prevention of burns in the elderly developing the ... · however, the survey also showed that the...
TRANSCRIPT
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Prevention of Burns in the Elderly – Developing the framework
for an Education Package.
Alwena Willis 10566971
Registered Nurse
This thesis is presented in partial fulfilment of the requirement for the
Master of Health Professional Education
of the University of Western Australia
Education Centre
Faculty of medicine, Dentistry and Health Science
2010
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Declaration
Having completed my course of study and research towards the degree of
Master by Research (by thesis), I hereby submit my thesis for examination in
accordance with the regulations and declare that this thesis is my own
composition. All sources have been acknowledged and my contribution is
clearly identified in the thesis.
The thesis has been substantially completed during the course of enrolment in
this degree at UWA and has not been accepted for a degree at this or another
institution.
Alwena Willis
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Abstract
Introduction
Burns in the elderly are a challenging problem faced by many burn units
throughout the world. The effect of an ageing population on demand for burn
centres needs to be addressed. A 12-year retrospective study on burns in the
elderly recently conducted at Royal Perth Hospital showed there was an
increase of 14.9% in admissions during the last 4 year period of the study,
compared to the previous 8 years. Prevention through education can be
effective at reducing burns, and education should be targeted to specific
groups. Very few education campaigns are targeted at the elderly, and a
community assessment is an important first step to developing any education
program. Therefore, prior to developing an education programme, it is important
to ascertain the views and understanding of elderly members of the community.
The research aim is to develop the framework of an education package
targeting the elderly over 65 years who live independently in their own homes or
a retirement village and providing them with the education they need to prevent
burns in the home and to know the appropriate first aid should a burn occur.
To facilitate the development of the education package it is important to
ascertain the views and understanding of elderly members of the community
therefore a study in the form of a knowledge needs assessment was
undertaken to gather this information.
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The research question is:
What do the elderly community aged over 65 years know of burn
injuries, burn first aid and preventative measures?
The findings of this study have been used in the development of a framework of
an education package designed to be disseminated by health professionals to
the elderly throughout the state including the country and metropolitan areas,
and differing cultural groups within our elderly community in Western Australia.
Participants
The group targeted was a convenience sample of elderly people over 65 years
who lived independently in their own homes or retirement village. A total of 165
participants were approached to complete a survey of knowledge of burns risks,
first aid and preventative measures, with a response rate of 41% (n=68).
Methodology
Mixed methodology was used, collecting data from quantitative/qualitative
surveys and qualitative focus group discussions. This approach facilitated the
retrieval of demographic information and definitive data on burns, and at the
same time allowed an in- depth view of the participants‟ knowledge of burn
injury, burn first aid and preventative measures. The survey questions were
analysed using SPSS v 17.0, using descriptive analysis for the dichotomous
and multiple-choice questions within the survey. The focus group interviews and
the unstructured survey questions were transcribed, reviewed and content
analyses used to code and identify keywords that linked into themes or
categories.
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Results
In categories considered high-risk activities for a burn injury, such as cooking
meals and making hot drinks 61.8% of the cohort still cooked their meals daily,
with 95.5% of them making two or more hot drinks a daily. Hot water tap
regulators were installed in 51.6% of the cohort‟s homes with 27.9% of the
cohort stating that they had received a burn injury in the last 20years.
Approximately 70% of the cohort stated that they had confidence that they
would know what to do if they sustained a burn injury, but according to the
survey, only a quarter of them actually have a reasonably good knowledge of
what to do in an event of a burn.
Conclusion
Even though 70.6% were confident that they would cope with a burn injury, Part
A of the survey contradicts this assumption and shows the need for education in
burns first aid for the elderly. The study identified the areas of concern for the
elderly in Western Australia and the results of the survey highlighted them.
However, the survey also showed that the elderly are open to learning burn first
aid and prevention measures, and can be more resilient than we often
anticipate. Ensuring that they know and understand the preventative measures
they can have in their homes to decrease the risk of them being burnt, and to
provide them with the knowledge, they need to implement correct first aid, will
give them the tools that they need to ensure that any burn injury they receive
will be minimised.
From this survey, an education package has been designed for the elderly in
our community using a social constructivism learning theory, taking into
consideration the ageing process, and the challenges involved in teaching the
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elderly over age 65 years. This package is designed to be disseminated by
health professional throughout the state in various country and metropolitan
areas.
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Acknowledgements
I would like to thank so many people for their support through what seems such
a long journey to me. It has been a challenging time, which has had me riding a
roller coaster of emotions, enthusiastic one minute, and in total despair the next,
but a worthwhile journey all the same.
My appreciation goes to all the wonderful teachers who have imparted their
knowledge to me along the way and have shown me nothing but support.
Everyone I have encountered within this course has been wonderfully
supportive, enthusiastic, and willing to help, so to the wonderful team of the
Masters of Health Professional Education course, I thank you.
I have been very fortunate with my supervisors and I appreciate and admire
them immensely.
To Dr Adrienne Huber our time together was short but during that time, I
learned so many things that have helped me along my way, so thank you for
starting me on my journey.
To Winthrop Professor Fiona Wood, I thank you for contaminating me with the
enthusiasm for improving burn care especially through education. Your
commitment to educating as many people about burn first aid as we can is
inspiring and I am grateful to be in the position of working with you. I thank you
for your support and all your help.
To Associate Professor Sandra Carr who saw me floundering and took me on
board and who has helped me in so many ways it is difficult to put in words.
Thank you for being patient and supportive for answering my endless questions
and for reassuring me when I felt overwhelmed. Your support of me during this
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time has been invaluable and without your help, I would not have completed this
journey. You have been an amazing help and I cannot express eloquently
enough how much I appreciate it.
To Associate Professor Annette Mercer who helped me finish the journey I am
immensely grateful for your help and support.
To all the team at RPH Burns unit and Telstra Clinic who have helped and
supported me along the way I thank you. You are an amazing group of people
to work with and I count myself lucky to be part of such a brilliant team. To the
McComb Research foundation for a grant to assist me with time to prepare my
Thesis, I thank you very much.
To my friends at Princess Margaret Children‟s Burn unit, I thank you for your
endless support and kind words and for being there for me.
To all my colleagues and friends from ANZBA who all have this wonderful
desire to improve all aspects of burn care, your offers of help and support have
been immensely heart-warming and appreciated.
To Aaron Berghuber who defies all the quotes of men not having any patience,
they had obviously not met you. Your help has not only been invaluable but
your calm manner and friendship have made tasks that seemed impossible,
reasonably easy. I thank you for always being willing to help and in such a
gracious way.
To my nephew Mel Griffiths, for his unstinting support and help, for giving up his
precious time to help me and for having someone in the family who understood
what I was going through. Your achievements inspire me. Thanks, Mel you are
wonderful.
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To my amazing children Sian and her husband David, Paul, Katrina, Adelle and
Thomas who support me in everything I do, who always believe I can achieve
what I set out to do even though at times I am unsure. I thank you all for your
love, your patience and support and for believing in me. You are my life and
everything I do; I do it for you. To my granddaughter Carys whom I love very
much, I thank you for just being part of my life.
