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CHILD LIFE SPECIALISTS’ PERSPECTIVES ON NON-PHARMACOLOGICAL INTERVENTIONS
FOR PEDIATRIC BURN PATIENTS DURING WOUND CARE
Thesis
Submitted in Partial Fulfillment
Of the Requirements for the
Degree of
Masters of Arts in Education
Emphasis in Child Life in Hospitals
Mills College
Spring 2015
By
Amanda Marie Trapp
Thesis Advisors:
________________________________
Priya Shimpi, PhD
Associate Professor of Education
________________________________ ____________________________
Linda Perez, PhD David Donahue, PhD
Professor of Education Associate Provost and Dean of Faculty
iii
Acknowledgements
This thesis would not have been possible without the support of my family, friends,
colleagues, Mills College School of Education faculty, and Child Life community. I would first
like to thank my family, especially my mom, dad, grandparents, and sister for their eternal
support and supreme confidence in my abilities. My sister, Sarah, was especially instrumental in
this process as she took on the role of my research assistance and learned how to transcribe and
code data to support the validity of my results. Additionally, I extend my sincere gratitude to my
friends and colleagues who shared in this experience and made it possible to grow, learn, and
laugh throughout this journey. I would like to especially acknowledge Mollie and Sharon, who
were by my side every step of this process, and Britta, who’s editing enhanced the quality of this
thesis exponentially.
I thank the Mills College School of Education faculty for their positivity, encouragement,
and belief in this research. This paper could not have come to fruition without the guidance of
Dr. Priya Shimpi, Dr. Linda Perez, Professor Betty Lin, and Professor Susan Marchant, all of
whom inspire me and continually push me to achieve excellence. Finally, I am grateful to the
Child Life community who not only responded to my recruitment message, but also forms the
basis for this exploratory study that seeks to give voice to Child Life Specialists supporting
pediatric burn patients. I hope that the insights disclosed in this paper will aid all those that work
in pediatric burn wound care and encourage them in their endeavors to support this unique
population.
iv
Abstract
Wound care procedures utilized to treat burns have historically been associated with high
levels of pain and distress in burn patients. At the same time, the monitoring and management of
pediatric burn patients’ pain has generally been poor (Gandhi, Thomson, Lord, and Enoch,
2010). The current study examines Child Life Specialists’ roles and perceptions in supporting
pediatric burn patients’ coping and pain management during wound care procedures. Eight Child
Life Specialists who currently work with pediatric burn patients or who have done so within the
past five years were interviewed. Results were drawn from emergent themes and suggest that
interventions geared towards education, communication, relationship, play (e.g. play during the
procedure, medical play following the procedure), timing and environment, pain management,
individual factors, and caregiver involvement influence patients’ and families’ coping with
wound care procedures. Overall, participants reported that they believe Child Life Specialists’
non-pharmacological interventions promote increased coping, pain management, and mastery
during wound care procedures for the majority of pediatric burn patients. These findings are in
line with current trends in procedure support for burn wound care and indicate a clear need to
utilize non-pharmacological, Child Life interventions to provide comprehensive, quality care to
children undergoing wound care procedures.
v
Table of Contents
Introduction 1
Theoretical Framework 3
Literature Review 7
Methods and Procedures 18
Results 21
Discussion 33
References 43
Appendix A 48
Appendix B 51
Appendix C 53
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
1
Child Life Specialists’ Perspectives on Non-Pharmacological Interventions for
Pediatric Burn Patients during Wound Care
My interest in, and passion for, working with the pediatric burn population developed
over the course of a five-week rotation I experienced this past summer during my Child Life
internship at the University of Chicago Medical Center Comer Children’s Hospital [UCMC]. I
was initially hesitant about supporting these patients due to the intense and sometimes critical
nature of their injuries. However, as my experience and comfort in developing and implementing
interventions to serve these children grew, I felt more drawn to working with these patients and
their families.
The more I engaged with this population, the more I realized their need for psychosocial
interventions. The nature of the injuries – whether the burns are due to boiling water, fire, or
frostbite – and the initial wound care experiences are often traumatic. This can leave children
particularly vulnerable to negative effects of hospitalization, such as post-traumatic symptoms
and increased anxiety. During my rotation at UCMC, I also observed that many families traveled
significant distances in order to receive wound care at a designated burn center. Several families
reported that they were not able to visit as often as they would like to due to transportation
difficulties.
Furthermore, all of the burn patients I worked with had repeated exposure to wound care.
Specifically, they had experiences with dressing changes, both at the bedside and in
hydrotherapy, and frequently with surgery, typically for the application of Biobrane, a synthetic
skin dressing, or skin grafts. I witnessed the pain that these pediatric patients endured during
various procedures, which led me to reflect on the need for support surrounding these wound
care experiences. As the patients frequently remained in the hospital for a week or longer, I
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
2
realized there were many opportunities to provide procedural support before, during,
immediately following, and in between wound care sessions.
During this internship, I observed Child Life Specialists implement interventions with
patients and families to increase coping with medical experiences and promote adjustment to
hospitalization. These included preparations for surgeries and procedures, procedural support,
and therapeutic activities such as medical play sessions. Throughout my rotation in the burn unit,
I considered which interventions were most needed by each individual child, and adapted them
accordingly. One school-aged girl in particular comes to mind when I think of providing
procedural support during her hydrotherapy sessions. She was hospitalized for burns acquired
while watching fireworks at her house on the Fourth of July, and was treated in the hydrotherapy
tub every morning leading up to her skin graft surgery. This meant that the dressings on her
wounds were removed, her burns on her legs were submerged, and then they were cleaned with a
cloth. There was one day when I entered the unit in the middle of the procedure, and she was
silently crying while gripping the sides of the tub. I considered what had been helpful in previous
hydrotherapy sessions, assessed her current needs, and planned my interventions accordingly.
With support, this patient was able to utilize deep breathing exercises we had practiced and
squeezed my hand when the wound care became excessively painful. She also engaged with
games on my iPad when the pain dulled intermittently throughout the procedure. When engaging
with the iPad, I observed that her body and face appeared to relax and her breathing became
more regular. These observations demonstrate the power of procedural support in reducing pain
and anxiety patients experience during these frequent and painful procedures. Moving forward, I
am interested in discovering what interventions Child Life Specialists frequently utilize (i.e.
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
3
preparation, distraction, relaxation) and perceive to be successful in supporting pediatric burn
patients during wound care procedures.
As I begin this research, I feel excited about discovering psychosocial interventions that
may be shared and implemented to support pediatric burn patients. While my experiences at
UCMC drive me and fuel my passion, I am also aware that they can lead to bias. For example, I
found distraction to be particularly helpful in promoting effective coping for patients during
hydrotherapy sessions. Other Child Life Specialists may or may not agree about its effectiveness,
and I need to be objective when collecting and analyzing the data. It is imperative that I
continually reflect on my past experiences in order to maintain self-awareness. Furthermore, as I
design the method by which to conduct the research, I will include measures that increase
objectivity and reduce subjectivity (e.g. use of a research assistant to compare and contrast
interpretations of the data). Utilizing past research to guide my study also supports the credibility
of my method and findings. Ultimately, the support Child Life Specialists offer is a vital element
of every pediatric patient’s care plan, and this study leaves me enthusiastic about expanding
research on support available for pediatric burn patients.
Theoretical Framework
In the following section, supporting pediatric burn patients during wound care procedures
is explored using contemporary theories. These theories include the gate theory of pain, Piaget’s
theory of cognitive development, Erikson’s theory of psychosocial development, attachment
theory, and coping theories. These theories provide a lens through which professionals can
develop interventions to support children undergoing painful procedures.
In their critical review of burn pain management, researchers Summer, Puntillo,
Miaskowski, Green, and Levine (2007) state that, “Not only is acute burn injury pain a source of
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
4
immense suffering, but it has been linked to debilitating chronic pain and stress-related disorder”
(p. 533) and “procedural pain…is the most intense and most likely to be undertreated” (p. 535).
Because pain in burn patients continues to be undertreated, it is essential that a variety of
methods of reducing associated pain and anxiety are studied (Summer et al., 2007). In order to
do this, it is important to first gain an understanding of how pain works in the human body.
According to the gate control theory of pain, sensory input is competitive. Neural
gateways allowing sensory input in may be open or closed to different degrees and may
determine whether the pain signal is inhibited or allowed to pass through the gate (Kuttner,
2010). Based on this theory, distraction techniques work through the descending inhibitory
system to close the gate and reduce the pain experienced (Kuttner, 2010). Similarly, guided
imagery, in which the child is instructed to imagine alternate scenarios, may also absorb enough
of the child’s attention to disallow the pain signals to pass through the gate (Kuttner, 2010).
Using this pain theory, Child Life Specialists – professionals trained to promote effective
coping for hospitalized children (Thompson, 2009) – use their developmental background to plan
and implement non-pharmacological interventions to be used in conjunction with medical
treatments to manage burn patients’ pain and anxiety. Developmental theories, such as Piaget’s
theory of cognitive development and Erikson’s theory of psychosocial development, can be used
to determine which interventions will be most effective for children of different developmental
levels. For example, Piaget suggests that children between zero and two years old are in the
sensorimotor stage of development (Thompson, 2009). In this stage, infants and toddlers are
exploring their world through their senses and learn by acting on objects. Thus, a Child Life
Specialist seeking to support a one year old during a painful procedure might choose a cause-
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
5
and-effect toy as a distraction tool, which will compete with the pain stimuli and, ideally, reduce
the amount of distress experienced.
