically appraised by Yuxiang et al (2011) and Tengvall et al (2010) both identify limitations of previous studies and used these limitations to inform the design of their own research. For example Yuxiang et al (2011) cites a study demonstrating the effect of traditional Chinese medicine on managing burn pain, explaining its limitations in exploring the multidimensional burn pain experience. Therefore his study would incorporate qualitative interviews to focus on and deepen the understanding of patients experience. Also Tengvall et al (2010) highlight studies that show conflicting evidence, offering a rational for these findings, demonstrating that the review was balanced and not biased (Hek and Moule, 2006). Each study was granted ethical approval, with informed consent obtained by three, however Tengvall et al (2010) fail to give any information regarding consent from the participants, offering the reader no reassurance that ethical principles were adhered to. Thus potentially leaving the author open to criticism of ethical violations which Polit,

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Beck and Hungler (2001) explain can impact on the scientific merit of a study as well as on the subjects well-being. Recruitment and sampling procedures are clear with inclusion and exclusion criteria detailed. Yuxiang et al (2011) and Tengvall et al (2010) used non-probability purposive-sampling, typical in phenomenological research, as it selects people who have experienced the phenomenon of interest (Ellis,2010). However because samples tend to be self-selected, the risk of sampling bias is greater than any other sampling strategy and its representiveness can be questionable (LoBiondo-Wood and Haber,2006). However as generalisability is not considered as important in qualitative research as it is in quantative, a small convenience sample of eight and twelve respectively was considered sufficient for this kind of study. Carrougher et al (2003) also used convenience sampling but with a much larger sample size of eighty-four patients, consistent with quantative studies. Whereas Byers et al (2001), still using a nonrandom method of sampling, determined the sample size of 23 by the use of power analysis, a method to estimate how large their sample size should be to adequately test their research hypothesis (Polit and Beck, 2010). However the author identifies limitations to the generalisability of the findings as a convenience, homogenous sample was used. (Yuxiang et al (2011) explain that the sample size was not fixed or predetermined, but rather determined by the saturation point of the data. Therefore interviews were ceased when the information being collected had become repetitive and no new themes emerged. The data collection procedures were clearly explained and appropriate methods of data collection used by each study. Yuxiang et al (2011) collected data via taped semi-structured interviews, using an interview guide that was piloted, to ensure clarity of the questions and follow up probes, thus adding validity. As appropriate with qualitative research, new questions were developed and included in subsequent interviews as new issues and themes emerged (Creswell, 2003).

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All interviews were conducted by the same experienced researcher to ensure consistency and reliability of the information collected (Valente, 2003). Ellis (2010) describe semi-structured interviews as a challenge for the novice researcher therefore the fact that the researcher was experienced and highly familiar with burns patients, would add depth and richness to data collected. Despite this, the use of one researcher increases the potential for bias due to the conscious or unconscious attitudes or motivations of the researcher (Burns and Grove, 2007).The additional use of questionnaires would add reliability as the absence of an interviewer would ensure there was be no bias reflected in the respondents reaction to the interviewer rather than to the questions themselves (Polit, beck and Hungler, 2001). Carrougher et al (2003) state which data collection instruments will be used, but fail to give a rational for their inclusion or indication of their trustworthiness thus adding weakness. It is essential for the researcher to describe each instrument used, its accuracy and its limitations (Valente, 2003). In contrast Byers et al (2001) provide a clear and convincing rationale for the instruments used, including citations and demonstrates instrument reliability by performing sample reliability testing. Data analysis methods appropriate to qualitative research were used by Yuxiang et al (2011) and Tengvall et al (2010) with procedures clearly detailed. However Tengvall et al (2010) identifies their lack of quantative statistical methods as a limitation.

To add credibility Yexiang et all (2011) used two researchers to independently code the first two transcripts and then compared results to develop a coding structure for the rest. Direct quotes were also used to support the themes identified. To obtain trustworthiness and preclude selectivity, Tengvall et al (2010) states that continual critical scrutiny and testing of the results of the analysis were performed together with one of the co-authors.

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Carrougher et al (2003) and Byers et al (2003) use statistical tests that match the data and hypothesis, with the evidence of statistician input using statistical packages. Descriptive statistics were clearly presented. The levels of significance were clearly stated against each result allowing the reader to draw their own conclusion as to how confident they are in the researchers claim of a true result (Valente, 2003). The study results are clearly identified and complete, with no evidence of manipulation of analysis to favour particular findings. They are linked back to and answer the research question. The findings of Tengvall et al (2010) and Yuxiang et al (2011) suggest that burns patients experience uncontrolled pain both physically and psychologically, which is present during the entire care trajectory, with procedural pain described as the most excruciating. They concluded that patients reporting greater pain during hospitalisation, reported poorer adjustment in the months after discharge. Both identify limited generalisability in their findings to all burns survivors as convenience samples were used with Yuxiang et al (2011) cautioning that social cultural beliefs potentially affected results. Recall bias may have also influenced the results as interviews were conducted six to twelve months post discharge. Carrougher et al (2003) reported the amount of procedural pain subjects reported experiencing was significantly higher than procedural treatment goals and that patients with the highest level of procedural pain also reported the lowest level of satisfaction. However the results show no correlation between average pain scores and choice of treatment goal, this therefore questions if patients use actual pain experiences as a guide to satisfaction and indicates a willingness to accept some pain. Conversely the findings of Byers et al (2001) contradict this as procedural pain scores were slightly lower than patients acceptable level of pain. However the results were not statistically significant with generalisability limited due to a convenience

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sample and the study design failing to control variables that may influence pain. In discussion the results were all compared and contrasted with other research findings and where results contradicted previous research a rationale was given for this. Each paper describes the clinical implications of its findings and recommends future research to improve theory and knowledge.

3.2: Are non-pharmacological interventions such as virtual reality and hypnosis effective at reducing procedural pain experienced by adult burns patients? Studies selected to answer this question were conducted by Hoffman et al (2008) and Van Twillert et al (2007), exploring the effects of virtual reality (VR) on procedural pain, and Askay et al (2007) and Shakibaei et al (2008) who examine the effects of hypnosis on procedural pain. All papers use the abstract to provide a clear explanation of the topic under investigation in which they identify the problem and illustrate the importance of the research problem to knowledge development and practice (Valente, 2003). A brief summary of the study design and main findings are included. These details are important as it enables the reader to decide whether the article is of interest to them and to decide if they should access the whole article of not (Parahoo, 2006). Hofman et al (2008) explore the adjunctive use of water friendly immersion VR to distract the patient from their pain during burn wound debridement in the hydrotherapy tank. Each patient spent three minutes of wound care with no distraction and three minutes with VR during a single wound care session. Alternatively Van Twillert et al (2007) uses VR throughout the entire duration of the wound care session, studying its effects on procedural pain and anxiety, and compares the effectiveness of VR to that of standard care and other distraction techniques.