My thanks would not be complete if I did not thank my Heavenly Father who
guides me in everything I do and has helped me to keep going by answering the
prayers of someone perhaps not always worthy. I thank you for your
unconditional love.
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Table of Contents
Page
Title Page 1
Declaration 2
Thesis Abstract 3
Acknowledgements 7
Table of Contents 10
Chapter One- Introduction 16
1.1Background 16
1.2Literature Review 18
1.3 Methodology 22
1.4 Results 23
1.5 Discussion 23
1.6 Health Education Framework 23
1.7 Conclusion 24
Chapter Two – Literature Review 26
2.1 Introduction 26
2.2 Search Strategies 26
2.3 Literature Reviewed 27
2.4 The Ageing Population 28
2.5 Burns in the Elderly 32
2.6 Burns first aid 40
2.7 Burn Prevention and Education 41
2.8 Elderly Education 45
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Page
2.9 Social Constructivism 46
2.10 Research Methods 47
2.11 Community Nurses 48
2.12 Conclusion 48
Chapter Three- Methodology 51
3.1 Introduction 51
3.2 Recruitment 53
3.3 Sample 55
3.4 Data collection 56
3.4.1Survey 56
3.4.2 Survey Instrument Development 56
3.4.3 Reliability and Validity 60
3.4.4 Focus Groups 61
3.5 Analysis 63
3.6 Ethics 64
3.6.1 Confidentiality and Intellectual Property 64
3.7 Limitations of the Design 65
3.8 Conclusion 66
Chapter Four- Results 67
4.1 Introduction. 67
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Page
4.2 Sample 67
4.3 Survey 68
4.3.1 Scenario Questions 68
4.3.2 Demographic data 69
4.3.3 Risk factors for burn 71
4.3.4 Fire Alert mechanisms 74
4.3.5 Knowledge of Burn first aid 75
4.3.6 Grandparents 79
4.3.7 Education 79
4.4 The Focus Groups 81
4.4.1 Focus Group One 81
4.4.1.1 Experiences of a Burn Injury 82
4.4.1.2 First Aid 83
4.4.1.3 What Burn Treatments they were 83
Taught when Young
4.4.1.4 Open Fires/Combustion Stoves 84
4.4.1.5 Back Burning on Property 85
4.4.1.6 Risk Factors 85
4.4.1.7 Smoke Alarms and Preventative Measures 87
4.4.1.8 Education 89
4.4.1.9 The Role Play 90
4.4.2 Focus group 2 92
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Page
4.4.2.1 Experiences of a Burn Injury 92
4.4.2.2 First Aid 93
4.4.2.3 What Burn Treatment they were taught, when 94
Young
4.4.2.4 Grandchildren 95
4.4.2.5 Open Fires/Combustion Stoves 95
4.4.2.6 Risk factors 96
4.4.2.7 Smoke Alarms and preventative measures 97
4.4.2.8 Education 98
4.4.2.9 The Discussion 99
4.5 Comparison of the Focus Groups 100
4.6 Conclusion 102
Chapter Five – Discussion 103
5.1 Introduction 103
5.2 Discussions 104
5.2.1 Demographics 104
5.2.2 First Aid 106
5.2.3 Risk factors 108
5.2.4 Prevention measures 112
5.2.5 Education 113
5.3 Limitations of Study 115
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Page
5.4 Conclusions 115
Chapter Six- Health Education Framework 118
6.1 Introduction 118
6.2 Framework 118
6.3 Strategic Direction 119
6.4 Education Package 121
6.5 Conclusion 122
Chapter Seven – Conclusion 123
7.1 Burns in the Elderly 123
7.2 Literature Review 123
7.3 Methodology 124
7.4 Results. 125
7.4.1 Demographics 125
7.4.2 Survey 125
7.4.3. Risk factors 125
7.4.4 Prevention measures 126
7.4.5 Education 126
7.5 Health Framework 127
7.5.1 Rationale for Developing an Education Framework 127
7.5.2 Strategic Direction 128
7.6 Conclusion 128
8.0 References 130
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Appendix 1. Table.2.3 138
Appendix 2. Formal letter of Introduction 139
Appendix 3. Patient Information Sheet 141
Appendix 4. Consent Forms 145
Appendix 5. Survey Forms 147
Appendix 6. Healthcare Framework 162
Appendix 7. Education Package 163
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Chapter 1
Introduction
1.1 Background
Burn injuries are devastating, and when they occur in the elderly those injuries
can be overwhelming. Many factors can compound to make burn injuries more
severe such as inadequate, inaccurate, or the complete absence of first aid.
Consequently, this can affect the recovery process of the elderly person, which
is often complex and lengthy. Furthermore, burns in the elderly tend to be more
serious and take longer to heal and need extensive rehabilitation in comparison
to the younger adult age group, who have both physical and psychological
resources in their favour.1,2
The elderly frequently have deteriorating physical health, hearing and vision
loss, decreased mobility and loss of dexterity, all of which can result in slower
reaction times and risk assessment impairment. Together, these factors make
the elderly more vulnerable to a burn injury and more importantly, can influence
the length of hospital stay and survival. Additionally health issues such as
dementia, delirium, confusion and disorientation have a significant bearing on
the treatment, recovery and rehabilitation of the elderly person. This often
results in a complicated discharge due to their extensive rehabilitation needs,
with family members often unable to offer adequate support due to work
commitments, lifestyle or geographical distances, leading to a compromise in
the independence of the elderly person.3,4
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People are living longer and birth rates are declining, therefore, the population
of Australia over the age of 70 years is expected to double by 2051.5 This will
have a significant impact on the future social systems of the country and in
particular the health economy, with an expected increase in demand on
healthcare and support services.
To ascertain whether there was an increase in admission of burns in the elderly
to the State Adult Burn Unit in Royal Perth Hospital, a retrospective descriptive
study was conducted on burn injury in the elderly over the age of 70 years
between the years of 1995-2006. The study consisted of twelve years of data
divided into three four-year blocks, the last four-year block showing an increase
of admissions by 14.9% compared with the previous period.6 Consequently, this
increase means an increase in workload and resources for the State Adult Burn
Unit and Royal Perth Hospital. Unfortunately, documentation of burns first aid
administered at the time of the injury was often missing in the case notes, and
in those that were documented, the first aid was often incorrect or inadequate.
The findings from this study prompted further questions:
Are the elderly with a burn injury applying first aid prior to
hospitalisation?
What do the elderly know of burn injuries, burn first aid and
preventative measures?
Could increasing their knowledge in this area help prevent burn
injuries and reduce the number of elderly admitted into hospital?
This study reported in this thesis is an attempt to answer the research question:
What do the elderly population of Western Australia know of burn
injuries, burn first aid and preventative measures?
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The method used was to conduct a survey of a representative sample of people
over the age of sixty-five years of age who live independently in their own home
or a retirement village in Western Australia. The aim of the research is:
To determine the baseline knowledge of the elderly in burn
preventative measures
To determine the baseline knowledge of the elderly in burns first
aid knowledge
To determine if cost is a factor for lack of preventative measures
such as smoke alarms, first aid training, hot water temperature
gauges.
To determine if the elderly have any cultural beliefs regarding
burn first aid.