Similarly, Erikson’s theory dictates that a one-year-old is in the trust versus mistrust
stage, which emphasizes the importance of consistency in caregiving (Thompson, 2009). Having
caregivers who are consistently present provides infants with the ability to trust that they will be
taken care of and that the world is safe. Attachment theory further supports parental involvement
as it describes the importance of a parental figure in providing children with a sense of safety and
security (Thompson, 2009). As a result, parental presence would be an appropriate intervention
to reduce distress for an infant undergoing burn wound care procedures.
In addition, theories on children’s coping relate to the effectiveness of non-
pharmacological interventions. Coping can be described as “constantly changing cognitive and
behavioral efforts to manage specific external and or internal demands that are appraised as
taxing or exceeding the resources of the person” (Lazaraus & Folkman, 1984, p. 141, as cited in
Thompson, 2009, p. 31). This theory suggests that children use one of two strategies to cope with
traumatic experiences: emotion-based or problem-based coping strategies (Thompson, 2009).
Emotion-based strategies are used to regulate emotional responses and may include reappraisal
of a situation, distancing, escape-avoidance, and self-control (Ercan, 2003; Thompson, 2009).
Problem-based coping strategies, on the other hand, focus on identifying and solving the
problems that are causing the stress (Ercan, 2003). Such strategies may include information
seeking, distraction, seeking social support, planful problem solving, and confronting a stressful
situation (Ercan, 2003; Thompson, 2009). Child Life Specialists are able to assess for pediatric
burn patients’ preferred methods of coping, and can use this information in conjunction with
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
6
their knowledge of developmental and pain theories to inform their practice and interventions
devised to reduce pain and anxiety during wound care procedures.
Opportunities for control are one form of problem-based coping that can support pediatric
burn patients. Theoretically, supporting pediatric burn patients in understanding their pain
triggers, what exacerbates their pain, and what helps them to reduce it can help these children
begin to develop cognitive mastery and control over their discomfort, resulting in improved
coping (Kuttner, 2010). Control can also be supported through allowing patients to partake in
their procedure. For example, patients may take off some or all of the dressings themselves with
the support of staff during dressing changes. Burn center staff can be supported in learning
hygiene modifications, such as providing patients with gloves, which allow the children to
participate in their wound care. This gives the patients increased control over the source of their
pain. By providing options for patients regarding pain management, such as distraction, guided
imagery, deep breathing, and participation, children experience an increased sense of control
(Kuttner, 2010).
The preceding theories support the efficacy of non-pharmacological treatments in
reducing pediatric burn patients’ pain and anxiety during painful procedures such as
hydrotherapy and dressing changes. Because Child Life Specialists are educated on pain, child
development, and coping theories and are trained in implementing these psychosocial
interventions, I am interested in learning about their perceptions of the effectiveness of non-
pharmacological interventions and when they should be used with children of different
developmental levels. I interviewed Child Life Specialists in order to ascertain what
interventions they believe are effective for managing pediatric burn patients’ pain and distress,
when they use those interventions, and if such techniques are used when Child Life staff are not
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
7
present. I hope that this information will be useful for supporting Child Life and hydrotherapy
staff relations and will help Child Life Specialists in advocating for these interventions for burn
patients.
Literature Review
Introduction
In the United States, approximately 250,000 children between 0 and 17-years-old
annually acquire burn injuries significant enough to require medical attention. Of those children,
around 15,000 children are hospitalized due to the extent of their burn injuries (Burn
Foundation). While the depth, size, and cause of burns may vary, all pediatric burn patients will
experience pain and the majority will be subjected to distressing procedures as their wounds are
treated. Hydrotherapy involves the use of water in the treatment of burns and serves many
purposes, including cleaning the burn surface, debriding the wounds, removing topical
treatments, and reducing wound bacterial load (Langschmidt et al., 2013). Hydrotherapy always
includes dressing changes (the removal of old bandages and application of new dressings), and
typically involves either immersion therapy, in which the patient in submerged in a tub, or
shower carts (Langschmidt et al., 2013). According to a study on North American burn centers,
83% of facilities reported regularly using hydrotherapy as part of burn wound care (Davison,
Loiselle, & Nickerson, 2010).
While hydrotherapy and dressing changes are useful and necessary in the treatment of
burns, they commonly produce significant pain in patients. This literature review examines the
current need for non-pharmacological pain management options for pediatric burn patients
during hydrotherapy sessions and dressing changes, non-pharmacological interventions proven to
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
8
reduce pediatric burn patients’ pain during procedures, and the role of the Child Life Specialist in
implementing these interventions.
The Use of Non-Pharmacological Interventions to Manage Pediatric Burn Patients’ Pain
This section addresses previous research that supports the need for non-pharmacological
interventions to reduce pediatric burn patients’ pain and anxiety during wound care procedures,
specifically hydrotherapy sessions and dressing changes. First, the history of pediatric burn
patients’ pain management is examined. Next, wound care procedures and frequency are
discussed. Finally, the scope of pain management for pediatric burn patients during wound care
procedures is briefly explained.
Gandhi, Thomson, Lord, and Enoch (2010) acknowledge that while “pain and distress are
highly associated with burns in children,” the monitoring and management of pediatric burn
patients’ pain has generally been poor (p. 1). Pain has been connected with adverse physiological
and emotional effects, including noncompliance with treatment leading to prolonged healing
(Gandhi et al., 2010), presence of trauma symptoms (Bakker, Maertens, Van Son, & Van Loey,
2013), and anticipatory anxiety related to fear of pain during impending procedures (McGarry et
al., 2013). Furthermore, evidence has been gathered to support findings that pain disrupts
neuroendrocine responses, leading to increased metabolism and altered thermoregulation,
impairs wound healing, and may reduce immune function (Henry & Foster, 2000).
Wound care for burn injuries necessitates consideration of pain management. Dressing
changes are frequently conducted multiple times per day, and hydrotherapy sessions may be
scheduled daily at the beginning of treatment. In a study on pediatric burn patients’ experiences,
children described dressing changes as, “The most painful thing [they] had ever done” and stated
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
9
that they “didn’t know the human body could experience so much pain” (McGarry et al., 2013, p.
609).
Pain in children with burns is typically managed through a variety of interventions
including pharmacologic therapies and complementary therapies. Pharmacologic therapies may
involve anesthesia, opioid analgesics, and non-opioid analgesics (Henry & Foster, 2000), while
complementary therapies typically include education, distraction, relaxation, cutaneous
stimulation, acupuncture, biofeedback, hypnosis, imagery, cognitive, and behavioral techniques
(Gandhi et al., 2010). Complementary therapies may also be referred to as non-pharmacological
interventions. Because they have been found to significantly reduce procedural pain, anxiety, and
distress, non-pharmacological interventions should be used in conjunction with the
pharmacologic therapies (Summer et al., 2007). Studies show that interventions that “reduce in-
hospital distress may accelerate and improve both physical and psychosocial recovery” of burn
patients (Summer et al., 2007, p. 536). This is especially critical due to the frequency of the
procedures and the intense levels of pain and distress described by pediatric burn patients.
Non-Pharmacological Interventions
In the current section, empirically-based non-pharmacological interventions are described
in support of pain management by reducing the emotional (i.e. anxiety) pain associated with
hydrotherapy sessions and dressing changes. The three stages of non-pharmacological
interventions and timing of the interventions for burn wound care are briefly described, and then
a synthesis of current literature on each stage is examined individually.
Non-pharmacological interventions can be broken into two primary stages during
hydrotherapy sessions: psychological preparation prior to and following the procedure and
procedural support. Both stages are intended to reduce patients’ pain, distress, and anxiety
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
10
surrounding the procedure. These components should be initiated as early as possible in patients’
recovery process to reduce procedural pain and its adverse effects (Henry & Foster, 2000;
Richardson & Mustard, 2009). Furthermore, the monitoring of pain should be accurately
measured and efforts to manage it should be continuously implemented (Gandhi et al., 2010).
Preparation. Preparation is noted as the first step in supporting pediatric patients during
stressful procedures (Stephens, Barkey, & Hall, 1999). In this section, the need for and benefits
of preparation is examined. According to Stephens et al. (1999), it is important to explain to
children the importance of the stressful procedure, what they can expect during the procedure,
and what their role will be during the procedure. Two sources of discomfort for pediatric burn
patients involve fear and the unknown, both of which can be addressed through education and
preparation (Henry & Foster, 2000). Because the fear of being hurt is one of the greatest fears
among children (Slaw, Stephens, & Hall, 1986), preparation is essential in providing pediatric
patients with information. This education gives pediatric burn patients cues regarding what kind
of pain they will experience, how much pain they may experience, and how long they will
experience pain. This further supports them in knowing when they will no longer be in pain,
creates an opportunity for children to ask questions, and allows discussion regarding how
children would like to cope with anticipated pain. Research by Lazarus and Folkman (1984)
states that “uncertainty about any aspect of the elements involved in an invasive procedure can
limit the child’s ability to develop any effective control and thereby increase feelings of
helplessness and stress” (Stephens et al.,1999, p. 227). Preparation, therefore, serves to eliminate
this uncertainty and promote control and mastery over invasive procedures such as hydrotherapy.
McGarry et al. (2013) reports that pediatric burn patients found their first dressing
changes, to be especially traumatizing. The children in this study reported feeling “worried,”
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
11
“nervous,” and “scared” because they did not know what was going to happen during the
procedure (McGarry, 2013, p. 610). It is often during this initial dressing change that the patients
first see their burn wounds, and one child stated that he had not expected the burn to look “ugly”
(McGarry et al., 2013, p. 610). Through education, children can be prepared for visual, auditory,
and tactile sensations they are likely to experience.