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Both studies use a quantative, quasi-experimental within-subject design. This type of design has no control group and no randomisation, which as LoBiondo-Wood (2006) affirm are important characteristics necessary to enhance the internal validity of a study. Therefore this design method is considered weaker than true experimental designs (Hek and Moule, 2006). Conversely Polit, Beck and Hungler (2001) defend that as nursing research often occurs in natural settings in which it can be difficult to deliver an innovative treatment randomly to some people but not to others, therefore quasi-experimental designs introduce some research control when full experimental rigor is not possible. This design problem was identified by Hoffman et al (2008) explaining that a double blind study would be impossible due to the special experimental equipment needed, therefore a within-subject design was necessary. Hoffman et al (2008) also explain that as burn centre staff administered analgesia at their discretion to patients before the intervention, a within-subject design would ensure that levels of pharmacological analgesia were the same in both the VR and control conditions during the same wound care procedure. These statements provide a sound rational for the selection of the study design. Askey et al (2007) propose to study the effectiveness of clinical hypnotic analgesia in order to gain a better understanding of the effects of hypnosis on different components of pain in a clinical setting, and compares it with an attention-only placebo for burn pain during debridement. Shakibaei et al (2008) also study the effectiveness of hypnosis on pain but also that of re-experiencing trauma in burns patients. Both studies were undertaken using quantative randomised controlled trials (RCT), considered by the Centre for Reviews and Dissemination (2001) to be the gold standard of research designs in which effectiveness of interventions are to be studied. Ellis (2010) explains that as RCT control many of the variables than a simple-experimental

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design does not, they have found favour as a source of evidence in medicine. As both studies aimed to study the effectiveness of hypnosis in the clinical setting this design was considered appropriate. Each paper includes a balanced literature review providing an impartial understanding of current knowledge on the topic (Polit and Beck, 2010). Mainly primary research is cited, important as secondary sources can be influenced by the authors perceptions and bias (Burns and Grove, 1999). However LoBiondo-Wood and Haber (2006) argue that secondary sources can provide different ways of looking at an issue or problem. Limitations of the literature are identified and used to demonstrate a clear link between the literature and the formation of the research question (Moule et al, 2003), concurrent with Polit and becks (2010) opinion that literatures reviews in quantative study can help to shape research questions, contribute to the argument about the need for a study and also suggest appropriate methods to aid the development of a theoretical framework. Each study states that informed consent was obtained from participants and ethical approval gained by all but one study. Unfortunately Van Twillert et al (2007) make no mention of ethical committee approval, which Burns and Grove (1999) explain is essential before research can be undertaken as their role is to determine that ethical principles are being applied and that the rights of individuals are being adhered to. Despite this, Van Twillert et al (2007) have incorporated strategies to monitor side effects throughout the intervention in order to protect the participants from physical and psychological harm (Hek and Moule, 2006). Participants were assured that if they experienced any side effects the intervention would be interrupted immediately, thus demonstrating non-maleficence (Parahoo, 2006). In contrast Hoffman et al (2008) propose to assess nausea to identify the incidence of simulator sickness sometimes associated with VR but make no indication as to whether the intervention would be stopped if this arose.

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The issue of potential deception or as defined by Burns and Grove (1999), violation of the right to self-determination, arises in the study by Shakibaei et al (2008) whereby the control group were unaware that the intervention group were receiving hypnotherapy, staff were informed of the blind nature of the study but not the participants. This lack of full disclosure is described by Polit and Beck (2010) as deception as the researcher has deliberately withheld information about the study and therefore can be problematic ethically as it interferes with the participants right to make truly informed decision regarding participation. However Polit and Beck (2006) state that some researchers believe that if the study involves minimal risk to subjects and there are anticipated benefits to society, then deception may be justified. Shakibaei et al (2008) state that patients were told that their records would be used in a research study, but give no assurances of confidentiality being maintained. Cormack (2000) advises that during the course of data collection researchers may be told much that is confidential, therefore must give assurances of confidentiality and anonymity. Ryan et al (2007) stipulate that it is the duty of the researcher to do so. Each paper clearly describes the target population with a clear inclusion and exclusion criteria. The limitations of using probability purposive sampling techniques have been highlighted by Hoffman et al (2008) and Askay et al (2007) who identify selection bias in recruitment procedures. Parahoo (2006) explains that although the researcher sets inclusion criteria a judgement still needs to be made about whom to include or exclude, concluding that the use of random allocation could have avoided this. Also all of Hoffman et als (2008) sample were male, thus making it difficult to generalise the findings. However, they conclude that no correlations were found between reduction of pain ratings and patient variables such as sex. Yet a sample size of only eleven would be

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unlikely to yield results of significance. Parahoo (2006) explains that if a sample is too small, it may fail to detect that an experimental intervention is more effective than the conventional one. Thus suggests the use of power calculation to determine the size of sample necessary to confirm or reject correlation or causal relationships between variables. This method was adopted by Shakibaei et al (2008) who state that a sample size of twenty-two subjects per group was planned with power set at ninety percent. To minimise systematic bias Askay et al (2007) and Shakibaei et al (2007) randomly assigned subjects to either intervention or control group with the use of a randomisation table. Therefore any bias, which may occur, will do so by accident as a result of chance (Hek and Moule, 2006). To control variables within the sample, Hoffman et al (2008) randomised the order in which the control condition and the treatment condition were administered, so that each had an equal chance of occurring first or second for each patient. Thus controlling the extraneous variables such as analgesia administered pre-treatment, therefore ensuring that the intervention is the only variable responsible of the outcome (Burns and Grove, 2007). Data collection procedures are clear, with the use of a variety of visual analogue and graphic related scales utilised. (As listed in appendix C). A rational for instrument selection has been offered with reference to research stating the reliability of the instruments chosen. This adds rigor as Burns and Grove (1999) emphasise that for a quantative study to be rigorously conducted it must have precise measurement tools. LoBiondo-Wood and Haber (2006) maintain that the success of a study depends on the data-collection methods chosen and employed. Stating that the process the researcher goes through to evaluate and select the instruments to measure variables is of critical importance to the potential success of the study.

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A clear explanation and justification of appropriate data analysis methods were presented by three papers, however Hoffman et al (2008) gave no explanation or rational for statistical analysis. As this is a quantative, quasi-experimental study, inferential statistics would normally be used to measure relationships and differences between variables (Ryan et al, 2007). Valente (2003) states that inferential statistics allow the reader to draw cause and effect conclusions, hence relate the findings to the target population. To rule out threats to validity such as the possibility that the results could be due to chance, all levels of probability were set below P 0.05 , thus providing statistical significance, which Ellis (2010) explains can provide the reader with confidence in the research findings. Valente (2003) clarifies that as the risk of chance diminishes confidence in the results increases. However as Hoffman et al (2008) do not disclose the amount or to whom pre-treatment analgesia was given it is difficult for the reader to ascertain the influence of medication on the results. The use of a Pearsons Correlation test to measure the relationship between the amount of analgesia given before the intervention and pain scores, would aid transparency and ensure rigour by avoiding bias, which Parahoo (2006) describe as the greatest threat to reliability and validity of the data. Each paper provides an objective presentation of the findings using tables, graphs and diagrams to facilitate readability, which LoBiondoWood and Haber (2006) describe as typical to quantative studies. Results were not manipulated to favour particular findings, with negative results clearly displayed. Possible limitations of both the findings and study design were acknowledged and implications for future research identified. The results of these studies provide strong evidence to support the adjunctive use of VR or Hypnosis as procedural pain was clinically significantly reduced. The findings will be further compared and contrasted within discussion in chapter four.