To determine if the elderly feel an education and prevention
campaign would be of benefit
To use the outcomes of the study to develop an education
package on the subject of burns first aid and preventative
measures
1.2 Literature Review
Chapter 2 discusses the literature reviewed in the undertaking of this study,
which includes articles concerning the elderly, the ageing process, burns, and
teaching the elderly. Following is a summary of the review of the literature.
In the burn literature reviewed, the definition of elderly is variable, with ages
ranging from 55 years to 75 years. Research shows that age is a major
influence on morbidity and mortality in the elderly; this makes comparison of
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these research papers difficult.4 Geographical differences such as climate can
also have a major effect on morbidity and mortality in this age group, as
countries with hot climates and mild winters have less house fires and therefore
less flame and inhalation burn injuries that entail a higher risk of mortality.
Similarly, countries can have different cultural issues that contribute to burns
such as type of clothing worn, and means of heating and cooking, all of which
impact on the epidemiology of burns within those countries. Although these
factors made comparison of burns in the elderly a complex undertaking, many
similarities were found within the studies reviewed.
High percentages of the Western Australian elderly population live in their own
homes with or without a partner and continue to attend to their own cooking
needs. It is well documented that cooking and home-related accidents are a
leading cause of preventable injury in the elderly.2,6 In a study by Ho 2 of 94
burn patients over the age of 60 years, it was shown that 90.4% of the burn
admissions were due to domestic accidents. Likewise, in a study of 20 burn
admissions over the age of 65 years, Redlick 7 stated that the home was the
most common place of injury for the burn admissions examined, with the
kitchen being the predominant place of injury. Undoubtedly these activities can
be hindered by age related diminished functions and a reduced capacity to
manage everyday activities, which make the elderly more vulnerable to burn
injuries. 2,3,6, 7
The review of the literature revealed that first aid prior to hospitalisation in the
elderly is frequently excluded for exploration, however, one of the few studies
that include this information regarding burn first aid is the study by Ho.2 In their
study of 94 elderly patients admitted with a burn injury, they found that more
than one third of their patients had received no first aid, with 43% of patients
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having received inappropriate first aid. These factors were considered
contributory factors to prolonged hospital stays and increased mortality. By
contrast, a study by Chang 8 did not consider burn first aid in relation to
outcomes, but rather focused on outcomes related to total body surface area,
burn aetiology, inhalation injury and gender differences.
Similarly, other retrospective studies into burn outcomes that took into account
variables and their effect on outcomes, were reviewed.9-11 As with the Chang 8
study, burn first aid and its possible effect on outcomes were not discussed in
these studies. Consequently, the questions of whether first aid is being
administered, whether it is adequate and appropriate and whether it does have
an effect on burn outcomes is difficult to ascertain. This gap in the literature is
significant, as in the elderly age group, effective first aid administered at the
time of the injury can have a major influence on patient outcomes and
mortality.12, 13 With correct burn first aid, involving cooling the burn under
running water for approximately 20 minutes, pain levels are decreased, the heat
is removed and progression of the burn is prevented.12, 13
Advanced surgical techniques, silver dressings, and superior skin cultures have
revolutionised burn treatment. However, these advancements have not been
reflected in the prognosis of elderly patients, which continues to be relatively
poor compared to those in the younger adult age group.7 Many factors
contribute to poor prognosis in this age group and many studies have been
conducted to ascertain the main factors involved. The Pomhac 14 study on
predictors of survival related to age, found that there is a considerable
difference between burn injuries in the 60 years age group compared to the 80
years age group, due to co-morbidities and declining physiological reserve.
However, it was also found that there has been an improvement in survival in
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the 80 years age group compared to historical controls. Similarly, the study by
Rao9 found that co-morbidities did influence the outcomes of burns in the
elderly, and that total body surface area (TBSA) and inhalation injury have a
significant effect on mortality in this age group when compared with younger
age groups.
Research has shown that many of the burn injuries in the elderly occur within
the home, and could be prevented with an education program specifically
directed at the elderly population, tackling the issues that are relevant to them.
Studies related to burn prevention and to the design and developing of
education programs were reviewed. Tan15 implemented the burn prevention
campaign of a perspective study of elderly groups over 60 years who attended
a „Burn Prevention Education Seminar‟. It was found that there was a significant
increase in burn prevention knowledge after the multimedia campaign and
community presentations with the preferred method of education within the
campaign being the community presentation.15
Cutilli 16 states that due to the many changes that occur during the ageing
process both physically, and more importantly cognitively, education of the
elderly needs careful consideration, and there is a need to understand the
education strategies that take into account these changes, which is often a
challenging process. Articles related to the education of the elderly were
reviewed.
Participants in an education session can include people with different
educational levels and differing health issues. It is therefore important that
educational programmes for the elderly should be connected to the participants
of the group, their experiences and interests.17
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Because of the learning needs of the elderly, the education program detailed in
this study was designed using the theoretical framework of Social
Constructivism, incorporating a diversity of strategies to aid the potentially wide
variety of learning styles.
A review of the literature on Social Constructivism found limited scientific
research, with most articles consisting of interpretations of Social
Constructivism by the author. A variety of views were documented, with Hein18
stating that learning is a social process when people are engaged in any form of
social activity, and that all social activity is in fact a learning process. He then
went on to emphasise the importance of cultural background and personal
experiences in the process of learning, especially in the elderly population.18
Social Constructivism allows the elderly learner to participate in the learning
process, with the health educator facilitating the learning process in a social
environment such as senior citizen centres or retirement villages, to help them
learn about burn first aid and preventative measures.
1.3 Methodology
Chapter 3 discusses the methods used in the study and the advantages of the
mixed methodological approach used.
The research design consisted of a mixed methodology community survey with
a focus group component. The mixed methodology allowed the use of different
approaches to answer the research questions, using both quantitative and
qualitative data. The study consisted of a survey designed to help gain an
understanding of what burns first aid knowledge the target population have, and
to provide the demographic information and data needed. Furthermore, the
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study examined the insights on preventative measures the elderly have already
implemented, and their views on burn first aid and prevention measures.
The focus groups were conducted in order to gain a deeper perspective of their
concerns about burn injury, first aid and prevention.19
1.4 Results
In Chapter 4, the results of the study are discussed. The survey questions were
analysed using SPSS v 17.0, (http://spss.en.softonic.com/), using descriptive
analysis for the dichotomous and multiple-choice questions and using a nominal
scale, with the results divided into tables, and figures.
By contrast, the notes from the focus group interviews and the non-structured
questions in the survey were transcribed and reviewed using content analysis to
code and identify keywords, which linked into themes and categories.19 The
issues identified in the study have been used in the development of the
framework of an education package
1.5 Discussion
Chapter 5 contains a discussion of the results of the study and the implications
of them in the development of the educational framework.
1.6 Health Education Framework
Chapter 6 consists of the strategic directionof the framework for an education
package for the elderly population of Western Australia. This education package
will be designed to be delivered by various health workers around Western
Australia, including Community Nurses, Burn Specialist Nurses, Aboriginal
Health Workers and General Practitioners.