In a study on pediatric burn patients between three and ten years old, Multi Modal
Distraction [MMD], a device with preparation videos, interactive games, and touch-and-find
stories, was utilized to reduce children’s pain and distress surrounding their first dressing change
post-burn injury (Miller, Rodger, Kipping, & Kimble, 2011). Participants were provided with
either a combined protocol of preparation and distraction during the procedure using MMD or
standard distraction during the procedure. Findings suggest that patients using the combined
MMD protocol experienced less pain and distress than did the control group (Miller et al., 2011).
The researchers explain that previous studies demonstrate the benefits of education and
procedural support. Namely, that preparation alleviates misconceptions, informs children about
what to expect during the procedure, and provides some sense of control over what may happen
to them (Miller et al, 2011). As will be discussed further in the following section, distraction
provides additional support to these patients as it diverts their attention away from the painful
and often fear-invoking stimuli they are subjected to during wound care (Miller et al., 2011).
Preparation can also be implemented following procedures such as hydrotherapy and
dressing changes. In this context, preparation serves to support children in “preparing a memory”
(Solnit, 1984, as cited in Thompson, 2009) for the next wound care procedure. Debriefing
following procedures that will be repeated can reduce exaggerated memories of the procedure,
and patients may experience a reduction in anxiety in subsequent procedures (Chen, Zeltzer,
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
12
Craske, & Katz, 1999, as cited in Thompson, 2009). This post-procedural preparation process
was found to be especially beneficial for younger children (Chen, Zeltzer, Craske, & Katz, 2000,
as cited in Thompson 2009).
Procedural support. Following preparation interventions, procedure support should be
available to pediatric patients to provide continuity of care and reduction of pain and distress.
The management of patients’ pain during procedures, especially recurring procedures, is
imperative for reducing adverse effects such as increased anxiety, decreased rehabilitation
compliance, and re-traumatization of the patients. A variety of non-pharmacological techniques
have been studied to support their use for helping burn patients of all ages during dressing
changes. Some interventions have been studied in adult burn populations, such as relaxation and
hypnosis, and others have been specifically researched in pediatric burn populations, such as
cognitive-behavioral techniques (i.e. distraction) and parental presence. Each of these forms of
procedural support are described in the following paragraphs.
The relaxation process supports children in entering a “gradually deepening state of rest
characterized by increased feelings of warmth and comfort” (Kuttner, 2010, p. 189). Research
shows that adult burn patients using jaw relaxation techniques (Fakhar, Rafii, & Orak, 2012) and
using breathing relaxation techniques experienced reduced anxiety and pain during dressing
changes (Park, Oh, & Kim, 2013). Though it has been found to be effective with adults, further
research with children is needed to understand the effects of relaxation techniques on pediatric
burn patients’ procedural pain and anxiety. Despite this gap in the literature, several studies find
relaxation techniques to be helpful in pain management for pediatric patients experiencing
abdominal pain or painful procedures in general (Brent, Lobato, & LeLeiko, 2009; Power,
Liossi, & Franck, 2007; Uman, Chambers, McGrath, & Kisely, 2008, as cited by Kuttner, 2010).
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
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This research supports the effectiveness of relaxation as a non-pharmacological intervention for
pediatric patients in pain. Future research is needed to bridge the research gap and provide
insight on relaxation techniques for pediatric burn patients.
Likewise, multiple studies have revealed the benefits of hypnosis on supporting the adult
burn population. According to Kuttner (2010), hypnosis is “an altered state of consciousness,
achieved through a narrowing of attention and focused concentration” (p. 53). Hypnosis is a
helpful adjunctive in reducing patient anxiety and pain intensity and improving opioid efficiency
and wound outcome (Berger et al., 2009). Two other studies by Frenay, Faymonville, Devlieger,
Albert, and Vanderkelen (2001) and Askay, Patterson, Jenson, and Sharar (2007), suggest that
patients’ anxiety before and during dressing changes was reduced when hypnosis was employed.
While younger children are not cognitively able to utilize hypnosis and imagery techniques,
studies have shown that children five years old and older are able to use these techniques to cope
with invasive procedures (Kuttner, 1989; Olness & Gardner, 1978, as cited by Stephens et al.,
1999). Although further research is needed to study the effects of this intervention on pediatric
burn patients in reducing anxiety and pain, Kuttner (2010) maintains that children are “highly
responsive to hypnosis and can be trained to use self-hypnosis for injuries and many illnesses”
(p. 54).
In addition, cognitive-behavioral techniques have been studied in regards to supporting
children during painful procedures. This may involve various forms of cognitive tasks, such as
distraction. Distraction can be described as “the active diverting of the child’s attention…
inviting the child to shift attention onto a chosen, interesting, and more pleasant physical object
than the painful procedure” (Kuttner, 2010, p. 154). In addition to the research on Multi-Modal
Distraction, a form of distraction called augmented virtual reality has been demonstrated to be an
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
14
effective tool in reducing children’s pain during dressing changes (Mott et al., 2007). Augmented
reality involves projecting virtual reality images onto the physical world, which were displayed
on a screen in Mott’s study of pediatric burn pain management. The sensory cues (visual,
auditory, and touch) were shown to provide cognitive distraction for the patients 3 to 14 years
old, which appeared to significantly reduce their pain more than standard distraction and
relaxation alone (Mott et al., 2007).
As the experts on their children, parents can provide professionals with insights into the
most effective tools for helping children manage their pain. While not all caregivers are able to
provide procedural support, their presence may have a positive impact on supporting pediatric
patients during painful procedures such as hydrotherapy and dressing changes. According to
Bauchner, Waring, and Vinci (1991), parents regularly request to be present when their child was
undergoing a procedure (Stephens et al., 1999). Caregivers are able to support their children
using distraction, guided imagery, and other techniques. Furthermore, a study by Ross and Ross
(1984) revealed that 99 percent of nearly 1000 children ranging from five to twelve years old
believed having a parent present would be the most helpful if they were in the worst amount of
pain, even if they did not believe the parents could reduce the pain (Stephens et al., 1999).
Caregivers are also able to provide valuable information about their children; they are able to
support medical staff in assessing, observing, and interpreting their children’s symptoms,
behaviors, and responses (Kuttner, 2010).
Based on the studies described above, procedure support techniques reduce pain and
distress during burn wound care procedures in the pediatric population. However, as has been
noted, pediatric burn patients’ pain has historically been poorly managed, and wound care
procedures demonstrably cause intense pain for the pediatric burn patient population. Thus, non-
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
15
pharmacological procedure support techniques should be used in conjunction with
pharmacological aids in order to effectively manage patients’ pain during wound care
procedures.
Communication. When supporting children before, during, and after painful procedures
such as hydrotherapy and dressing changes, it is important to utilize communication techniques
in order to effectively respond to their distress. In this section, the importance of responses to
children in pain is described with emphasis on word choice and methods of acknowledging pain.
Kuttner (2010) describes several appropriate responses to children in pain, including:
demonstrating empathy in a professional, practical manner; explaining in a developmentally
appropriate manner the processes taking place in the child’s body; acknowledging the pain;
explaining the steps that are or will be taken to reduce the child’s pain; and, as the healthcare
professional, keeping yourself calm. These techniques have been found to be supportive in
aiding children’s coping abilities when in pain (Kuttner, 2010). Furthermore, Kuttner (2010)
notes that it is essential that soft but clear language is utilized with children, so as to reduce
confusion (i.e. I.V. may be construed as “ivy”) and increased anxiety surrounding medical
experiences (i.e. “Your burn is smaller than…” as opposed to “Your burn is as big as…”).
Through these responses to children’s pain, pediatric patients are shown that adults are aware of
children’s experiences and are able to bear witness to their suffering while providing clear
explanations and support to manage the pain.
In addition, a natural and automatic response to pain is crying (Kuttner, 2010). Crying is
a means of expression, and may be necessary to help the child cope. It is not, however, useful to
tell a child “It’s okay to cry” prior to the child crying, as this could convey that the procedure
would be so painful that the child should cry. Rather, providing honest descriptions of what to
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
16
expect, while allowing the child to create his or her own description during and following the
procedure, would be most helpful (Kuttner, 2010).
Research has shown that certain forms of communication with children in a hospital
setting can increase anxiety. According to studies by Chorney et al. (2009) and McMurtry,
Chambers, McGrath, and Asp (2010), caregiver and healthcare professional empathy and
reassurance during procedures are associated with higher levels of child distress and decreased
coping, while humor and distraction are correlated with lower levels of distress and increased
coping. The implication of these findings is that specific choice of language can communicate to
children different messages, and repeated reassurance may actually indicate to them that they
need to be concerned about the impending procedure.
Based on this research, the importance of communication between health care
professionals and children undergoing painful procedures cannot be emphasized enough. As
children are undergoing hydrotherapy and dressing changes, it is essential that professionals
communicate with children in a purposeful and intentional manner so as to effectively
acknowledge their experiences and promote positive coping.
The Role of the Child Life Specialist in Hydrotherapy and Dressing Changes
There is a clear need for increased management of pediatric burn patients’ pain during
wound care procedures, and non-pharmacological interventions and intentional communication
techniques play a significant role in reducing pain and distress during these procedures. This
section examines the role of Child Life Specialists in implementing these interventions and
supporting this population.