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3.3: Does the use of virtual reality and hypnosis result in reduced medication consumption for pain relief by adult burns patients? Three studies were selected to answer this question, as within their study design medication consumption was recorded when VR or Hypnosis were used adjunctively with standard pharmacological interventions. Wright and Drummond (2000) investigated the therapeutic effect of rapid induction analgesia (RIA) on procedural pain, anticipatory anxiety, relaxation levels and medication consumption. RIA is a hypnotic technique introduced by Barber (1977) which is used for the treatment of pain. The study by Patterson et al (2006) uses VR technology to make hypnotic analgesia less effortful for patients undergoing painful wound-care procedures, and to increase the efficiency of hypnosis by eliminating the need for the presence of a trained clinician. Also Berger et al (2010) whose study focused on the impact of a pain protocol using hypnosis on pain intensity, anxiety, clinical course and costs. Each paper clearly identifies the topic under investigation, defining procedural pain as a significant problem for the burns patient as complete analgesia is rarely attained, even when large doses of opioids are prescribed (Wright and Drummond, 2000; Berger et al 2010). This provides a good argument for the importance of the problem to clinical practice (Valente, 2003). The aims of each study are clearly defined with the research questions developed directly from the problem (Hek and Moule, 2006). All three studies used quantative research methodologies but include different design elements. Wright and Drummond (2000) propose to investigate the therapeutic effect of the independent variable hypnosis on several dependant variables including pain and medication consumption, therefore a RCT is considered appropriate. Patterson et al (2006) utilises a quasi-experimental design measuring the variable pre and post intervention and then compares the results. A

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weakness of this design is that there is no control group to compare a placebo or standard care to the outcome; therefore the results may have occurred regardless of the effects of the intervention (Ellis, 2010). However Parahoo (2006) advocates that quasi-experiments cannot establish cause-and-effect relationships with certainty, but they can establish strong links. In addition there was no random assignment to the allocation of subjects also no strategies to control extraneous variable such as subject bias; whereby the researcher may have assigned those more likely to respond positively to the new intervention to the experimental group (Parahoo,2006). Therefore the use of a RCT may have produced more credible results that are attributed to the intervention itself rather than other factors (Parahoo, 2006). Nonetheless as the intention of the study was to determine if an innovative approach to hypnosis was worthy of more formal investigation the design methodology was considered appropriate. Berger et al (2010) undertook a combination of an evaluative study to evaluate the impact of a pain protocol using hypnosis, an experimental design to establish the effectiveness of using hypnosis during wound care, and a retrospective study to gather data from patients admitted before the policy was implemented thereby creating a historical control. By using mixed methods the study demonstrated the use of method triangulation, a technique which Polit, Beck and Hungler (2001) advocate to enhance credibility, as it distinguishes true information from information that may have errors. Patterson et al (2006) and Berger (2010) include a literature review that cite a breadth of relevant and current research; however many of the references used by Wright and Drummond (2000) are over ten years old, therefore considered out-dated (Valente, 2003). However Ryan et al (2007) explain that there are exceptions to this, for example areas where there is a lack of research, advocating that the inclusion of some historical as well as contemporary material can put the subject being studied into context. The review by Patterson et al (2006) is balanced and not biased as conflicting evidence is clearly presented, using these

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findings to provide rational and direction for the research (Hek and Moule, 2003). Each paper states that Institutional Ethics Committee approval was obtained, with Wright and Drummond (2000) and Patterson et al (2006) stating that informed and written consent were gained from the participants. Berger et al (2010), however state that the study was conducted with the patients oral consent. Burns and Grove (2009) advise that when an oral consent is gained from a subject a witness is required, and a written summary of what is to be said should be approved by an institute review board. These details were not disclosed by the author leaving them open to criticism of potential coercion. There are also concerns as to the participants capacity to give informed consent, especially as the sample were patients with burns injuries severe enough to be admitted to Intensive care, therefore could be in acutely unwell and susceptible to delirium (Girard et al ,2008). To defend this argument delirium was part of the exclusion criteria with each patient assessed by an experienced psychiatrist prior to hypnosis. The authors used a non-probability convenience sample, described by Hek and Moule (2006) as the weakest sampling technique due to the potential for bias such as the over or under-representation of portions of the target population. This is demonstrated in the study by Patterson et al (2006) whereby all but one of their sample were male, despite being offered to both sexes. The author justifies this by explaining that the majority of burns patients are male, typically a 4:1 ratio. The sample size of Patterson et al (2006) was small for a quantative study, but acknowledges the limitations of this and recommends future studies with larger samples. Drop-out rates were identified and justified by Patterson et al (2006) and Berger et al (2010). Only Wright and Drummond (2000) use random sampling, with Patterson et al (2006) and Berger et al (2010) highlighting the lack of randomisation as a limitation to their study design. Stating that a RCT would have controlled the influence of potential historical factors, thus

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cannot definitively say that reductions in pain, anxiety and medication were attributable to the hypnotic intervention as opposed to the course of time. Data collection procedures are clear and appropriate to answer the question (Hek and Moule, 2006). Berger et al (2010) use a retrospective design to collect data for their historical control group, which Parahoo (2006) explains can limit accuracy as the researcher is relying on data that was probably not originally collected for research purposes, therefore lacks the rigour with which research is carried out. Wright and Drummond (2000) performed a feasibility study to determine whether induction was effective when RIA was given before showering, thus ensure that the circumstances were conducive to effective data collection (Valente, 2003). Polit and Beck (2004) explains that undertaking a small-scale test can ascertain whether a proposed approach is appropriate. In this case difficulties with communication were identified and the study design changed. Data analysis procedures were only clearly explained by Berger et al (2010) with proposed statistical tests matching the data and clear evidence of statistician input, thus adding validity. However to rule out threats to validity each study uses inferential statistical tests to identify if the relationship or difference between variables is statistically significant (Ryan et al, 2007). Thus allowing the reader to draw cause and effect conclusions and relate the sample to the target population (Valente, 2003). To test changes in medication intake Wright and Drummond (2000) performed Wilcoxons matched-pairs signed-ranks test for ordinal data, a non-parametric approach considered appropriate by Polit and Beck (2010) as these tests are used when data distribution can be skewed. In this case it was necessary because of potential ceiling effects in

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patients who took large quantities of medication and because some patients requested no medication at all. Patterson et al (2006) used a non-parametric Spearman Rho correlations test to measure the relationship between hypnotisability scores and the change in pain scores. Hek and Moule (2006) consider this an appropriate test as it shows how strong the relationship is a between variables, however as the sample size is small it was unable to demonstrate a statistically significant association. Each paper clearly presents their findings, with each study reporting a reduction in pain scores resulting in reduced medication consumption. However each study has limitations in their design methodology which may affect the validity of their findings, thus making it difficult to conclude that the results were directly due to the intervention or policy as opposed to other variables. These findings and limitations will be discussed further in chapter 4.

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CHAPTER 4 DISCUSSION This chapter will draw appropriate conclusions from the studies reviewed, critically analyse the implications of their findings and discuss their application to clinical practice. Gaps in knowledge will be identified and recommendations for future research will be made.