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In considering the ageing population and the need to identify strategies to
ensure the health service are able to cope with the expected increase in burns
in the elderly; other education packages designed for the elderly in Western
Australia will be reviewed. The elderly population in Western Australia is a
growing population, and consists of many diverse groups, which include the
indigenous population, Australian born, and the elderly from various
multicultural backgrounds. Amongst them, there is much diversity both
economically, and socially, all of which will need to be considered in the
development of an education package.
Teaching the elderly involves many considerations such as how they learn, their
incentive to learn and the cognitive changes that occur with the ageing process.
These cognitive changes according to Cutilli16 involve four main functions:
sensory function
processing speed
working memory and
inhibition
Some or all of these functions may be diminished to some degree in the elderly.
Consequently, these are important considerations in the development of the
education package to enable the needs of all of Western Australia‟s elderly
population to be met.
Another factor to consider is that not all of the cognitive changes in the elderly
are losses, and along with increased age comes the benefit of experience.
Therefore, one way to teach the elderly is to use the experiences they have
accumulated in their lives to help them learn the things they need to know now,
and social constructivism utilises those experiences in the learning process.
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Older adults often have a wealth of knowledge and life experience that they
have gained over the years that they can draw upon and relate to the learning
experience, but the elderly must also see the importance for the learning
experience in the first place and agree that the topic is relevant to them.17
1.7 Conclusion
Chapter 7 consists of the conclusions of the study and contains an overview
and assessment of the findings of the research study aims.
The long-term objective of this project is to reduce the number of elderly people
presenting to Royal Perth Hospital‟s State Adult Burn Unit with a burn injury,
therefore the conclusion and summary will discuss the results of the study
related to the questions to be addressed.
The conclusion will also address what direction needs to be taken next, such as
further research or further development of the framework and the delivering of
an education package.
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Chapter Two
Literature Review
2.1 Introduction
This chapter provides a review of the literature, with the search strategies
employed in obtaining the relevant literature identified, including a summary of
the keywords used. An overview of studies relating to the ageing population is
presented, before an examination of the literature concerning burns in the
elderly. An overview of the published information on the impact of first aid
measures is also presented, as is a summary of the literature concerning elderly
education. Social Constructivism theory is examined, before the chapter
concludes with a review of the literature relating to the study‟s methodology.
2.2 Search Strategies
The literature for this study was gathered from a variety of sources to provide a
comprehensive review of the literature. The following websites were searched:
Databases:
Ebsco CINHAL
Ovid Medline
ERIC
Google Scholar
UWA Library search
Specific journals:
Burns
Journal of Burn Care and Research
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Government sites
Western Australian Department of Health and Ageing
Department of Health – Injury Prevention Branch
Australian Bureau of Statistics
Healthinfonet
The search was refined using specific journals such as „Burns‟ and „Journal of
Burn care and Research‟ which were then individually examined for relevant
burn articles.
2.3 Literature Reviewed
For this study, 135 articles or websites covering the different elements of the
study were reviewed. The keywords used in the search were as follows:
Burns, Elderly, Aged 65years and over, Geriatrics, Demographics, Elderly
Education, Ageing, Geragogy, Prevention, Risks, Injury, Health education,
Health Promotion, Health Prevention, Health Frameworks, Constructivism,
Learning theories, Social Constructivism, mixed methodology, Coding,
Qualitative Research, Focus Groups, Surveys: Ageing Population, Population
Statistics, Australia, Western Australia, Adult learning, Teaching, Adult
Education, Community Nursing, Burns first aid
The majority of literature reviewed consisted of Burns in the Elderly and Burn
Prevention followed by Education of the Elderly, Ageing and Research. These
five categories constituted 75% of all the literature reviewed while Education
Packages, Social Constructivism with Education Burn First Aid and Community
Nurses made up the remainder.
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The number of articles reviewed consisted as tabled below.
Table 2.1 Articles Reviewed
Categories Number of Articles
Burns in the Elderly 35
Burn Prevention 26
Elderly Education 16
Education 7
Health Education 11
Research 12
Ageing 12
Community Nurses 4
Burns First Aid 4
Constructivism 8
2.4 The Ageing Population
Because people are living longer and birth rates are declining, the population is
ageing and by 2013, 2.6 million Australians will be over the age of 70 years,
with this figure expected to double by 2051.5 People over 65 years of age in
Australia constitute 13.3% of the population. Western Australia‟s growth in the
elderly age group has increased 3.7% from June 2008 to June 2009.5 This
increasing population age is not unique to Australia, which fares well when
compared with other countries. For example, Sweden has 18.3% of the
population over the age of 65 years, and the United Kingdom has 16.6%. New
Zealand and the United States of America are similar to Australia in terms of an
ageing population, with both countries having 13% of the population over 65
years.5
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The ageing population is likely to have a considerable impact on the future
social systems of Australia and on the health economy in particular. It is
expected that as the population ages there will be subsequent increases in
demand on healthcare and support services. Consequently, the Australian
Government has responded to this by introducing health education and
promotion strategies to encourage active independent living.20 Strategies aimed
to achieve active independent living in older Australians by promoting good
health and healthy ageing, as well as by encouraging the reduction of health
risk factors such as smoking, obesity and inactivity. The Health and Ageing
Working group lists preventative health as one of their five main priorities, and
although the focus is on reducing the burden of disease, preventative measures
in all fields are considered of benefit to the overall health economy.20
In Madrid in 2002, the Second World Assembly on Ageing held by the United
Nations put forth a political declaration known to most as the „Madrid plan‟,
which has three main priority directives, including objectives and actions
intended to aid in their implementation.
Those priority directives are:
1) Older persons and development;
2) Advancing health and well being into old age; and
3) Ensuring enabling and supportive environments.
The Australian Government has stated its commitment to the „Madrid Plan‟ and
have already commenced implementation of it.20
Butler 21 in his paper on „Population ageing and health‟ states that one of the
reasons people are living longer is due to improved nutrition and the inroads
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into disease prevention and cure that medical research has achieved. He
argues that the ageing population as a group has had greater exposure to
toxins such as high fat diets and smoking, and therefore will suffer the
accompanying related health effects, such as heart disease and stroke.21
Because of these factors, Butler 21 expresses concern that governments are not
being proactive enough in their preparation for the anticipated increase in
healthcare demand. Furthermore, Butler 21 states that the responsibility for the
ageing population should involve everyone, including the people themselves,
and that governments should encourage them to contribute in taking care of
their own health and well-being.21
Geriatric medicine and research along with investment in health promotion,
education and prevention, would enable the elderly to gain the knowledge they
need to be proactive in their health and well-being. 21 Differing to Butler
however, Getzen 22 in his paper on „Population ageing and health‟, argues that
the projected health economic increase is not simply due to the aging
population but is more likely due to the high cost associated with the
development of the technology now used through medical research, a
development which has occurred concurrently with population growth.