Researchers agree that a multi-disciplinary approach to managing pediatric burn patients’
pain is essential in providing high quality care (Gandhi et al., 2010; Henry & Foster, 2000;
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
17
Richardson & Mustard, 2009). Child Life Specialists are professionals trained to address the
psychological, social, and intellectual needs of pediatric patients in medical settings (Bandstra et
al., 2008). A Child Life Specialists primary function is to reduce the impact of stressful and
anxiety-provoking experiences within medical settings, which often takes the form of preparation
and procedural support for painful and invasive procedures (Bandstra et al., 2008). A survey
finds that Child Life Specialists report receiving training in non-pharmacological techniques
such as providing preparation and information, therapeutic play, and medical play. Child Life
Specialists in this study endorse preparation, reassurance, and positive reinforcement when
supporting children in pain, which they believe to be effective in reducing children’s pain
(Bandstra et al., 2008).
Because research shows that reassurance can actually decrease children’s coping
(Chorney et al., 2009; McMurtry, Chambers, McGrath, & Asp, 2010), further research is needed
to understand how Child Life Specialists currently utilize reassurance and the effects this
technique has on children in pain. Furthermore, research is specifically needed to understand
how Child Life Specialists support pediatric burn patients before, during, and after hydrotherapy
and dressing changes. The developmental knowledge needed to assess children’s coping and
plan interventions makes Child Life Specialists ideal candidates for implementing non-
pharmacological techniques. Their training allows them to provide developmentally appropriate
interventions for patients undergoing wound care procedures. Kuttner (2010) proposes that Child
Life Specialists are among the healthcare professions who may be trained to guide children’s
hypnotic experiences intended to reduce pain and anxiety during procedures. Using their
knowledge of children’s development, coping, and importance of relationships, Child Life
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
18
Specialists are able to individualize interventions to support pediatric burn patients’ pain
management during hydrotherapy and dressing changes.
Conclusion
When combined with pharmacological analgesics, non-pharmacological interventions are
supportive of pediatric burn patients’ pain management and anxiety reduction during wound care
procedures. Child Life Specialists are professionals who work in medical settings and are
specially trained in implementing non-pharmacological interventions. Research is currently
needed to understand the role Child Life Specialists play in supporting pediatric burn patients
during these procedures, and the perceived effectiveness of these interventions in combatting
patients’ pain and anxiety. This explorative study examined Child Life Specialists’ perceptions
of their use of non-pharmacological techniques, communication styles, and the effectiveness of
interventions in supporting this vulnerable population.
Methods and Procedures
The current study provides insight into the ways in which Child Life Specialists support
pediatric burn patients during wound care procedures and the self-perceived effectiveness of the
interventions. Theoretical and empirical research suggests that non-pharmacological
interventions are effective in reducing pain and distress during these procedures when used in
conjunction with pharmacological treatments. Given their background and training in child
development, coping, preparation, and procedural support, Child Life Specialists are ideal
administrators of these non-pharmacological interventions. This research focused in particular on
Child Life Specialists’ perspectives on their experiences in supporting pediatric burn patients
during hydrotherapy and dressing changes. Due to the lack of literature describing Child Life
Specialists’ role with this population, this exploratory study extends the current understanding of
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
19
how these professionals work with the medical team to manage children’s pain and anxiety
during burn wound care.
Participants
Participants in this study included eight female Child Life Specialists who work with
pediatric burn patients and support them during wound care sessions. All participants were
employed as Child Life Specialists working with pediatric burn units currently or within the past
five years (1/1/2009-12/31/2014). The average length of time the participants worked with
pediatric burn patients was 39.75 months (range: 5 – 108 months). The participants worked at six
different hospitals located in California, Florida, Ohio, Colorado, Pennsylvania, and New York.
Six of the interviews were conducted via recorded phone call, and two were conducted via email
questionnaire. For the purposes of the current study, IRB approval was obtained prior to
recruitment, there was no discrimination on the basis of age, gender, or socio-economic status,
and all participants were recruited through the Child Life Forum operated by the Child Life
Council. Data was collected between January 8, 2015 and February 12, 2015. Detailed
participant and patient population characteristics are described in Table 1, found in Appendix B.
Materials and Procedures
Interviews were semi-structured, qualitative in nature, and constructed to gain deeper
insight into Child Life Specialists’ experiences in supporting pediatric burn patients during
hydrotherapy sessions. Guiding questions were used to provide some structure to the interviews,
and participants were asked follow-up and clarification questions based on their responses.
Questions were primarily open-ended and focused on the roles Child Life Specialists fill during
wound care sessions, their views of children’s coping during these procedures, and how they
support pediatric burn patients prior to, during, and following these procedures. Interviews
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
20
gathered through phone calls were approximately 40 minutes and recorded on the researcher’s
phone for data collection. See Appendix A for a list of guiding questions.
Coding and Analysis
Data was transcribed and analyzed, and conclusions were based on emergent,
exploratory, inductive analysis of the interview data using descriptive data analysis and coding
(Merriam, 2009). This study is qualitative and exploratory in nature, and gives voice to Child
Life Specialists who work with a highly specific group of patients and families. Although the
results will not be generalizable due to the qualitative design, repeated themes or ideas between
respondents were identified and analyzed to convey the participants’ experiences in and
perspectives on supporting pediatric burn patients during hydrotherapy and dressing changes.
Validity
In order to minimize personal biases towards the topic, including beliefs in the benefits of
non-pharmacological interventions and understanding of child development and coping theories,
the researcher’s thesis supervisor, research assistant, and critical friends group reviewed the data
coding and interpretation to promote reliability and validity. Furthermore, the questions asked of
interviewees were open-ended to promote objective gathering of data. All questions were derived
from a review of current literature and piloted on peers within the critical friends group. All
participant data were kept in a secure location, which was only accessible to the principal
investigator and project research assistant. The participant database, coded data, and all other
electronic data were kept on a password-protected computer to which only the principal
investigator had access. All data were kept for a period of 7 years, after which it may be
destroyed. No names or potentially identifying information were attached to the data; instead,
participant codes were randomly assigned.
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
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Results
This study examined eight Child Life Specialists’ perspectives on supporting pediatric
burn patients through the use of non-pharmacological interventions during wound care
procedures, specifically dressing changes and hydrotherapy sessions. Throughout the interviews,
it was apparent that each Child Life Specialist [CLS] individualized her interventions to align
with each child’s and family’s specific needs. Emergent themes suggest that interventions geared
towards education, communication, relationship, play (e.g. play during the procedure, medical
play following the procedure), timing and environment, pain management, individual factors,
and caregiver involvement influence patients’ and families’ coping with wound care procedures.
Specific tools and techniques participants reported using during wound care procedures to
support pediatric burn patients’ coping can be found in Figures 1 and 2 located in Appendix C.
Examples include using tools such as bubbles, vibration, books, and televisions, and techniques
such as relaxation and breathing techniques. A table is also included to demonstrate tools
available to wound care staff when Child Life Specialists are not present, as many participants
reported that Child Life staff do not work in the evenings when many dressing changes occur
(see Figure 3 in Appendix C). Overall, participants reported that they perceive that Child Life
involvement in wound care procedures supports increased coping for pediatric burn patients
during hydrotherapy sessions and dressing changes. As stated by Participant 5, “It’s the reason
we’re there, it’s to help minimize the trauma that [pediatric burn patients] experience and to
maximize their coping abilities and strength… Anytime we’re involved in procedures, that’s our
goal, less stress and anxiety and optimize coping.”
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Education
All participants discussed the role of education in wound care procedures. Education was
described as geared towards patients (when developmentally appropriate) and caregivers, and
was reportedly implemented before, during, and after procedures. Education for caregivers will
be discussed in the section focusing on caregiver involvement.
Participants frequently noted that they felt unable to prepare children and families prior to
the first wound care procedure. This is related to the emergent nature of the injury, incompatible
work hours (e.g. patients were admitted overnight when Child Life Specialists were not present),
and lack of availability at the time of admission (e.g. the CLS was working with another family
and unable to arrive at the procedure in time for preparation). When they are able to prepare
children and families, participants reported utilizing tools and techniques including preparation
books, medical play, dolls and stuffed animals, bandages and medical equipment used during
dressing changes, Medkin Dolls, iPads, and verbal explanations. One Child Life Specialist stated
that the hospital she worked at was developing an iPad application that focused on preparation
and would likely include dressing changes. Participants described preparation sessions as useful
for providing children and families with expectations for the procedure, normalizing the medical
materials, and creating coping plans for managing pain management. Participants further
explained:
We’re actually working on developing an electronic educational book that has…
features of burns…how they heal, [and] typical interventions. (#4)
When I prepare children for a dressing change I do discuss pain and how to help
manage it. If you don’t prepare the child for the discomfort they will not be able
to harness the coping strategies to help ameliorate the pain and distress they are
feeling. If you tell them what they are likely to feel and then give them a strategy
to help with that sensation or feeling they feel much more empowered to cope
through the dressing change. (#8)
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23
Education was reported not only to be implemented during preparation sessions, but also
during wound care procedures. Participant 4 explained, “We do a lot of education throughout, so
especially the school aged kids that we’re working with, we are able to…educate them on their
skin, and how the body heals, and the medication we use and let them ask questions [during the
breaks].” Furthermore, education has been used to reinforce the reason for the procedures and to
help alleviate misconceptions. Participant 5 stated that she explains to children, “This is why
we’re doing this. I know you don’t like it, but this is why it’s important,” and Participant 6 stated
that she would use “medical play with [the patients] afterwards just so they could understand…
why the dressing changes were happening even if they got very upset during them just to… make
sure they didn’t feel it was punishment or anything.” Some participants shared that they
continued the education after the procedure: “I do a lot of processing afterward and medical play
to make sure the children don’t have any misconceptions or worries after going through the
dressing change, hearing what the RN and MD have to say, and seeing their wounds” (#8).