4.1: Do all adult burns patients experience unsatisfactory levels of pain relief during routine wound care procedures? Each of the studies verify that burns patients do experience increased levels of pain during wound care procedures, with patients describing their experiences as excruciating, the worst pain imaginable and similar to torture (Yuxiang et al, 2011; Tengvall et al, 2010). Therefore suggesting that the experience is both physically and psychologically distressing, findings which are comparative to previous studies by Choiniere et al (1989), Esselman et al (2006) and Patterson et al (2006) in which pain after burns is identified as a major clinical problem. However the study by Carrougher et al (2003) discovers that the majority of patients perceive that no pain during wound care is an unrealistic goal, with 58% - 70% of patients reporting that they would be satisfied even if they experienced procedural pain levels of 1-6 on a 10point GRS, therefore demonstrating a willingness to accept some level of pain. In support of this hypothesis, Byers et al (2001) observed that patients procedural pain was slightly lower than their acceptable level of pain despite increased pain scores, therefore they could be considered to be satisfied with levels of pain relief. Nevertheless despite these contradictory findings, which may be due to study limitations as detailed in chapter 3, they do highlight themes and contextual factors which contribute to patients dissatisfaction of pain management, and therefore have implications for clinical practice. Such

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issues include inconsistencies in pain assessment, a lack of education resulting in misconceptions on the part of patients and health care professionals, and elements of nursing practice which contribute to increased levels of pain. These potential barriers are also identified by Summer et al (2007) who suggest that perhaps it is time to stop insisting that burn pain is a very difficult type of pain to treat and question if we are doing the very best to treat it? This suggestion is particularly poignant as Carrougher et al (2003) found that worst procedural pain is often fleeting and associated with unexpected painful events such as nurses tugging on adhered dressings, staple removal and sharp debridement of healthy tissue, therefore recommends that care providers attempt to prevent these events during future dressing changes. In order to address these problems and reduce the discomfort of wound-care, Hanafiah et al (2008) suggest; soaking dressings prior to removal, changing the type of dressing as some dressings are more painful than others to remove, allowing sufficient time for analgesia to work before commencing procedures, and creating a supportive environment in which painful procedures are performed in an unhurried manner. This is particularly crucial as Yuxiang et al (2010) found that if the first dressing change evoked extreme anxiety and emotional distress, these responses are likely to increase over time and may lead to long-term pain management problems. Other nursing practices found to exacerbate pain in burns patients are identified by Tengvall et al (2010) in which daily activities such as bed making create waves of pain that continue for some patients throughout the day. Suggesting that nurses need to be mindful of creating pain, and continually communicate with patients during care to assess their pain and the impact of their practice. Yuxiang et al (2010) suggests that addressing patients concerns regarding pain before nursing interventions can greatly relieve anxiety and improve compliance, with patients reporting that they wanted to be taken seriously regarding their interpretation of their pain and request that their pain be continually

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assessed during care. This view is also consistent with the finding of a study by Choiniere et al (1989) in which the differences between patients and nurses assessment of pain and medication efficacy were compared. Equally in the study by Yuxiang et al (2010) it has also been evident that both patients and health care providers misconception about the use of opiates may have contributed to some of the negative results and could be regarded as a barrier to pain management. Thus education is required regarding addiction and tolerance as there is no evidence that addiction occurs more often in burn patients than in other populations requiring opioids for acute pain (Latarjet and Choiniere, 1995). Furthermore although burn pain is a unique and complex challenge for all health care professionals and patients, these findings highlight areas of clinical nursing practice that could be improved to ultimately increase patient satisfaction and improve pain management. Our fundamental goal should be to give pain control a high clinical priority, through comprehensive training, education and support evolving best practice.

4.2: Are non-pharmacological interventions such as virtual reality and hypnosis effective at reducing procedural pain experienced by adult burns patients? Each of the studies affirms that daily wound care provokes substantial amounts of pain which pharmacological analgesics alone are often inadequate to control. Therefore advocate the adjunctive use of VR or hypnosis to distract patients from their pain during wound care. In the studies by Hoffman et al (2008) and Van Twillert et al (2007) the findings present a strong argument for the effectiveness of VR, with pain scores significantly reduced when VR was used compared to standard care without distraction. Hoffman et al (2008) reported a drop from a severe 7.6 to a moderate 5.1 during wound care, with patients

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that reported the strongest illusion of going inside the VR world demonstrating the greatest analgesic effects, with a drop from a severe 7.2 to a mild 3.7 during VR. These findings are mirrored by Van Twillert et al (2007) who report that 13 out of 19 patients reported reductions in pain greater than 33% when using VR and those participants which responded well to VR attaining a reduction of 56%. However, not all patients seem to benefit from VR as demonstrated by Hoffman et al (2008) who identify that participants whose presence ratings were below mean, showed no significant reductions in pain ratings. Indicating that absorption levels were key to its success, a theory considered by Maani et al (2011) who question if stimulus intensity may be an important determinant of whether and when distraction will occur, explaining that as a painful stimulus reaches an intense level, it will attract attention and therefore impede the effectiveness of distraction. Nevertheless Hoffman et al (2008) dispute this argument as 6 patients with the highest worst pain scores still showed a 41% reduction in pain during VR. The studies by Askay et al (2007) and Shakibaei et al (2008) both demonstrate that hypnotherapy can be effective in reducing pain, with the hypnosis groups showing significantly lower pain ratings than the control group. This significant reduction in pain from baseline to postintervention is consistent with the finding of similar studies by Wright and Drummond (2000) and Frenay et al (2001). However its effectiveness also appears to be dependent on absorption levels, with absorption increasing with more hypnosis sessions, suggestive of a cumulative effect as demonstrated by Jenson and Patterson (2005) in which the effects of hypnosis were increased and longer lasting with more sessions. This phenomenon has also been found to be true for VR whereby Hoffman et al (2001) found that the effects of VR were increased with multiple treatments. Therefore, despite promising reductions in pain ratings, before these potentially costly and time consuming interventions can be routinely incorporated

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into practice, a better understanding of the variables which predict the success of VR and hypnosis are needed. A theory supported by De Jong et al (2007) who advocate that in order to select an appropriate non-pharmacological intervention the assessment of individual patient characteristics such as coping style and locus of control are needed. As VR is largely dependent on extensive equipment and hypnosis requires the additional cost of a trained professional, is it feasible for every clinical area to have costly alternative therapies incorporated into practice? Are there alternative cost effective distraction techniques that nurses can utilise to improve the patient experience, such as watching television or listening to relaxing music? Both of which have been found to be effective at distracting the patients attention away from the procedure and decrease their perception of pain and anxiety. This was demonstrated by the findings of Van Twillert et al (2007) who reported that 50% of participants showed >33% reduction in pain during television distraction and Tan et al (2010) who found that music therapy significantly decreased the acute procedural pain, anxiety and muscle tension levels associated with daily burn care.

4.3: Does the use of virtual reality and hypnosis result in reduced medication consumption for pain relief by adult burns patients? Studies in which medication consumption was measured when nonpharmacological interventions were used adjunctively, do report reduced levels of pharmacological analgesia requirements. Wright and Drummond (2000) found that medication consumption was reduced in the Hypnosis group but not the control group, with paracetamol reduced from 2400mg to 1267mg and codeine reduced from 116mg to 64mg, during the twenty-four hour treatment period. In addition it was found that analgesic requirements decreased several hours after hypnosis, suggesting that the therapeutic effects of Hypnosis persisted after treatment. These findings are consistent with earlier studies by Patterson et al (1992) and Patterson et al (1997).