In contrast, Coorey 23 in his paper on „Ageing and healthcare costs in Australia‟
suggests that Australia should be well placed to cope with the changes
expected in the health care system due to the ageing population, and that
concerns of the expected increase in demand on our future health care services
is overly bleak. Coorey 23 further states that acknowledging this would improve
government policy making decisions concerning the ageing population, and
suggests that as society changes and health issues such as the number of
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31
people smoking decrease, the result will be an overall decrease in related
illness and its associated health costs.23
Andrews 24 suggests in his article on „Promoting health and function in an
ageing population‟, that health education and promotion are essential to help
benefit the well-being of the elderly in the coming decades, and that education
should be designed to cater for all social aspects of this population. The
Western Australian Health Promotion Strategic Framework 2007-2011 25
supports this view by suggesting that a framework for comprehensive health
promotion should include a broad range of activities such as education, skill
development programs, mass media campaigns, legislation, and community
action. One of their key strategic approaches is to target populations such as
the elderly, with the aim of reducing morbidity and premature mortality by
decreasing chronic disease and injury.25
Although much of the literature examined differ in opinion on ageing and the
future of health care costs, they all conclude that the ageing population should
have a greater responsibility in their own health and well-being and that
educational campaigns in health matters are beneficial to aid this. Regardless of
the debate on whether the cost of health care system will or will not increase
due to the ageing population, research have shown that the number of elderly
people admitted to the State Adult Burn Unit of Royal Perth Hospital is
increasing.6 This is likely to have an impact on the cost and resources of the
State Adult Burn Unit and therefore Royal Perth Hospital, and is likely to result
in more pain and suffering from burn injury for an increasing number of our
elderly.
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32
2.5 Burns in the Elderly
Studies have shown that although survival from burn injuries continues to
improve across almost all age groups, this is not the case with the elderly. Even
though the elderly often make up only a small proportion of the burn population,
with an ageing population, that proportion of burn injuries will increase.7, 26 In
recent years, there have been many advances in burn treatments, with
improvement in surgical techniques and scientific technological advancements
such as artificial dermis and cultured epithelial cell spray. In addition, there have
been other advancements such as nanocrystalline silver dressing products and
the introduction of nutritional support, all of which have helped improve the rate
of survival in burns patients.1, 26 For many reasons, including the psychological
and physical features of the ageing process, the prognosis for our elderly
patients do not always reflect these advancements. Prognosis for the elderly
with a burn injury continues to be poor when compared to the younger adult
population, and studies have shown that in the elderly, the greater the
percentage of total body surface area burnt, the greater the likelihood of
mortality.1, 2, 27
Directions in Injury Prevention, 28 a report by the National Injury Prevention
Council states:
„Severe burns have an enormous impact on the victim and their family,
they are very costly, and they present particular problems for acute care
and rehabilitation‟. (p.24)
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33
Burn injuries in the aged are associated with a higher degree of morbidity and
mortality, take longer to heal, and tend to require an extended recovery period
and more intense rehabilitation than for other age groups. Furthermore, the
elderly often have pre-existing medical problems, which can contribute to the
length of their hospital stay and their chances of survival.3, 7, 29 In addition, the
elderly population may have disabilities such as failing hearing or vision,
decreased mobility and dexterity, as well as declining reaction time and aptitude
for risk assessment, all of which impact on their ability to manage everyday
activities. 3, 7, 29
During hospitalisation, the elderly may have less tolerance to medication and
surgical procedures, be more susceptible to infection, and may suffer from
delirium and confusion, all of which are contributory factors to longer recovery
and rehabilitation.4, 14, 30, 31 To maintain independence, this age group requires a
high level of input, which is often complicated due to inadequate family
support.3
This review of the literature found the majority of research pertaining to burns
and the elderly are retrospective, descriptive studies conducted at various
centres, which focus on morbidity, mortality and burn prevention. Many of these
studies cite flame as the most frequent aetiology of burns, with differing
mortality rates. Scalds was cited as the second most frequent aetiology with the
exception of four studies which found scalds to be the most predominant
agent.2, 6, 7, 32
Alden‟s 33 retrospective case control, observational study conducted on burn
injury in patients with dementia was the only study from the United States of
America (USA) of burns in the elderly that showed scald as the predominant
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34
agent. Wibbenmeyer 29 retrospective descriptive study on predicting survival
rates in the elderly with a burn injury, found that of the 308 patients admitted
with burns over the age of 60 years, flame was the most prevalent cause of
burn at 69% with a mortality rate of 30.2%. Likewise a retrospective review by
Lionelli 26 in 2005 on factors affecting mortality in burns in the elderly, showed
that of 201 patients over the age of 75 years, flame was also the prevalent
cause of burn injury at 73.6%, with a 47% mortality rate. However, studies that
have stratified ages into age groups have shown that age differences play a
major role in mortality, the significant difference in the mortality rates between
these two studies may be the result of age difference.
In a retrospective descriptive study considering the effects of pre existing co-
morbidities on mortality in the elderly aged 55 years and over conducted by
Lundgreen 4 in 2009, it was found that flame was the most predominant cause
of injury, with a mortality rate of 18.5%. Significantly, when these rates were
stratified to age they found the mortality rates varied in the stratified age groups
as follows:
Table.2.2
Age Groups Mortality Rates
55-64 years 9.7%,
65-74 years 16.5%
75 years + 32.7%
Lundgreen 4 concluded that age rather than co-morbidities was the deciding
factor in regards to mortality in the elderly.4 Similarly, a retrospective descriptive
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35
study of a cohort over 55 years of age by Pham 27 in the USA of the
epidemiology and outcomes in the elderly with a burn injury, concurred
Lundgreen‟s 4 finding that flame was the predominant causal agent, showing
that mortality rates increased as age increased. Most other studies also concur
with the findings that increased age leads to increased mortality, with some
studies aiming to identify if treatment has an effect on mortality rates.23,24.
A retrospective review in Birmingham, England by Rao 9 on the aetiology and
outcome of burns in the elderly, showed that in the 65 years and over group,
flame was the predominant agent at 49.2% with a mortality rate of 34%.