Communication
All participants spoke to the importance of language in working with pediatric burn
patients during wound care. Participants reassuring, comforting, and communicating with
patients through validating patients’ feelings, utilizing specific praise, reassurance, informing
them of when the procedure would end, asking questions, counting and breaking the procedure
into parts, choosing descriptive words purposefully, and protecting self-esteem. Participant 5
described the role of language in this way: “I think it’s the whole premise of therapeutic
language is that it doesn’t increase anxiety, it doesn’t increase confusion…We’re trying to
minimize the misconceptions that they have about what’s happening to them, and it gives them
language that they can relate to and cope with.”
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24
Validation, praise, and reassurance. At least half the participants in this study
described validating patients’ feelings (e.g. acknowledging that the procedure is hard and
painful, and that it is appropriate to cry), reassuring patients of the imminent conclusion of the
procedure or part of the procedure (e.g. counting down or singing a song that signified the end of
that part of the procedure), and praising the child for specific acts during the procedure.
Furthermore, they perceived increased control for patients through these verbalizations as they
reinforced for patients what was being done about the pain the patients expressed. Participants
stated that their goals in using this language was to promote control and help pediatric patients to
build the skills needed to manage and cope with the pain associated with wound care.
I do praise them for utilizing coping strategies and for holding still… I can almost always
find something specific to praise a child for and I value validating children’s feelings, but
I stay away from general reassurance and praise… It is more powerful to be specific in
your praise and give children concrete information regarding how they will know when
we are all done. (#8)
I think it helps… at the same time… it doesn’t take it all away… The hope is to kind of
help [to] build those coping strategies and to kind of help build their ability to manage
their pain a little bit more. And then kind of just like letting them know…it hurts and it’s
hard and this isn’t easy and we know we’re asking a lot of you… but you did it, and it’s
over now, and now we can… work past it. (#2)
Reassuring them that after we’re done washing everything, like, that was the worst part,
it’s all over. (#2)
Asking questions, dividing the procedure into parts, and self-esteem. Several
participants described supporting patients in verbalizing their experiences, verbally breaking
each procedure into parts, and protecting patients’ self-esteem and feelings of mastery. When
helping children to verbalize the pain they experience, participants reported asking questions
such as What hurts? How much does it hurt? and Where does it hurt? to promote understanding
of the pain and how Child Life and allied staff members can help support patients through it.
When breaking procedures into parts, participants reported that the goals included empowering
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
25
patients, making procedures more manageable, and protecting patients’ self-esteem as they
successfully got through each portion of the procedure.
When they get upset I like to identify why they’re upset, instead of…just assuming that it
hurts, or you know being able to identify what their actual need is. Sometimes they’re
crying because they’re upset and sometimes they’re crying because it hurts. Sometimes
it’s both, but letting them use that language to kind of navigate that conversation so we’re
not putting words into their mouth and kind of figuring it out from there…We do
acknowledge if it is pain… We’ll be like ‘Okay, well let’s try this to get through it.’
Because you don’t want to dismiss or invalidate their feelings or the words that they’re
using. You want to empower them to feel like they can communicate that information
and that we’re listening. (#4)
It goes back to building mastery, right? So if a kiddo feels like they were – they just
conquered a world record or something, something that they thought was totally
unfathomable, and here they just did it, so they feel like, “Okay, cool, I can do this, I can
do this again. As hard as that was, I got through it.” (#3)
The encouragement and breathing instruction helps a lot as it gives the child a knowledge
that they can get through it and are doing a great job, as well as gives them control over
something—their “job” is to breathe and count and hold my hand. With no
encouragement or breathing instructions, they get overwhelmed by the pain or anxiety
and will not stay calm. (#7)
Word choice. Almost all participants shared that they chose specific words to
communicate with children in pain either using therapeutic language or by taking direction from
the children on how they wanted to label their experiences.
We really try to cut out any… counting up, and starting from 1, but to count down. (#2)
I try not to use the word pain—but instead words like poke/uncomfortable. (#7)
A big thing that we advocate for here is trying to separate bath time from wound care.
Cause we don’t want kids going home constantly associating this pain with the bath. So
that’s also been a big challenge, is trying to get people to switch their language. Not
walking in and saying, “Okay, time for a bath!” and then you take them and it totally
traumatizes them if they’re done at the time. So that’s also been a big challenge, I would
say. (#1)
As far as other language… even like the dressing changes that we use, like the supplies, a
lot of the kids will come up with their own language, we use their form…We put
Neosporin on it and one patient just wanted to call it yellow blanket, so we called it
yellow blankets on their legs! So kind of just modeling whatever language that they’re
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
26
using and making that the standard that even then staff is like ‘Okay, it’s time for our
yellow blankets!’ and we know yellow blankets cools our burn, so then that’s a positive
thing to look forward to. (#4)
Communication barriers. One participant shared that because her population was
primarily children from Mexico, the language barrier negatively affected her ability to
communicate with her patients. The following quote highlights how communication barriers can
affect the efficacy of non-pharmacological interventions.
I think that was kind of a limiting factor in my ability to help kids cope. It was one of the
things that was the most frustrating was not being able to communicate to kids about their
pain. (#6)
Relationship
All participants described the therapeutic relationship as important to building rapport
with patients and gaining their trust. Therapeutic relationships were perceived to increase
patients’ coping during wound care and the effectiveness of Child Life interventions. Often,
participants shared that this therapeutic relationship had the strongest effect on patients’ coping
when built prior to entering wound care. Child Life Specialists in this study described building
rapport through playing with patients, educating them, and engaging with them in settings
outside of wound care. Furthermore, trust was described as central to engaging patients in
activities such as distraction, relaxation techniques, and education. Through this trust, developed
as a result of the therapeutic relationship built between the Child Life Specialist and patient,
patients were reportedly more willing to try coping techniques and continue conversations after
the procedure to improve their wound care experiences.
When I have a therapeutic relationship built with them, they trust me. During the
treatment, they focus on my distraction and education instead of on the work the nurses
are doing. They are more willing to go back in for more treatments because they know I
will be there to help them through it. (#7)
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27
You’re going to be a lot more effective if you have good rapport and a good, trusting,
therapeutic relationship with the patient and the family. They’re going to be more open to
your interventions, they’re going to believe what you’re going to say, they’re going to be
willing to engage in things that may be out of their comfort zone because you’ve built
that trust. (#5)
Play
All participants reported using play, oftentimes medical play or play as distraction, to
support children’s coping during burn wound care. Respondents described play as useful for
revealing and clarifying misconceptions, promoting coping during procedures through
normalization of the environment and distraction from distress, building trust and rapport with
patients, and helping reduce anxiety through normalization of materials and the procedure. One
participant stated, “If we can get through the tough stuff, and we can try and make everything
else a little bit easier, that’s kind of our goal, so that’s when a lot of the play comes in,” (#4) to
emphasize the role of play as procedural support. Some participants noted that play was more
helpful for younger children than older children, and others defined play differently by age group
(e.g. younger children played with toys, while older children enjoyed watching a movie of their
choice).
I think it’s effective because that’s what kids are the most comfortable with, and that’s
what they feel the most confident and proficient at. Every kid feels pretty good about
playing. So I feel like if we’re able to really like find what they enjoy, then it makes the
procedure go a lot more smoothly, and they’re able to – even if you know they’re crying
with washing when it’s really, really painful and [they’re] not engaged, we’re able to get
them re-engaged in it, you know, once they’re feeling less pain and that part’s over. (#2)
I think [play is] huge. I always tell parents when I’m talking to them that if we can trick
[patients’] brains into focusing on something else, just like our distractions, it can make a
world of difference in there… Play isn’t always the answer… but as much as we can
incorporate play, not only does it provide some sort of normalization… I think it builds
that trust. (#4)
I like do some medical play if they turn out to be pretty anxious, over time are becoming
more and more anxious, I definitely like to just try out medical play to desensitize them a
little bit to that stuff and help them express what that they’ve gone through. (#1)
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28
One participant noted that children’s abilities to play during the procedure was impacted by their
specific burns:
It depended on the extent of the dressing change and also kind of how intrusive the burn
area was, it was a lot easier I think to help kids use play as a distraction when it was, you
know, a burn on their feet versus there were often burns that were you know closer to
their field of vision, or that limited their ability to play. So when it was in their hand that
was burned it was harder to get them to engage just because of the area that they had to
work on. (#6)
Timing and Environment
All participants stated that timing affects their interventions, and that it is important that
they are able to begin their interventions prior to the start of the procedure in order for them to be
optimally effective. For example, one participant noted that she does not feel that she is able to
improve patients’ coping if their anxiety has escalated prior to her arrival to wound care. This
highlights the importance of Child Life Specialists educating wound care staff on how they can
work together to support pediatric burn patients, and how to make appropriate consults to help
the wound care go as smoothly as possible. Given this information, coordination of timing
becomes imperative for Child Life Specialists to effectively support children’s coping with
dressing changes and hydrotherapy.