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Despite these encouraging results it was also found that the decrease in ratings correlated significantly and positively with absorption scores, thus indicating that the greater capacity for absorption, the larger the decrease in pain rating at post-burn and consequently additional analgesic requirements. Therefore, consistent with the findings of Hoffman et al (2008) and Van Twillert et al (2007), indicates that not every participant was able to benefit from the intervention. Encouragingly Patterson et al (2006) recognise this dilemma, explaining that as considerable concentration is required to selfgenerate the scenarios used in an induction and to imagine the objects cued by a hypnotist, patients experiencing significant pain, or those having taken strong analgesics may not benefit, as they are only able to exert limited amounts of cognitive effort, thus achieving incomplete absorption. As a consequence their study introduced VR technology to make hypnotic analgesia less effortful for patients and increase its efficiency. The results from this study are promising with a 50% reduction in opiates given before, during and immediately after wound care; a much greater decrease than demonstrated by Wright and Drummond (2000) and Askay et al (2007) in which traditional hypnosis was studied. Therefore it could be concluded that VR hypnosis could potentially be attractive for use with patients struggling with absorption and as a consequence aid in the reduced need for pharmacological analgesia. The study by Berger et al (2010) also reported that the procedural opioid Fentanyl and sedative Propofol requirements were strongly reduced after introduction of hypnosis compared to a historical control group. However as their study was to assess the impact of a pain protocol including hypnosis, a protocol introduced to change clinical practice and to standardise pain management, it questions if a historical control from before implementation of a new protocol could really be considered a true control, as nursing practice may be different. In particular a computer system to display pain levels and opioid doses was introduced to make pain visible on the screen which facilitated

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ease of continual pain assessment. Also opioid rotation was introduced when increasing doses of opiates resulted in unsatisfactory analgesia or over sedation. Therefore it cannot be concluded that these reductions in medication consumption were as a direct result of the inclusion of hypnosis or as a consequence of improved opioid efficiency and improved pain management practices. Therefore, despite encouraging evidence that the adjunctive use of non-pharmacological interventions can result in reduced medication consumption in adult burns patients, to improve procedural pain management practice this must include a cycle of care tailored to the individual patients needs, and involve; continual assessment, prompt analgesia, and regular evaluation of care plans, incorporating both pharmacological and non-pharmacological interventions to ensure both physiological and psychological aspect of pain are addressed. 4.4: Future research These results support additional research to identify variables which predict the success of VR and hypnosis, new knowledge which could be used to identify individual patients suitability for these interventions, and may help to address the problems faced by some patients with regard to limited absorption or hypnotisability. As these results find favour with using distraction as a means of diverting the patients attention away from the pain stimulus, research to develop simple cost effective methods and techniques which could be incorporate into everyday nursing practice could be beneficial to help patients cope during painful wound-care procedures, and improve the patient experience. More research is needed with regard to the feasibility of incorporating VR or hypnosis into practice, assessing the initial cost of implementation against potential savings due to improved patient outcomes, such as a reduction in the need for skin grafting, anaesthesia and shorter hospital stays.

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Word Count: 8793 REFERENCE LIST Askay, S.W., Patterson, D.R, Jensen, M.P and Sharar, S.R.,(2007). A randomized controlled trial of hypnosis for burn wound care. Rehabilitation Psychology, 52 (3), pp.247-253. Barber, J. (1997). Rapid induction analgesia: a clinical report. American Journal of Clinical Hypnosis. 19, pp.138-147. Berger, M.M., Davadant, M., Marin, C., Wasserfallen, J., Pinget, C., Maravic, P., Koch, N., Raffoul, W. and Chiolero, R.L., (2010). Impact of pain protocol including hypnosis in major burns. Burns, 36, pp.639-646. Burns, N. and Grove, S.K., (1999). Understanding nursing research. 2nd ed. Saunders: Philadelphia. Burns, N. and Grove, S.K., (2007). Understanding nursing research building an evidence-based practice. 4th ed. Saunders Elsevier: Missouri. Burns, N. and Grove, S.K., (2009). The practice of nursing research appraisal, synthesis and generation of evidence. 6th ed. Saunders Elsevier: Missouri. Byers, J.F., Bridges, S., Kijek, J. and LaBorde, P., (2001). Burn patients pain and anxiety experiences. Journal Burns Care Rehabilitation, 22 (2), pp.144-149. Carrougher, G.J., Ptacek, J.T, Sharar, S.R., Wiechman, S., Honari, S., Patterson, D.R. and Heimbach, D.M., (2003). Comparisons of patient satisfaction and self-reports of pain in adult burn-injured patients. Journal of Burn Care Rehabilitation, 24, pp.1-8. Carrougher, G.J., Ptacek, J.T., Honari, S., Schmidt, A.E., Tininenko, J.R., Gibran, N.S., et al. (2006). Self-reports of anxiety in burn-injured hospitalised adults during routine wound care. Journal of Burn Care & Research, 27, pp.676-681.

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Caldwell, K., Henshaw, L. and Taylor, G., (2005) .Developing a framework for critiquing health research. Journal of health, social and environmental issues, 6 (1). pp. 45-54. Centre for Reviews and Dissemination (CRD) (2001). Understanding Systematic Reviews of research on effectiveness. 2nd ed. University of York: CRD. Choiniere, M., Melzack, R., Girrard, N.,Rondeau, J. and Paquin, M., (1990). Comparison between patients and nurses assessment of pain and medication efficiency in severe burn injuries. Pain, 40, pp.143-152. Choiniere, M., Auger, F. and Latarjet, J., (1994). Visual analogue thermometer: a valid and useful instrument for measuring pain in burned patients. Burns, 293, pp.229-235. Choiniere, M., Melzack, R., Rondeau, J., Girard, N. and Paquin, M.J., (1989). The pain of burns: Characteristics and correlates. Journal of Trauma, 29, pp.1531-1539. Cormack, D.,(2000). The research process in nursing. 4th ed. Blackwell Publishing:Oxford. Creswell, J.W., (2003). Research design: qualitative, quantative and mixed methods approaches. Thousand Oaks, CA: Sage Publications. Critical Appraisal Skills Programme (CASP) (2012) Available from: http://www.phru.nhs.uk/Pages/PHD/CASP.htm [Accessed 20.01.2012] Dauber, A. Osgood, P.F., Breslau, A.J., Vernon, H.L. and Carr. D.B., (2002). Chronic persistent pain after severe burns: a survey of 358 burn survivors. Pain Medicine, 3, pp.6-17. De Jong, A.E.E., Middelkoop, E., Faber, A.W. and Van Loey, N.E.E., (2007). Non-pharmacological nursing interventions for procedural pain relief in adults with burns: A systematic literature review. Burns, 33, pp.811-827.

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Ellis, P., (2010). Understanding research for nursing students. Learning matters:Exeter. Ellis, P., (2010).Evidence-based practice in nursing. Learning matters: Exeter. Ely, C. and Scott, I., (2007). Essential study skills for nursing. Elsevier: Edinburgh. Esselman, P. C., Thombs, B. D., Magyar-Russell, G., & Fauerbach, J. A. (2006). Burn rehabilitation: State of the science. American Journal of Physical Medicine & Rehabilitation, 85(4), pp.383-413. Frenay, M.C.,Faymonville, M.E., Devieger, S., Albert, A. and Vanderkelen, A., (2001). Psychological approaches during dressing changes of burned patients: A randomised study comparing hypnosis against stress reducing strategy. Burns,27 (8), pp.793-799. Girard, T.D., Pandharipande, P.P. and Ely, E.W. (2008) Delirium in the intensive care unit. Critical Care, 12 (3) S3 Hanafiah, Z., Potparic, O. and Fernandez, T., (2008). Addressing pain in burn injury. Current Anaesthesia & Critical care, 19, pp.287-292. Harandi, A.A., Esfandani, A. and Shakibaei, F., (2004). The effect of hypnotherapy on procedural pain and state anxiety related to physiotherapy in women hospitalised in a burn unit. Contemporary Hypnosis, 21 (1), pp.28-34. Hek, G. and Langton, H. (2000). Systematically searching and reviewing literature. Nursing Research,7 (3), pp.40-57. Hek, G. and Moule, P., 2006. Making sense of research:An introduction for health and social care practitioners. 3rd edn. Sage Publications:London. Hoffman, H.G., Patterson, D.R., Carrougher, G.J. and Sharar, S.R., (2001). Effectiveness of virtual reality-based pain control with multiple treatments. Clinical Journal of Pain, 17 (3), pp.229-235.