Furthermore, the study aimed to see if early surgical intervention reduced
mortality, however, the findings showed no significant difference in the timing of
surgical intervention and mortality and concurred with most studies that
mortality was significantly related to age, total body surface area (TBSA) and
inhalation injury.9
In contrast, the Khadim 34 retrospective descriptive study based on Rao‟s 23
study on mortality estimates in the elderly burn patients in their unit compared to
the Birmingham unit, showed that early aggressive therapy, which included
early surgical intervention and the use of intensive Care Units (ICU), did reveal
a correlation to better survival in the elderly. They stated that their mortality rate
of 12.6% was significantly lower than the Rao 23 study of 34%. However,
Khadim 34 states that in their study, the cohort had fewer burns in the over 50%
TBSA category, which is known to have an effect on mortality rates in this age
group, and this factor may have been significant
By comparison, Keck‟s 35 2009 review of the current literature in burn treatment
for the elderly, argues that early surgical intervention is controversial in the
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36
elderly and cites studies that both support and oppose it. Keck 35 concurs with
others that age and TBSA play the major role in mortality, and state that
although lower than the general adult population, survival in this age group has
still improved since the 1970‟s. Keck 35 argues that because of this, there is a
need for increased rehabilitation facilities to ensure as optimum a return to
normal as possible.35
A retrospective descriptive study by Baux36 in 2008 of 37 elderly burn patients
aged 70years and over who had presented to their unit showed flame burns as
most common at 65.3% with a mortality rate of 30.6% and also showed that
78.1% of burns in this age group were from domestic accidents such as cooking
and bathing accidents.36
The 2010 retrospective descriptive study by Yin 37 on the characteristics of
elderly burns in Shanghai, also showed that flame was the predominant agent
of burn at 52.7%, but found a mortality rate of only 8%, which is considerably
lower than most centres. They also found that domestic burn injuries were high
at 73.6%, which was attributed to the change in the social structure in Shanghai
where family life is changing from a traditional one, consisting of different
generations living together in one family home, to one where the elderly now
often live alone. Yin 37 states that although the living standards have improved
in Shanghai, this is not always the case for the elderly. Furthermore, Yin 37
concludes that domestic injuries could be prevented with appropriate education
campaigns. This phenomenon of the changing family life is not exclusive to
Shanghai, and social structures around the world are changing resulting in
increasing numbers of the elderly finding themselves living alone, often with a
reduced income and a decreased standard of living.6, 35, 37
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37
The studies reviewed with scald as the predominant agent revealed different
overall results concerning mortality, which exposes a different view of burns in
the elderly. A retrospective descriptive study by Ho 2 in 2001 of the evaluation of
the epidemiology and outcome of 94 patients aged 60 years and over found
scalds to be the predominant agent at 62% with a mortality rate of 7.4%. This
was one of the few studies that gave figures for first aid prior to hospitalisation,
showing that 34% of those surveyed did not receive first aid prior to admission
and 30.6% presented with inappropriate first aid such as toothpaste, herbal
ointment, soy sauce and cigarette ash, with a further 35.4% unaccounted.2 A
follow up retrospective descriptive study of Ho‟s study by Wong 38 in 2007 on
an elderly burn prevention revealed similar figures, with 64% scalds and a
mortality rate of 6.8%, with two thirds of the burn injuries occurring at home.
First aid given was also reviewed and showed only 12% received appropriate
first aid with 88% having no first aid or inappropriate first aid.38
A retrospective descriptive study at Royal Perth Hospital of elderly patients over
70 years conducted over a twelve-year period to evaluate trends in morbidity
and mortality found the predominant cause of burn was scald at 49%, with a
mortality rate of 11%.6 Like the Hong Kong studies, first aid administrations was
reviewed, with the study showing that first aid was administered in 30% of the
cases, inappropriate first aid in 2%, and no first aid was administered in 11 % of
the cases. Unfortunately, first aid had not been documented in 57% of the case
notes presenting an obstacle in ascertaining whether first aid was administered
at all, and whether or not it was adequate. This is significant as effective first aid
can have a major influence on patient outcomes and including mortality in the
elderly.6
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38
Like the Hong Kong and Perth studies, the Redlick 7 cross sectional study of
2002, a survey of risk factors for burns in the elderly and prevention strategies,
and Klosovά 32 retrospective descriptive study of burn injury in senior citizens
over 75 years of age, state that scalds are the predominant cause of injury,
although it is difficult to correlate a congruence of the four studies for numerous
reasons. Climate, culture and age all differ in these studies with each
influencing the overall results of the studies to some degree, making the studies
difficult to compare.
The retrospective descriptive study conducted by Klosovά 32 in 2005 showed
that scald was the predominant agent of burn at 43%, but with a mortality rate of
27%. This mortality rate is considerably higher than the Willis or Wong 6,38
studies, potentially due to the Klosovά 32 study age range of 75 years and over.
As other studies have shown that this age group have a higher mortality rate,
this may be the factor affecting the difference between the studies.6, 32, 38
Redlick 7 found that although scalds were the predominant cause of burn injury,
there was also a high mortality rate of 46%, which is comparable to studies
where flame is the main cause of the burn injury. The Redlick 7 study
concentrated on preventative measures rather than on the actual burn cases
making it difficult to assess the reason the mortality rates found were higher
than the Willis and Wong 6, 38 studies. Whether the differences are due to the
treatment approaches or the age differences in the studies or other factors is
hard to say.6, 7, 38
Climate may also be a defining issue between burn aetiology and consequently
mortality rates. Both the Wong and the Willis 6,38 studies were conducted in
countries that experience a warm climate, which might result in lower incidence
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39
of burn injuries caused by house fires and heating sources. By comparison, the
Redlick and Klosovά 7,32 studies, are from countries with a colder climate
(Canada and the Czech Republic respectively), and consequently it is possible
that a higher incidence of house fires were a significant factor compared with
the Hong Kong and Perth 2, 6, 38 studies. There is a higher component of
inhalation injuries in house fires, which leads to a higher mortality rate, and this
is likely to be a defining issue in the difference between mortality rates in the
studies from the four countries.6, 7, 32, 38
The main factor to be considered, however, is that the age group defining the
elderly is not uniform between the studies, with the cohort‟s ages varying from
55 to 75 years of age. This makes comparing the studies accurately difficult, as
a discrepancy of 10 to 20 years can make a significant difference in burn
outcomes as the Lundgreen and Pham4, 27 studies illustrate with their age
stratification.
The other significant factor is the difference in aetiology of the injury where
flame injuries may also have had an inhalation component. This increases
mortality, making it difficult to compare this group of studies.
Table 2.3, shows an analysis of eighteen articles that have been reviewed
which includes the study, their most frequently cited aetiology, mortality rates,
age group, cohort size and mean TBSA percentage. This table helps to identify
the differences between age groups, aetiology and mortality rates, all of which
combine to make comparison of these studies difficult.
Table 2.3 Appendix 1.
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40
2.6 Burns first aid
Lack of published information concerning first aid measures used prior to
hospital admission makes it difficult to study its effect. Only three studies Ho2,
Wong38 and Willis6 had this important information, indicating that there is
relatively little literature on burn first aid knowledge in the elderly. Despite many
burns studies neglecting to factor in first aid administration, it is known that
effective first aid can have a major impact on the patient outcome. Therefore, an
important question is whether a lack of first aid administered at the time of the
injury has a significant impact on morbidity and mortality.
In a study in Perth on minor burn injuries in adults presenting to the regional
burns unit in Western Australia, 39 only 39% of the 227 cases had received
appropriate first aid and 61% received inadequate, inappropriate or no first aid.
Inappropriate first aid included application of ice or applying topical agents such
as honey or toothpaste.