If I arrive late to a dressing change and child is already in pain or anxious, it is very
difficult to calm them down. Distraction and/or education needs to be done at the
beginning until the end. (#7)
Trying to catch them after [the procedures has] already started… the kid’s already upset,
it’s really, it’s a lot more difficult for us to try to get them back into good coping skills or
distraction or any type of prep. (#2)
We often get called down to whirlpool like it’s happening, and the kid, you can hear them
in the background just freaking out. Like ‘Oh can you come down?’ I used to, but I
realized how ineffective it was, and now I won’t go. I’ll tell them I’ll use some
techniques when they get back upstairs to try and help them cope, but…I can’t help them
at that point. (#5)
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29
Timing was also described in relation to post-procedure support. Several participants
shared that they typically returned to patients’ rooms to process and discuss wound care (e.g.
how it went, what they could do better next time) after a lapse of time (often a few hours). These
debriefing sessions were reportedly intended to empower patients to continually improve their
coping during subsequent dressing changes.
I wouldn’t usually do it right when they got back in the room, like, “So, how was that for
you?” You know? It was usually later on, just kind of recap, talk about the day, or
strategize how, what else they could do at night or the next day, or how, is there anything
else I can do? (#3)
In addition to the effects of timing on patients’ coping abilities, most participants reported
that they observed increased coping and reduced fear when wound care procedures were done in
a treatment room or away from the bedside. With the exception of certain older children who
preferred their dressing changes to be done at the bedside, or patients who were in intensive care
units (ICUs) with extensive burns, most participants reported encouraging the use of treatment or
hydrotherapy rooms to promote coping. At the same time, many participants reported a lack of
consistency in the location where wound care was conducted.
Patients who had procedures done in their bed expressed much more fear of dressing
changes than those in the treatment room. (#7)
The [patient’s] room needs to be a safe place and wound care is not a safe thing and so
that’s going to ruin it for them and they’re going to be anxious the whole time. (#1)
Participants also reported modifying the environment to support coping and returning to baseline
through attention to factors such as lighting, noise level, and comforting objects.
Especially if it’s something that’s done at the bedside, or if we were in the tub and we
walk them back to the bed, I would make sure that they were as comfortable in their bed
as possible. So if it was a baby in a crib, I’d make sure their blankets were there, I’d do
some bubbles with them, you know, put on a soft lighting, soft music, just kind of create
as much of a, you know, they just had some serious trauma, so get them back down to a
baseline. (#3)
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30
Pain Management
Several participants reported that pharmacological pain management impacted the
effectiveness of their interventions, either positively or negatively. Those participants who stated
a need for increased pharmacological pain management tended to feel that their interventions
would be more effective with added pharmacological pain and anxiety control, or stated that they
had observed increased coping with the use of pharmacological pain management. Some
participants also stated that distraction supported coping and pain management with certain
children.
I think [patients’ coping with wound care procedures]… followed their pain level, so as
their pain started to become more bearable, they could cope better, you know? And so
that’s where that whole medication piece, the pain management was always a sideline,
on-going issue… the timing of the medication, the dosages, all of those factors, it really
played a key, pivotal role. (#3)
We participate in our pain team, so we work a lot with the physicians to talk about a
better pain control… as well as trying to come up with a new tool to accurately assess
pain… [So when] it hits a certain point during a dressing change… the dressing change
needs to stop and the child needs to have more medication or we need another Plan B.
(#4)
There have been several kids that they’ve chosen to do conscious sedation at the bedside
to do wound debridement and it’s gone so well… the kids aren’t nearly as anxious,
they’re much more willing to be interactive and talk about their burns, because it’s not
such a scary thing. (#5)
We’re working on a new protocol which we’re trying to get all the first dressing changes
to be under sedation since there’s the debridement and that can be so difficult and
traumatic for kids. Because we’ve kind of noticed a pattern, which we didn’t do research
on, we probably should have, but that when they’re sedated for their first one their
subsequent dressing change went better than if they were not sedated. Because I think
they didn’t remember the first one, and then we were able to prep them I think that really
made a huge difference, that we were able to get in there, talk them through it, there
wasn’t the debridement so they didn’t have to see the blisters being popped and pulled off
and that more heavy debridement kind of more of a light wash, you know, hopefully at
that point and so I definitely see the benefit in that. (#4)
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31
These quotes highlight the role of various medications and sedation – pharmacological
interventions to facilitate pain management – in supporting children’s coping during wound care
procedures. Participants in this study perceived increased coping with collaborative forms of
pain management, utilizing both pharmacological measures implemented by the medical team
and non-pharmacological measures implemented by Child Life Specialists.
Individual Factors and Coping
Participants reported a variety of factors influencing children’s abilities to cope with
wound care procedures, including the developmental level of the child, parental anxiety,
previous medical experiences, temperament, the trauma of the injury, and daily factors (e.g.
whether or not the patient was tired or hungry). Participants described several examples of
modifying and implementing interventions throughout dressing changes to meet the unique
needs of the individual child, and communicated that different children need different levels of
involvement from Child Life over time as their wounds heal and they become more comfortable
with dressing changes. Several participants also reported increased coping when children were
allowed to help remove their dressings, which was reportedly successful with children as young
as two and half years old.
[Patients’ coping with wound care is influenced by], essentially, [everything] that took
place prior to, that either set them up for success or not… They go to an ER and just have
a bunch of things poked and prodded and they’re in excruciating pain, it’s just horrific –
mom screaming, crying, you know? It’s all those things that play. (#3)
What we essentially want for our patients to do is to cope the best that they can, given…
where their burn is, how deep their burn is, their age, and so we’re kind of considering all
those factors. (#4)
I [would] redirect the kids who were the anxious type because it tended to be a lot based
on temperament… And kids that tended to be easygoing before anything happened,
seemed to be the ones who were able to really build on their coping skills. (#6)
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
32
We can see a kid do really well for a few days, and then they have a really bad day. They
kind of just hit this point where I think they feel done and they’re frustrated and rightfully
so, especially in those younger kids that can’t fully understand or comprehend kind of
why this is happening to them. Or even the older kids just being like ‘Why… You know,
this should be done now’ or just getting frustrated with surgeries, and things like that. I
definitely think there’s a wave, and it goes up and down… If we’re wrapping and the kid
is doing well and is back to baseline, that’s a really good sign. (#4)
Caregiver Involvement
All participants described working in partnership with caregivers and many gave
examples of providing support to caregivers before, during and after wound care procedures.
Most participants stated that caregivers’ roles varied depending on how involved they wanted to
be, and that they often transitioned from providing emotional support to doing the dressing
changes themselves prior to being discharged from the hospital. Participants reported using
preparation to support parents through acknowledging and validating their feelings, providing
education about what to expect and what their roles could be during procedures, and
collaborating with parents on helping their children to cope during procedures. Furthermore,
some participants shared that parental presence can have a significant influence on promoting
positive coping in children.
Parents often have a lot of guilt, they have a really hard time actually seeing the burn for
the first time so I like to prepare [them] when I’m preparing the child. (#1)
We give them a good prep as to what to expect in the room, what their role can be, and
also kind of validating those feelings of like, understanding that it can be very
uncomfortable for them. (#2)
They have to wear the same gear that we do to be clean, to be sterile, and then they’re
allowed right at bedside, as close as they want to be, as much as they want to be involved
we encourage it, just because we have seen the benefits that it has on the children with
having them [present]. Especially with our population being typically under the age of 4,
their degree of separation anxiety is already heightened, so… we really see that if the
parents are there they tend to cope better…so we really do encourage parental
involvement. (#4)
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
33
If they’re really anxious [we try] to bring them down a little bit, and reinforcing that mom
or dad or the caregiver should hold onto them, comfort them as much as possible. (#1)
Caregiver anxiety was also described to be influential in children’s coping, and some
participants highlighted the role of supporting parents in order to promote effective coping in the
children.
Depending on the severity of the burn it can be very painful so I want them to know that
when they go [to the procedure room] that their child’s going to be crying, and these are
the things that we’re going to do to try and help them, but also try to reassure them that
typically once they get out of the water and get the wound covered, they cope very well.
(#5)
We typically do counting when we’re washing, regardless of the patient’s age, whether
it’s for the patient to engage in the actual act of counting or just I think it helps also to
give parents an idea of when the end is, because I think their anxieties are just as high as
the children. (#4)
I think that [patient] stands out to me just because it was this thing, this cycle of anxiety
and how it can feed off of itself. And I think looking backward in retrospect, probably
now I think that the work…was more with the mother and controlling her anxiety than
focusing the energy on [the patient]. (#3)
In summary, Child Life Specialists in this study reported using a variety of tools,
techniques, and collaboration efforts to support pediatric burn patients during wound care
procedures. Through implementing interventions geared towards education, communication,
relationship, play, timing and environment, pain management, individual factors, and caregiver
involvement, participants perceived that patients’ and families were better able to cope with
dressing changes and hydrotherapy sessions.
Discussion
The purpose of this study was to examine Child Life Specialists’ perspectives on non-
pharmacological interventions used to support pediatric burn patients during wound care
procedures such as hydrotherapy and dressing changes. Overall, participants reported that they
believe Child Life’s non-pharmacological interventions are effective for the majority of pediatric
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
34
burn patients at promoting increased coping and decreased anxiety during wound care
procedures. In the following sections, participants’ perspectives will be discussed in conjunction
with current research on education and procedural support, pediatric burn patients’ pain
management, and the role of the Child Life Specialist in wound care. Finally, limitations of this
study and implications for the field of Child Life will be discussed.