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Hoffman, H.G., Patterson, D.R., Magula, J., Carrougher, G.J., Zeltzer, K., Dagadakis, S., (2004). Water friendly virtual reality pain control during wound care. Journal of Clinical Psychology, 60, pp.180-195. Hoffman, H.G., Patterson, D.R., Seibel, E., Solanti, M., Jewett-Leady, L. and Saharar, S.R., (2008). Virtual reality pain control during burn wound debridement in the hydrotank. Clinical Journal of Pain, 24, pp.299-304. Jensen, M.P. and Patterson, D.R. (2005). Control conditions in hypnotic-analgesia clinical trials: challenges and recommendations. International Journal of Clinical Experimental Hypnosis,53(2),pp.170 197 Latarjet, J. and Choiniere, M., (1995). Pain in burn patients. Burns, 21 (5), pp.344-348. LoBiondo-Wood, G. and Haber, J., (2006). Nursing research methods and critical appraisal for evidence-based practice. Mosby Elsevier:Missouri. Maani, C.V., Hoffman, H.G., Morrow, M., Maiers, A., Gaylord, K., McGhee, L.L. and DeSocio, P.A., (2011). Virtual reality pain control during burn wound debridement of combat related burn injuries using robot like arm mounted VR goggles. The Journal of Trauma injury, infection and critical care, 71 (1), pp.125-130. Moule, P., Pontin, D., Gilchrist, M. and Ingram, R. (2003) Critical appraisal framework. Available from: http://hsc.uwe.ac.uk/dataanalysis/critframe.asp [accessed 21.01.2012] Parahoo, K., (1997). Nursing research principles, process and issues. Macmillan Press Ltd: Basingstoke. Parahoo, K.,(2006). Nursing research: principles, processes and issues.2nd ed. Palgrave Macmillan:Basingstoke.

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Patterson, D.R., Everett, J.J., Burns, G.L. and Marvin, J.A., (1992). Hypnosis for the treatment of burn pain. Journal of Consulting & Clinical Psychology, 60, pp.713-717. Patterson, D.R. and Ptacek, J.T., (1997). Baseline pain as a moderator of hypnotic analgesia for burn injury treatment. Journal of Consulting & Clinical Psychology, 65, pp.60-67. Patterson, D.R., Tinninenko, J. and Patacek, J.T., (2006). Pain during burn hospitalisation predicts long term outcome. Journal of Burn Care & Research, 27 (5), pp.719-726. Patterson, D.R. and Jensen, M.P., (2003). Hypnosis and clinical pain. Psychology bulletin, 26,pp.495-521. Patterson, D.R., Wiechman, S.A., Jensen, M. and Sharar, S.R., (2006). Hypnosis delivered through immersion virtual reality for burn pain: A clinical case series. International Journal of Clinical Experimental Hypnosis, 54 (2), pp.130-142. Perry, S., Heidrich, G. and Ramos, E., (1981). Assessment of pain by burns patients. Journal of Burn Care & Rehabilitation, 2, pp.322-327. Perry, S., (1984). Undermedication for pain on a burn unit. General Hospital Psychiatry, 6, pp.308-316. Polit, D.F. and Beck, C.T., (2004). Nursing research principles and methods. 7th ed. Lippincott Williams and Wilkins: Philadelphia. Polit, D.F. and Beck, C.T., (2010). Essentials of nursing research appraising evidence for nursing practice. 7th ed. Lippincott Williams and Wilkins: Philadelphia. Polit, D.F., Beck, C.T. and Hungler, B.P., (2001). Essentials of nursing research methods, appraisal and utilization. Lippincott:Philadelphia. Porter, J. and Jick, H., (1980). Addiction rare in patients treated with narcotics. New England Journal of Medicine,302:123.

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Ptacek, J.T., Patterson, D.R., Montgomery, B.K. and Heimbach, D.M., (1995). Pain, coping, and adjustments in patients with burns: Preliminary findings from a prospective study. Journal of Pain Symptom Management, 10 (6), pp.446-455. Richardson, P. and Mustard, L., (2009). The management of pain in the burns unit. Burns,35, pp.921-926. Ryan, F., Coughlan, M. and Cronin, R. (2007). Stept-by-step guide to critiquing research part 2: Quantative. British Journal of Nursing, 16 (12), pp.738-744. Shakibaei, F., Harandi, A.A., Gholamrezaei, A., Somoei, R. and Salehi, P.,(2008). Hypnotherapy in management of pain and re-experiencing of trauma in burn patients. International Journal of Clinical and Experimental Hypnosis, 56 (2), pp.185-197. Summer, G.J., Puntillo, K.A., Miakowski, C., Green, P.G. and Levine, J.D., (2007). Burn injury pain:The continuing challenge. Journal of Pain, 8 (7), pp.533-548. Tan, X., Yowler, C.J., Super, D.M. and Fratianne, R.B., (2010). The efficacy of music therapy protocols for decreased pain, anxiety, and muscle tension levels during burn wound dressing changes: A prospective randomised crossover trial. Journal of Burn Care & Research, 31, pp.590-597. Tengvall, O., Wickman, M. and Wengstrom, Y., (2010). Memories of pain after burn injury-The patients experience. Journal of Burn Care and Research, 31, pp.319-327. Valente,S., (2003). Critical Analysis of Research Papers, Journal for Nurses in Staff Development, Vol. 19 (3), pp.130-142. Van Loey, N.E.E., Maas, C.J.M., Faber, A.W. and Taal, L.A, (2003). Predictors of chronic post-traumatic stress symptoms following burn injury: results of a longitudinal study. Journal of Traumatic Stress, 16 (4), pp.361-369.

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Van Twillert, B., Bremer, M. and Faber, A.W., (2007). Computergenerated virtual reality to control pain and anxiety in pediatric and adult burn patients during wound dressing changes. Journal of Burn Care Research, 28, pp.694-702. Walliman, N. and Appleton, J., (2009). Your undergraduate dissertation in health and social care. Sage Publications: London. Wilder-Smith, O. and Arendt-Neilsen, L., (2006). Post-operative hyperalgesia; its clinical importance and relevance. Anaesthesiology, 104, pp.601-607. Wright, B.R. and Drummond, P.D., (2000). Rapid induction analgesia for the alleviation of procedural pain during wound care. Burns, 26 (3), pp.275-282. Younger, P., (2004). Using the internet to conduct a literature search. Nursing standard, 19 (6), pp.45-51. Yuxiang, L., Lingjun, Z., Lu, T., Mengjie, L., Xing, M., Fengping, M., Jing, C., Xianli, M. and Jijun, Z., (2011). Burn patients experience of pain management: A qualitative study. Burns, 38 (2), pp.180-186.

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Appendix A : Search Strategy


Electronic Databases Relevant to Health and Social Care Selected to Search Allied and Complementary Including occupational therapy, Medicine (AMED) physiotherapy and other related areas. Applied Social Sciences Includes subjects related to social Indexes and Abstracts (ASSIA) welfare, social policy and social work. British Nursing Index (BNI) Information about nursing, midwifery and community health care, mainly from UK journals. Cumulative Index of Nursing Includes nursing and health care. and Allied Health Literature (CINAHL) Cochrane Library Systemic reviews of health care evidence. EMBASE Peer-reviewed journals covering international biomedical literature. Including pharmacology, pharmaceuticals, science and clinical research. Health Management Includes a wide range of nonInformation Consortium clinical topics such as hospital (HMIC) policy, administration and management, inequalities in health and user involvement. MEDLINE/Pubmed Medicine and health care. PsycINFO Psychology database covering psychological aspects of illness and treatment, psychiatry and child development. It includes abstracts of journal articles, books and dissertations.