Another study assessed the knowledge of Burn first aid in 462 HealthCare
workers and 180 engineering students, where the respondents were asked to
comment on four scenario type questions, with only 18.8% providing correct
responses, indicating that burn first aid knowledge is poor in the general
community.40 A knowledge of and administration of prompt first aid prior to
hospital admission is essential to achieve the best outcome for the injured.12
Adequate and correct burns first aid improves the outcome for the burn patient,
and leads to a decrease of admission into a burns unit, and a decrease in
severity in the burns of those needing to be admitted.12, 40
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41
2.7 Burn Prevention and Education
Smoke alarms are a proven intervention that can help reduce the incidence of
house fires and consequently burn injuries.41 In Australia, legislation in every
state makes it compulsory to install smoke alarms in all new properties and
renovated homes. However, socioeconomic factors such as cost could preclude
the elderly from having smoke alarms in their homes.35, 41-43
Hot water is a major cause of burn injury in Australia with scald injuries common
in the elderly, who are more vulnerable to scalds. These injuries represent 49%
of hospitalised burn admissions at the State Adult burn unit, Royal Perth
Hospital in Western Australia.6 There is now Australia wide legislation to ensure
hot water temperatures in new residential or renovated homes are not greater
than 50oc. Unfortunately, many of our elderly live in older homes that do not
have this safety feature and cost could be a deterrent for many elderly in
safeguarding their homes by installing them.43, 44
In 2007, Alden 45 conducted a retrospective review of hot water tap burns to
assess socioeconomic factors related to them. The study found that 97% of
burn injuries occurred within the home, with 98% of the cohort having pre-
existing co-morbidities. Furthermore, the study concluded that the elderly were
often limited by income in buying and installing safety devices such as
expensive anti scald devices.45
In a prospective observational study by Stone 46 in 2000, hot water
temperatures were tested in 14 residential homes and 25 randomly picked
homes of elderly people, which showed that most of the residential homes
conformed to the government legislations. Unfortunately, half of the private
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42
homes had water temperatures of over 60 degrees as not all of the homes had
fail-safe thermostatic devices installed in order to prevent scalds.46
The retrospective descriptive study conducted in New South Wales by Boufous
on the epidemiology of scalds 30 in 2005 concurred with the Stone 46 study, and
found that as the elderly live in older homes which are not subject to hot water
tap regulations, more work needs to be achieved to aid the elderly in this area.
Scald is the most predominant cause of burns in Western Australia; therefore,
education of the elderly on the benefits of installing fail-safe thermostatic
devices in their homes is important in order to reduce the risk of a scald.
Furthermore, education on topics such as first aid treatment, burn hazards and
prevention, would be beneficial to the elderly, as research has shown that many
of the burn injuries in the elderly that occur within the home can be prevented.47,
48
McMurdo‟s 48 2000 review of healthy old age, found there was a lack of health
education for the elderly. Grant 47 2004 in his article on burn prevention,
suggests that before designing a burn prevention program, there should be a
community assessment to ascertain what is relevant, in order for the education
to be targeted effectively. To minimise or prevent an injury, the elderly need to
be aware of burn preventative strategies, and burn first aid knowledge as
informing the elderly will empower them in regards to their health and well-
being.47, 48
Grant 47 states that advanced practice nurses should help in the prevention of
burns by actively participating in health promotion programs in fire and burn
injury prevention. However, he also states that there is little evidence on the
efficacy of prevention programmes, and that most evidence comes from the
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43
efficacy of passive strategies such as smoke alarms, fail safe thermostatic
devices and the use of less flammable materials in clothes, such as nightwear.
Grant 47 suggests that prevention comes in three phases:
Primary - legislation and burn awareness education;
Secondary - the teaching of burns first aid; and
Tertiary – This includes the rehabilitation and recovery of a burn survivor,
in order to promote the maximum level of function and to minimise any
disability.
The Pomhac 14 2006 retrospective descriptive study on „Predictors of survival
related to age‟, found that there was a considerable difference between burn
injuries in the 60 year old age group compared to burn injuries in the 80 year old
age group. However, Pomhac14 conceded that their study was small and that
there was a need for multi-centre studies to understand the broader picture in
education of the elderly.
The Redlick 7 2002 cross sectional study administered a multiple-choice survey
to a group who had already sustained a burn injury about the circumstances
that led to their injury and burn injury risks, with a cohort group of uninjured
elderly people. When the data were compared, it was found that 85% of those
who had sustained a burn injury felt that their injury was preventable. Although
few participants had changed their habits post injury, 95% stated that a burn
prevention program would be useful. However, it was found that the cohort
group were at a higher risk for a burn injury, but that they took more burn
preventative measures, which were effective. Because of the study, a
prevention program for the elderly was designed, involving a multimedia
campaign and community education sessions.7 Tan 15 followed through and
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44
developed the burn prevention campaign and conducted an evaluation study in
which an elderly group over 60 years of age attending a „burn prevention
education seminar‟ were surveyed. It was found that there was a significant
increase in burn prevention knowledge after the multimedia campaign and
community presentations, and that the community presentation was the
preferred method in the educational campaign. Additional surveys were
conducted 4 to 6 weeks after the education, but they considered it was too soon
to determine whether the information could be retained long term, a factor that
could determine how frequently the education should be repeated.15 Judkins 49
review of burn prevention and rehabilitation in 1998 argues that short one off
programmes seems to achieve little and that any education programmes
undertaken should be long term.
In their 2007 retrospective descriptive study, Wong 38 stated that there have
been some successful burn education/prevention programmes aimed at
children, particularly in scald prevention, but very little for the elderly. Spalleck 50
conducted an evaluation study of the campaign, „Hot water burns like fire‟, a
scald campaign targeted for children, which involved testing the tap water
temperatures at selected homes and schools and assessing scald admissions
prior to and post the education. They found that the average hot water tap
temperature in the surveyed homes after the campaign was higher than prior to
the campaign, and scald admissions had increased. This, they reasoned was
due to the way the data was gathered pre and post campaign, which involved
two different research groups using different methods. Furthermore, they went
on to suggest that there is little evidence to prove that educational campaigns
affect change in behaviour and maintain that passive strategies such as
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45
promoting smoke detectors are more effective than campaigns designed to
encourage behavioural change.50
The American Burn Association has a comprehensive package for burn
education for various groups including the elderly on their website. However,
the literature search did not reveal any studies of the effectiveness of this
education or any centres that had adopted this education package.51
2.8 Elderly Education
In a clinical review in 2008, Cutilli 16 states that due to the many changes that
occur during the ageing process both physically and cognitively, education of
the elderly needs careful consideration, and an understanding of education
strategies is needed in view of these changes. All adults are individuals and
possess many differing characteristics that can affect how they learn and all of
these factors should be taken into consideration when planning and choosing
the correct learning theory for an education package for the elderly.52
Malcolm Knowles, considered the founding father of Adult learning, stated that
there were differences between adult learning (Androgogy) and the learning of
children (Pedagogy), and that adults were autonomous and self-directed with
their learning.53
Zemke 54 went on to suggest that adults are most motivated to learn if the topic
is relevant and useful to them and the subject interesting.54
Lieb 53 in his 1991 article „Principles of Adult Learning‟ concurred that adults
are more committed to learn when the learning has a meaning in their lives, and
that it is life experiences that have taught adults to be autonomous and self-
directed. An elderly learning group could include people with different
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46
educational levels; some may have left school early to gain employment, and
therefore received a lower formal education with others having gained a tertiary
education. Furthermore, the groups are often predominantly women and may
have health problems, therefore any educational programmes should be
designed to consider these factors and appeal to the experiences and interests
of the group.17
Imel 55 states that learning is achieved best in an informal environment, and that
teaching in small groups is an effective method in adult learning, which allows
the educator to become the facilitator and allows the group to take a more
active role. As a result, small group learning can be more effective and
productive than large group learning with members of the group all having a
chance to contribute their experiences and strengths to the process.55
Hein 18 1991 states that learning occurs when people are engaged in any form
of social activity, whether it is with family, at school or any social group, and that
all social activity is in fact a learning process. Therefore, this emphasises the
importance of cultural background and experiences in the process of learning
especially in the elderly population
2.9 Social Constructivism
Due to the learning needs of the elderly, this education program has been
designed using the theoretical framework of Social Constructivism. Review of
the literature on Social Constructivism revealed limited scientific research. Most
articles located were interpretations of Social Constructivism by individual
authors with every author seeming to have a different interpretation of the
theory, although the basis of the theory remained unchanged.