Procedural Support
Results of this study revealed that participants’ primary goals in working with pediatric
burn patients is to promote effective coping and provide patients with the ability to cope with
wound care procedures. Participants hoped that by the time patients were discharged from the
hospital, they and their families would have learned skills to help them cope with wound care
procedures at home. Participants reported seeking to accomplish this goal using a variety of
procedural support tools and techniques to facilitate coping, and empowering patients to use
coping skills during wound care procedures. These frequently focused on relaxation techniques,
distraction techniques, communication, education, and parent involvement. The following
paragraphs relate these findings to current literature on supporting children during wound care
and painful procedures using relaxation techniques, cognitive-behavioral techniques,
communication, education, and parental support.
Relaxation techniques. Previous studies show that relaxation techniques have been
supportive in helping children during painful procedures (Brent, Lobato, & LeLeiko, 2009;
Power, Liossi, & Franck, 2007; Uman, Chambers, McGrath, Kisely, 2008 as cited by Kuttner, L.
2010). The current study provides insight into how Child Life Specialists utilize relaxation
techniques during wound care procedures. Examples of relaxation techniques included having
the children blow pinwheels, engage in deep breathing, or practice guided imagery. The choice
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
35
of technique depended on individual factors including personal coping styles and developmental
levels. Participants’ responses revealed that they believe these techniques to be helpful for
supporting pediatric burn patients’ coping during dressing changes and hydrotherapy sessions.
Cognitive-behavioral techniques. All participants reported frequently using cognitive-
behavioral techniques, specifically distraction techniques, to support coping during wound care
procedures. These techniques were reported to be especially useful for younger children.
Participants described these techniques and play opportunities during wound care as effective in
capturing children’s attention when their pain intermittently subsided and was not at its peak.
Furthermore, some participants perceived distraction techniques as helpful in reducing children’s
experiences of pain as they attended to objects and activities other than the dressing change and
hydrotherapy session. These observations are in accordance with Kuttner’s (2010) description of
distraction as an active diversion of children’s attention to an object other than the painful
procedure at hand. Likewise, Miller et al. (2011) finds distraction supportive for pediatric burn
patients during wound care procedures as their attention was taken away from the painful and
fear-invoking stimuli experienced during dressing changes and hydrotherapy sessions.
Child Life Specialists in the current study further disclosed that they found distraction
techniques most effective when they had built rapport and trust with patients prior to the
procedure and were able to begin implementation of this intervention from the beginning of the
procedure. These findings are significant because they highlight the benefit and importance of
incorporating non-pharmacological techniques to supporting pediatric burn patients’ coping
during wound care procedures, and allowing time for Child Life Specialists to build rapport with
patients prior to the procedure to optimize children’s coping abilities during wound care
procedures. Child Life Specialists working with pediatric burn patients should use their
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
36
assessment skills to determine what form of distraction techniques would be helpful for each
individual patient and incorporate them into coping plans. Furthermore, Child Life Specialists
should educate and empower patients and families to use these skills to cope when they are not
present to facilitate the distraction techniques.
Communication. Deliberate language choice was reportedly employed to comfort,
reassure, and encourage pediatric burn patients and was perceived to promote self-esteem,
mastery, and positive coping during wound care procedures. Through coaching, providing
continued information about steps of procedure and progress made, and validation of patients’
experiences, participants reported that they observed increased coping in the pediatric patients.
Kuttner (2010) encourages many of these techniques for communicating with children in pain.
Important among these are: acknowledging children’s suffering; explaining in developmentally
appropriately language the process taking place in the child’s body and what to expect in the
procedure; explaining steps that will be taken to reduce the child’s pain; using clear, soft
language; and giving the child permission to cry when and if the child feels the need to do so
during the procedure. Furthermore, Participant 6’s observation that a language barrier appeared
to hinder her ability to help the children cope with the procedure highlights the detrimental
impact of a lack of communication during dressing changes. This statement supports the
importance of practicing bilingual Child Life Specialists.
As Child Life Specialists in this study reported using intentional language to support their
patients and families, they acknowledged using reassurance is an integral part of their treatment
plan. Interestingly, however, research has shown that empathy and reassurance from healthcare
professions can increase anxiety and has been associated with decreased coping (Chorney et al.,
2009; McMurtry, Chambers, McGrath, and Asp, 2010). Given that nearly all participants
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
37
reported comforting and reassuring patients during these painful procedures, a close examination
of how exactly participants are “reassuring and comforting” patients is warranted. Participants
described doing this through counting, providing education, validating and acknowledging pain,
informing patients of what will be done to address their pain, and notifying patients when the
painful parts of the procedure are completed. Additionally, the participants perceived that this
communication with patients during procedures increased their coping and sense of control
during the procedure. Continued research on how these specific means of comforting and
reassuring patients affects patients’ coping would be supportive in further understanding the role
of language and communication during painful procedures such as burn wound care.
Education. Participants reported using education before (e.g. preparation, medical play),
during (e.g. describing how the wound is healing), and following (e.g. medical play) wound care
procedures. Similar to research by Miller et al. (2011) and Chen, Zeltzer, Craske, and Katz
(1999), as cited by Thompson (2009), participants reported benefits of education including
alleviation of misconceptions, providing information about what to expect during the procedure,
and providing a sense of control. Despite the clear value of education, most participants reported
that they were infrequently able to prepare developmentally appropriate children prior to their
first wound care procedure and shared that most education was done after the first wound care
procedure. This is troublesome in light of research by McGarry et al. (2013), which found that
pediatric burn patients reported their first dressing changes to be especially distressing as they
did not know what was going to happen during the wound care procedure.
In light of this research, professionals involved in pediatric burn wound care should
devise protocols to incorporate education in these procedures with special attention to the first
dressing change. As described by one participant in this study, it may be beneficial to provide
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
38
pediatric burn patients with sedation prior to their first dressing change that is particularly painful
and frightening as the wound is debrided. This would allow for education prior to the first awake
dressing change and possibly improve patients’ abilities to cope with subsequent wound care
procedures.
Parent involvement. The current study found that participants perceived parent
involvement in wound care to be particularly helpful for young children that are especially
vulnerable to separation anxiety. As several participants reported that their pediatric burn
patients were predominantly under the age of four or five years old, the majority of their
populations would be vulnerable to separation anxiety. This anxiety is typically displayed when
the child’s attachment figure leaves, and begins around six months of age when babies develop
object permanence (Berk, 2003). Therefore, parental presence eliminates this stressor. In
addition, Kuttner (2010) states that caregivers have insights into what would be helpful for their
children during wound care procedures and are able to help interpret children’s cues during
wound care when assessing coping. Accordingly, some participants reported convening with
caregivers following wound care sessions to determine what they felt went well and what could
be improved in the future.
Participants also noted that caregivers frequently experienced anxiety associated with the
wound care procedures and seeing their children in pain. Child Life Specialists in this study
described providing education to reduce parental anxiety, supporting caregivers by giving them
specific roles during wound care, and informing them about what would be done to help their
child. Based on participants’ perspectives on the need for caregiver support, further explorations
regarding caregiver perspectives on wound care procedures would be beneficial for the Child
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
39
Life community in order to support caregivers and to determine the effectiveness of interventions
geared towards caregivers.
Pain Management
Gandhi et al. (2010) acknowledge that the monitoring and management of pediatric burn
patients’ pain has generally been poor. Non-pharmacological interventions, such as distraction
and education, have been proven to reduce procedural pain, anxiety, and distress in previous
studies. As such, Summer et al. (2007) state that these interventions should be used in
conjunction with pharmacological interventions to optimally support patients’ pain management
and coping during wound care procedures. Similar to what previous research has reported,
several participants shared that they felt pediatric patients’ pain was regularly undermanaged.
Furthermore, they felt that their interventions would be more effective in supporting coping and
pain management if pain was simultaneously effectively managed by pharmacological means
(e.g. sedation for the first wound care procedure or conscious sedation during dressing changes).
Research by McGarry et al. (2013) highlights the voices of children undergoing these
procedures. They verbalized that dressing changes were the most painful experiences they had
ever had, and they did not know their body was capable of experiencing such pain. These
pediatric burn patients’ perspectives are important revelations to the field, as they give insight
into the continued battle for pain management and suggestions for better reducing the trauma
associated with wound care procedures.
Furthermore, it is important to acknowledge the conundrum that exists when
pharmacological measures are enacted. Specifically, it would be prudent to more closely
examine whether these children are experiencing less pain or increased abilities to cope with the
pain with the use of sedation and other medications. Based on participant reports that the use of
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
40
pharmacological pain management has positively supported pediatric burn patients during wound
care procedures, it may be deduced that patients are better able to employ coping strategies when
the pain is lessened.
Role of Child Life Specialists in Wound Care
Throughout the interviews, participants in the current study frequently reported using
their developmental knowledge of children to individualize interventions and implement such
techniques as medical play and education, which a survey by Bandstra et al. (2008) reveals that
Child Life Specialists have specific training in. Furthermore, participants revealed that they
prioritized developing rapport and therapeutic relationships with the children and shared that
they felt that they were able to increase the effectiveness of their interventions through
developing patients’ trust. These results suggest that Child Life Specialists make ideal candidates
for implementing non-pharmacological interventions and supporting children’s coping during
wound care procedures. Because many participants in this study revealed that Child Life staff
was not always present for evening or weekend dressing changes, Child Life programs that serve
pediatric burn patients should consider finding ways to provide additional presence at these times
to promote consistency of care and coping support throughout pediatric burn patients’ wound
care experiences.