Hits Burn* or thermal Burn* or thermal and nonKeyword Searches pharmacological Burn* and pain Burn* and Pain and Nonpharmacological Burn* and Pain and Nonpharmacological not Children Burn* and Pain and Nonpharmacological not children and Hypnosis Burn* and Nurse* Burn* and Nurse* and Hypnosis Burn* and Nurse* and Hypnosis and research Burn* and Pain Management Burn* and Procedural Burn* and Procedural and nonpharmacological Burn* and Virtual reality Burn* and Rapid induction analgesia Burn* and procedural pain Burn* and nursing intervention Hypnosis and research Hypnosis and research and procedural pain and Procedural pain and patient satisfaction Undertreated and procedural pain Nurs* and Procedural pain Debridement and pain procedural Management and Procedural pain Management and Procedural pain and Nursing intervention RTC and Procedural pain RCT and Burn* and Procedural Pain 262896 45 487 7803 1863 1840

Refined with topic hits Nurses 10 Adult - 12 Virtual reality - 2 Pain associated with dressing change - 2 Nursing care 2 Pain - 27 Care - 11

1817

5173 1819 1817 3642 2193 1835 1994 23 2015 2272 6520 61 342 6 219 3 572 18

Pain - 29 Pain - 7 Burn pain - 3 Virtual reality 12 Wound treatment and pain regimes - 2 Further research 3 Burn pain - 16 Pain control during 15

Pain - 27 Pain - 49

Pain management 16 Burn pain - 15

184 14

Pain relief during - 4

46

Appendix B Critical Appraisal Framework for both Quantative and Qualitative Research
Topic Purpose Critique Is the knowledge already sought? Are the potential outcomes of the study realistic? Was the researcher(s) appropriately qualified/supported to undertake the research? Are there any concerns about any funding? What is the topic under investigation? Is the problem clear, precise and well defined? Does it match the purpose? Is it current and important to nursing? Is the problem appropriate and feasible for research? Are all the research questions and hypotheses developed directly from the problem? Is a good argument made for the importance of the problem to clinical practice, research, theory or knowledge and policy development? Citations include relevant and current research. Was there a search strategy with named databases and key search terms? Was the review balanced and not biased? Was the literature critically appraised? Was any conflicting evidence clearly presented? Did the literature review provide rational and direction for the research? Were any limitations of the literature identified? Inde x no 1 2 3 4

Problem

5 6 7 8 9 10

Significance

11

Literature review

12 13 14 15 16 17 18

47 Does the study have ethical approval? Are there any concerns about any funders of the research in relation to the process of the research described? Can the subjects give consent and understand the study? Is there clear evidence that the participants gave informed consent? Was there any coercion in recruiting participants? Did the research place unethical or unrealistic demands on participants? Were the participants protected from physical and psychological harm? If the participants were vulnerable, has this been clearly considered in the study? Were any governance issues dealt with appropriately? Are minorities excluded without a solid rational? There is clear evidence that privacy, dignity, anonymity and confidentiality were maintained throughout the study. Was the design of the study appropriate to the research questions? Would another design have been better? What are the limits of the design? Interventions and controls are described in detail. Was an appropriate sampling strategy used? Target population is clear and described appropriately. Eligibility or exclusion criteria, recruitment and sampling procedures are clear. Was a convenience or random sample used? If a random sample was selected, was it genuinely random? 19 20 21 22 23 24 25 26 27 28 29

Human Subjects/Ethics

Method/Researc h Design Interventions Sample

30 31 32

33

34 35 36 37 38 39 40 41

48 Sample size is appropriate. Did any of the sample drop out, and why? Were any biases in the sample group identified? The reliability and validity of instruments are cited, the rational for these instruments is clear and convincing. Limits to the instruments are clear. (e.g. Will the instruments gather the data needed?) 42 43

Instruments

Data Collection

Was an appropriate method of data collection used? Data collection procedures are clear. How many times were data collected? Will the data answer the question? Was the data collected by appropriate people? Data collectors are trained, reliable, and accurate. Circumstances of data collection were conductive to data collection (e.g. Confidentiality). Did the researchers minimise any risks stress, distress, or burden to subjects? Was the issue of deception dealt with appropriately in observational studies? Was the researchers role and relationship with the participants fully considered? Were the data authenticated in qualitative studies? Procedures match the research question, design and data collection. Statistical tests match the data and hypothesis. Was there evidence of data lost? Was there evidence of a statisticians input into complex Quantative analysis?

44 45 46 47 48 49 50 51 52 53

54 55 56 57

Data Analysis

49 Results are clear, complete and identified; they answer the research questions. Were the results and analysis linked back to the original research question? Were the results and analysis manipulated in order to favour particular findings? Results are compared and contrasted with other research findings. Conclusions and recommendations accurately reflect the data. No unwarranted conclusions or interpretations are made. Was the sample selected considered in relation to recommendations? Did the researcher acknowledge any limitations? Were limitations of the findings of the study identified, as well as limitations of the study design and techniques? Implications for practice, research and theory are discussed. 58 59 60

Results

Discussion Conclusions, Recommendatio ns, Limitations and Implications

61 62 63 64 65 66 67

Adapted from: Valente,S (2003) Critical Analysis of Research Papers, Journal for Nurses in Staff Development, Vol. 19 (3): 130-142. Hek,G and Moule,P (2006 ) Making sense of Research: An introduction for health and social care practitioners. London:Sage

Index numbers are used to reference (alongside the text) areas of the research papers that correspond to the questions being asked. Written in green for a strength and red for a weakness. This will assist assimilating the key points to analyse and evaluate within the Critical Review of the Literature and Discussion sections of the Dissertation.

Question 2: Appendix C : Question 1: Are non-pharmacological interventions such as virtual reality and levels of pain relief during routine wound care Do all adult burns patients experience unsatisfactory hypnosis effective at reducing procedural pain experienced by adult burns patients? procedures? Topic Topic

50 Study 3 Study 1 Study 2 Study 4 Study 5 patients Study pain after burn Study of Study 8 Burns Memories of6 Comparisons 7 patients Burns patients pain and Anxiety Virtual reality pain control during Computer generated virtual satisfaction and self-reports trial of Experiences. A randomized control of Hypnotherapy in management experience of pain injury the patients burn wound debridement in theexperience.to control pain and reality hypnosis for burn wound care. USA of pain and re-experiencing of management: A pain in adult burn injured patients. hydrotank. anxiety in paediatric and adult trauma in burn qualitative study. Sweden USA USA Byers et al (2001) patients. USA burnet al (2010) patients during wound Carrougher et al(2003) Askay et al (2007) Iran China Tengvall Hoffman et et al (2011) dressing changes. Shakibael et al (2008) Yuxiang al (2008) Netherlands Problem: Pain is Problem: Pain after burns is a Hypothesis: Problem: Van Twillert et al (2007) undertreated. major clinical problem, Patients satisfaction with pain Poor management of pain can Problem Problem: Problem: Problem: Problem: researchers report that burn management plans would be contribute to patient discomfort, and Most burns-injured patients rate There have been few randomised The healing and prolonged is Problem Purpose: to gain an pain Changing daily wound dressings is undertreated. highest among those patients that delayed pain from burn injuries Purpose their pain during debridement as provoke a substantial amountexperienced the least pain and of controlled studies on the complex and challenging. The understanding of the hospitalisation. and severe to excruciating. of pain in describe burn traumatic nature of burns patients experience Purpose: To patients with severe burn among patientsof clinical hypnotic also effectiveness whose Purpose wounds. Pharmacological analgesia. accidents can precipitate pain management and to patients experiences and experiences most closely matched Purpose: Purpose: factors analgesics alone are inadequate treatment analgesic goals. acute stress patients pain identify memories of pain during burn their To examine burn symptoms of To responsible for explore the adjunctive use of Purpose: nightmares, flashbacks, care to solve this problem. to acquire a deeper and anxiety experiences during water friendly immersion reality To improve on previous hyper-arousal and undertreated pain. understanding of how patients resting conditions and sleep to distract patients from their copePurpose: experience. methodologies and gain a better disturbances. with the procedures. The relationship of pain during burn wound To explore whether immersion understanding of the effects of contextual factors and debridement in the hydrotherapy VR can reduce procedural pain hypnosis on different Purpose: interventions to pain and anxiety tank. and anxiety during an entire components of pain in the clinical To examine the effects of were also explored. wound deeper hypnosis on both pain and reTo establish effective To acquire acare session and compare setting. pain intensity is Assessment of Through better understanding of VR to the of the of standard paramount to determining experiencing of trauma in pain management understanding effects patients burns patients pain and anxiety, Significanc care and other distraction burns patients. guidelines and issues of importance when treatment effectiveness. as well as association of e methods. during and after recommendations for providing care contextual factors and The majority of patients with a burn injury most burn patients Because Burn injury is one of the most interventions with pain and It is important to manage pain clinical practice. burns severe enough to require experience severe pain during painful injuries a person can adequately strategies for Significa anxiety, improveto obtain best hospitalisation report severe to wound care that cannot be endure, with subsequent wound pain possible outcomes. Therefore and anxiety management nce excruciating pain during wound controlled completely with opioid debridement more painful than can be identified. further integrating care, despite medication with Citations relevant and the most Citations relevant and the most analgesics, non-pharmacologic the initial injury. There are pharmacologic and nonCitations relevant and the Citations relevant and the most powerfulcurrent analgesics. opioid available. techniques that can be used in limitations to opioid analgesia, current available. Provided pharmacologic interventions most current available. Provided current available Literature addition to analgesic with unwanted side effects. are necessary for an Provided rational and rational and direction for drugs are rational and direction for effective review necessary. Frequency of necessary treatment plan direction for research. research. Limitations of lit research. debridement precludes Limitations of lit identified. anaesthesia. With an increased identified. Ethical approval. Ethical approval. Ethicalmandated focus on poor pain Ethical approval. approval. control there is increased focusInformed consent gained. Written consent given Human on hypnosis and other nonNo mention of consent or Written informed consent obtained Confidentiality maintained. Subjects/Et after verbal and written pharmacological techniques as info given Reassurance of confidentiality during or after by study research nurse. hics adjuncts to pain management. confidentiality. Right to study. Citations include relevant and Citations include relevant and Citations include relevant and Citations include relevant and discontinue at any time. most up to date research. most No rational given. most up to date research. Lit Literatur most up to date research. Lit Qualitative phenomenological Lit Quantative. up to date research. Lit A prospective, descriptive Qualitative review provided rational and approach used. review provided rational and review provided rational and design. review provided rational and e review Phenomenological Method direction for used. direction for the research. direction for the of adult direction for the research approach the research. A convenience sample research. Research Limitations of previous research Limitations of the previous Limitations of previous research Semi-structured 6-12 month post burn inpatients was prospectively Non-random sample of acutely Design identified. research identified. identified. interviews. interviews, taped and studied. In-patients undergoing burned adult patients. Oral and written consent given.transcribed verbatim. given. Informed consent Approved significant Ethical approval and written Interview guide used, burn wound careby intuitional review Institute review board approved No mention of ethical approval. board. consent obtained. Human piloted to ensure clarity enough to require opioid consent. After explanation of study of questions and follow premedication for wound care Subjects If experienced side effects pt were identified within 5 days of informed consent given. ? ethical as control group not up probes. New questions Ethics Nausea monitoredincluded assured they could stop fully aware of nature of study. developed and but no injury and asked to participate. mention of being interviews. if intervention. Only Hypnosis group were. in subsequent able to stop felt unwell.

Question 3: Does the use of virtual reality and hypnosis result in reduced medication consumption for pain relief by adult burns patients? Study 9 Study 10 Study 11 Topic
Rapid induction analgesia for the alleviation of procedural pain during burn care. Australia Wright and Drummond (2000) Problem: Burns patients must endure intense pain during their regular dressing changes. Purpose: To investigate the therapeutic effects of RIA on resting and procedural pain, anticipatory anxiety, relaxation levels and medication consumption in 30 hospitalised burn patients. Hypnosis delivered through immersion virtual 51 reality for burn pain: A clinical case series. USA Patterson et al (2006) Problem: Not every patient benefits from hypnosis, hypnotisability is related to outcome. Not every patient who might benefit has access to hypnotic analgesia. Purpose: To develop a 3D, immersive VR technology that could guide patients through the same steps used when hypnosis in induced through an interpersonal process. To make hypnotic analgesia less effortful for the patient and to increase the availability of hypnosis by eliminating the need for the presence of a trained clinician. Intent of the study was to determine if an innovative approach to hypnosis was worthy of more formal investigation. Literature finds hypnosis promising for pain relief. This method may make hypnosis more available to patients overall and more effective for those with low hypnotisability scores. Literature provided rational and direction for research. Not biased balanced, limitations identified. Ethical approval and written consent gained.

Impact of a pain protocol including hypnosis in major burns. Switzerland Berger et al (2010) Problem: Pain is a major issue after burns even when large doses of opioids are prescribed. Purpose: To measure impact of a pain protocol using hypnosis on pain intensity, anxiety, clinical course and costs, within a critical care setting.

Problem and Purpose

Significance

Literature review Human Subjects Ethics

Complete analgesia through the administration of opioid analgesics is rarely attained; thus, psychological therapy for pain management may have a role as an adjunct to opioid therapy. Citations include relevant and current research. All patients provided informed consent, approved by ethics committee. Patients informed that the study involved testing a hypnoticrelaxation technique. Quantative RCT Random allocation before baseline assessments. Pilot study conducted on 2 patients to determine whether induction was effective when RIA given before shower. This Identified limitations and research design changed so that induction should proceed after patients had completed showering and wound cleaning and before topical application of medication and new dressings.

To improve pain management protocols for burns patients.

Citations include relevant and current research. Literature provided rational and direction for research. Patients given oral consent. ? ethical is oral enough? Coercion? Capacity as acutely unwell. Institutional ethics committee approval.

Method Research Design

Quantative - mixed Experimental Uncontrolled Case clinical case series Clinical case series. No control group No random assignment. Baseline measures of pain and anxiety taken following wound care day 1 = no VR. Before wound care day 2 patients received VR hypnotic induction. Pain and anxiety

Quantative- mixed Experimental- cause and effect Evaluative- evaluating before and after policy Prospective study of historical patients as a control. Treated patients were matched with historical controls for sex, age, and burned surface area. There was no blinding of any of the participants to the on- going procedure, nor the medications. Hypnotic induction and specific suggestions

52