Other Considerations
While previous research has shown that hypnosis techniques and distraction in the form
of virtual reality may positively impact pain and anxiety reduction during burn wound care
procedures, participants in this study did not report using these tools during burn wound care
procedures. In a survey by Bandstra et al. (2008), Child Life Specialists reported limited formal
training in these two techniques, which may relate to their lack of incorporation into burn wound
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
41
care procedures. It is also possible that funding for virtual reality systems may be scarce and
prevent Child Life Specialists from having access to them. Additionally, this discrepancy may be
a result of the small sample size and does not necessarily indicate that these techniques are never
used during these procedures. Additional training should be available to Child Life Specialists to
empower them to incorporate these tools and techniques in supporting pediatric burn patients
during wound care procedures.
Limitations and Implications
Though the sample size is small, this study lends an in-depth look at Child Life
Specialists’ experiences and perceptions of supporting pediatric burn patients during wound care
procedures. Results of this study indicate that Child Life Specialists are experienced in providing
non-pharmacological support to pediatric burn patients during painful wound care procedures
through distraction and relaxation techniques, education, intentional and planned communication
strategies, and caregiver support. Furthermore, participants reported that they perceived their
interventions to increase patients’ coping during dressing changes and hydrotherapy sessions.
This study is the first research study to closely examine the role Child Life Specialists hold
during burn wound care procedures and the perceived effectiveness of their interventions to
support coping, pain management, and empowerment with dressing changes and hydrotherapy
sessions. Future research should focus on objectively studying the effectiveness of these
interventions and extending the size and diversity of the participant sample. Furthermore,
additional studies should examine the effects of what Child Life Specialists consider to be
“reassurance” on patients’ coping, closely examining the relationship between pharmacological
pain management and coping abilities, and exploring additional non-pharmacological
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
42
interventions, such as virtual reality and hypnosis, that Child Life Specialists may be further
trained in to promote effective coping during wound care procedures.
Conclusion
In sum, the current study adds a new dimension to the research literature on Child Life
Specialists’ perceptions of non-pharmacological interventions geared towards supporting
pediatric burn patients’ coping and pain management during wound care procedures. Results
showed that participants perceived that their individualized interventions increased coping and
mastery related to dressing changes and hydrotherapy sessions. These findings are in line with
new trends in procedure support for burn wound care and indicate a clear need to utilize non-
pharmacological Child Life interventions to provide comprehensive, quality care to children
undergoing burn wound care procedures.
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
43
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Appendix A
Sample Guiding questions and follow-up topics for interviews:
1. Do you work solely in the burn unit or do you work on other units also? Do other child
life specialists work with the burn population, or are you the only CLS following these
patients?
2. How would you describe the patient population you work with in the pediatric burn unit?
a. What ages do you typically work with?
b. Family factors?
c. Backgrounds?
d. Lengths of stay?
3. How often are you present for children’s hydrotherapy sessions?
a. Do you go to every session with them?
b. Do you support every child who goes to hydrotherapy?
4. Are parents allowed to participate/be present during hydrotherapy sessions?
a. How are parents involved (i.e. what roles do they play)?
b. How do you provide education/support to parents surrounding hydrotherapy
sessions?
5. How do you prioritize patients’ needs when scheduled for hydrotherapy compared to
other patients’ needs?
6. How do you assess patient needs and develop goals for implementing non-
pharmacological interventions during hydrotherapy sessions?
a. What are you typical treatment goals for patients (and families)?
b. How effective do you perceive your interventions to be towards meeting your
goals during these sessions?
7. How often are you able to prepare children prior to their first hydrotherapy session?
a. What preparation tools do you use?
b. Who (what age groups) do you use these tools with?
8. In what ways do you support children’s coping during the hydrotherapy procedure?
a. How does their coping change over time (as they have repeated hydrotherapy
sessions)?
b. Types of procedural support
c. Tools
9. What forms of post-procedural support do you typically implement to support patients’
hydrotherapy experiences?
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
49
10. How do you believe timing of the implementation affects the outcome of the
intervention?
a. Ideally, when do you introduce non-pharmacological interventions to the patients?
11. Is play used to support pediatric burn patients during hydrotherapy sessions?
a. How is play incorporated? Medical play, therapeutic play, therapeutic art?
b. How effective is play at reducing patients’ pain, anxiety, and distress?
12. Please describe a significant memory you have from an experience supporting a patient
during wound care procedures?
a. What makes this memory significant for you?
13. Please describe the role of therapeutic relationships in your work with the patients in
hydrotherapy.
a. How therapeutic relationships are built?
b. What role do you believe therapeutic relationships play in the effectiveness of
interventions? (i.e. outcomes, empowerment)
14. How do patients talk about their injuries? How do you respond to what they say?
a. How do you address the issue of trauma related to the patient’s injuries?
b. Trauma related to hydrotherapy (repeated trauma)
c. Do you let children bring it up or do you ask them directly about their injuries?
15. Is there any specific language you use to communicate with children in pain before,
during, and immediately after hydrotherapy?
a. How do you think this language influences the outcome of your interventions/the
child’s experience of pain?
b. How do you talk about “pain” with the child/address the child’s pain?
16. How/do you comfort and reassure patients during hydrotherapy? What specific words,
phrases, body language, or actions do you use to communicate reassurance and comfort?
a. Can you give me an example of what that looks like?
17. How do you practice self-care after a difficult hydrotherapy session, and do you find that
you have any emotional triggers when working with children in hydrotherapy?
18. How do you collaborate with other members of the medical team in hydrotherapy to
promote your goals (i.e. increased coping, reduction of anxiety)?
a. What non-pharmacological interventions do you know to be available to pediatric
burn patients during hydrotherapy sessions at your hospital when you are not
present?
b. How do you educate other staff about the importance of non-pharmacological
interventions?
i. How do you explain CL services (your goals) to new hydrotherapy staff
(i.e. students)?
c. Do you feel that other staff members take ownership of implementing these
interventions in your absence?
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
50
d. Do you feel that patients have support to help them cope when you are not
present?
e. How do you feel other hydrotherapy staff members perceive your role?
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
51
Appendix B
Table 1
Participant and Hospital Characteristics as Reported by Participants
Part. Time Unit Location Pop. Characteristics
______________________________________________________________________________
*0 3 yrs. Burn Clinic Colorado Infancy through adolescence;
high Hispanic population
1 5 mo. Adult/Pediatric Burn Unit New York Most patients under five years;
often lower-income; scald burns
prevalent; high Black population
2 10 mo. Trauma/Orthopedics Unit Ohio Majority of patients between six
with 10 designated burn months and five years old; often
patient beds lower-income families
3 37 mo. Burn Unit California All ages 0-21; high Mexican,
Spanish-speaking population; often
lower-income families
4 4 yrs. Trauma/Orthopedics Unit Ohio Most patients under four years; high
with 10 designated burn Black, Caucasian, and Somali pop.
patient beds
5 9 yrs. Critical Care Unit Florida Most patients are toddlers; mid- to
lower-income families; frequently
scald burns
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
52
6 4 yrs. Burn Unit California All ages 0-21; high Mexican,
Spanish-speaking population; often
lower-income families
*7 13 mo. Burn Unit/ Pennsylvania Infancy – 18 years old; often lower-
Special Care Unit income families; length of stay
typically 1-2 weeks, sometimes one
month or longer
______________________________________________________________________________
Notes. Part. = Participant. Time = Amount of time worked as Child Life Specialist with pediatric
burn patients. Pop. Characteristics = Patient population characteristics.
*Participants responded to interview questions via email.
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
53
Appendix C
Figure 1. Coping tools. This figure provides a list of coping tools reportedly used by participants
as described in their own words. List is not comprehensive, but illustrates samples of tools
participants highlighted during their interviews.
Coping Tools
Timer Mirrors
Video games TV, movies, portable DVD players
I Spy books, reading books Pinwheel, party blower
Toys e.g. cause and effect, bath toys Sensory toys e.g. rain sticks
Bubbles Music
Vibration Comfort items/favorite things
Light spinner Visual schedule
iPad Conversation
“Tent” or “Shield” to limit visibility of wound care
WOUND CARE INTERVENTIONS FOR PEDIATRIC BURN PATIENTS
54
Figure 2. Coping Techniques. This figure provides a list of coping techniques reportedly used by
participants as described in their own words. List is not comprehensive, but illustrates samples of
techniques participants highlighted during their interviews.
Coping Techniques
Guided imagery Coping plans e.g. Strategizing a coping plan prior
Education during procedure to procedure starting
Distraction Explanation of what is happening during wound
Counting care procedure
Singing Encouragement e.g. how well the patient is doing,
Soothing touch/words that the procedure is almost done
Rocking babies Comfort positioning e.g. sitting child on caregiver’s
Parent involvement lap chest-to-chest
Coaching Vibration near wound site or another part of body
Hand-holding Breaks e.g. allowing times in which the wound are
Breathing techniques not being touched
Comforting presence Opportunities to touch/explore new medications
Normalization of environment prior to application
Promoting feelings of safety Breaking procedure into parts e.g. supporting the
Setting up environment prior patient in coping through the cleaning of one
to procedure wound at a time
Adjusting the order of burns/parts Play
of body cared for to fit patient
preferences when possible
Figure 3. Coping Tools/Techniques Reportedly Used when Child Life is not Present. This figure
provides a list of coping tools/techniques reportedly implemented by/available to wound care
staff when Child Life is not present described in the participants’ own words. List is not
comprehensive, but illustrates samples of techniques participants highlighted during their
interviews.
Coping Tools/Techniques Reportedly Used when Child Life is not Present
Toy/distraction bin Deep breathing/coping techniques depending
TV, movies on nurse doing wound care procedure
iPad Encouragement to maintain routines
e.g. bubbles