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47
Social Constructivism is believed to have originated with Jean Piagets „stage
theory‟, which describes the four stages of development.56 Social constructivists
believe that learners actively construct knowledge, that their learning is based
on their previous experiences, and that they create meaning through the
interaction with their environment as well as social interaction with each other.56,
57
2.10 Research Methods
This study used a mixed method approach including both quantitative and
qualitative data collection methods. Martin 58 (2000) describes qualitative
research as understanding the person‟s views and experiences which have
bearing on a study, while quantitative research focuses on discrete and
measurable areas in a study. The mixed methodology applied in this study
allowed the use of different approaches to answer the research questions.
Combining the quantitative and qualitative data collection methods facilitated an
understanding of the knowledge of burn first aid and preventative measures that
the elderly have from a comprehensive viewpoint. Burke Johnson 59 2004 states
that both quantitative and qualitative methods use empirical observations and
have safeguards to minimise bias. In today‟s research, many disciplines
conduct differing types of research relevant to their field of expertise within a
specific area. All of this research is relevant to the overall understanding of the
topic, so it is of benefit for researchers to understand both methods, as this will
help to facilitate a greater understanding of the topic studied.59
The data collection methods consisted of a community survey with focus group
discussions. Barbour 19 states that any group discussion can technically be
classed as a focus group with the difference between a discussion and a focus
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48
group discussion being, the participation of the researcher as moderator and
actively encouraging the discussion. The use of the focus groups allowed a
more personal perspective of burns first aid and preventative measures to be
attained.19
Punch 60 and Creswell‟s 61 books on research comprehensively discuss the
different areas of conducting research such as mixed methodology, sampling,
coding qualitative data and analysis, and were used extensively as a reference
for all aspects of the research in this study.
2.11 Community Nurses
Nurses, General Practioners and Aboriginal Health Workers will participate in
the delivery of the education package to the elderly community. Runciman 62
2006 stated that health promotion was an important part of the role of the
community nurses, and is often embedded in their daily work. Abbott 63 states
that Aboriginal Health Workers have an important role as educators and health
promoters within their communities. The role of doctors, nurses and aboriginal
health workers in health education within the community is an important one, as
they are often the only source of appropriate health messages, and are held in
high esteem by the community.
2.12 Conclusion
This chapter provides a review of the literature, and identifies the search
strategies employed and an overview of studies relating to the different aspects
of the research question. Areas covered included the ageing population, and
although much of the literature examined differs in opinion on ageing and the
future of health care costs, they all conclude that the ageing population should
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49
have a greater responsibility in maintaining their own health and well-being.6, 21,
24
Examination of the literature concerning burns in the elderly, studies shows that
although survival from burn injuries continues to improve across almost all age
groups, this is not the case with the elderly. For many reasons, including the
psychological and physical features of the ageing process, the prognosis for our
elderly burns patients does not always reflect this improvement.1, 2, 27
Comparing studies is difficult due to many factors, the main factor being that the
definition of elderly is not uniform between the studies, with the cohort‟s ages
varying from 55 to 75 years of age. This makes comparing the studies
accurately difficult, as a discrepancy of 10 to 20 years can make a significant
difference in burn outcomes as the Lundgreen and Pham 4, 27 studies show with
their age stratification.
In addition, an overview of the published information on the impact of first aid
measures and a summary of the literature concerning elderly education were
discussed. It is known that effective first aid can have a major impact on the
patient outcome.40 Therefore, an important question is whether a lack of first aid
administered at the time of the injury has a significant impact on morbidity and
mortality. It is disappointing that many studies do not factor in first aid
administration into their research. Due to the many changes that occur during
the ageing, process educating the elderly needs careful consideration. Their
individual and differing characteristics can affect how they learn and all of these
factors should be taken into consideration when planning and choosing the
correct learning theory for an education package for the elderly.18
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50
Social Constructivism theory was examined, and was found limited in scientific
research. Most articles located were interpretations of Social Constructivism by
the author with every author seeming to have a different interpretation of the
theory, although the base reasoning was the same. Social constructivists
believe that learners actively construct knowledge, that their learning is based
on their previous experiences, and that they create meaning through the
interaction with their environment as well as social interaction with each other.56,
57
Literature on research methodology particularly mixed methodology was also
reviewed and Burke Johnson 59 2004 states that both quantitative and
qualitative methods have safeguards to minimise bias and use empirical
observations. Many disciplines conduct different types of research relevant to
their field within a specific area. All of this research is relevant to the overall
understanding of the topic, so researchers benefit in understanding both
methods.59
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51
Chapter Three Methodology
3.1 Introduction
Burns in the elderly are complex, severe, take longer to heal, and need
extensive rehabilitation compared to the younger adult age group.2, 7, 26
Community assessment is an important first step to designing and developing
any educational program and therefore it is important to ascertain the views and
understanding of burn injuries, first aid treatment, and preventative measures in
an elderly population within the community.47
The research aim is to develop the framework of an education package
targeting the elderly over 65 years who live independently in their own homes or
a retirement village. This will provide them with the education they need to
prevent burns in the home and to know the appropriate first aid should a burn
occur and the following research question was considered.
What do the elderly population of Western Australia know about know of burn
injuries, burn first aid and preventative measures?
The aims of the research are:
To determine the baseline knowledge of the elderly in burn
preventative measures
To determine the baseline knowledge of the elderly in burns first
aid knowledge
To determine if cost is a factor for lack of preventative measures
such as smoke alarms, first aid training, hot water temperature
gauges.
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52
To determine if the elderly have any cultural beliefs regarding
burn first aid.
To determine if the elderly feel an education and prevention
campaign would be of benefit
To use the outcomes of the study to develop an education
package on the subject of burns first aid and preventative
measures
The target group for the education program was the independent elderly aged
65 years and over living in their own home or a Retirement Village. These
participants are most at risk of receiving a burn injury due to their independent
living, and would be the most able to participate in the education program and
implement the burn prevention strategies.
A cross sectional descriptive study design was used, with data collected using
surveys featuring both quantitative and qualitative items and focus group
discussions.
This method was used as it is a simple descriptive or observational study that
can be conducted on a representative sample of a population, and are useful to
gather information on health-related aspects of people's knowledge, attitudes,
and practices which is the aim of this study. This was chosen as many studies
have been conducted to measure the efficacy of such programs as family
planning, anti-smoking measures, and other public health and health-promotion
interventions and therefore is a suitable method for this study.
64
The data collection methods facilitated the retrieval of demographic information
and definitive data on the participant‟s knowledge of burn injury, prevention, and
practices concerning burn first aid. Data collected included factors important for
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understanding their learning needs, the beliefs of the participants, and the
teaching strategies that will need to be developed.
Quantitative research is mainly used to test a hypothesis or theory, while in
contrast, qualitative research facilitates gaining a greater understanding of the
topic being researched.60 Martin 58 describes quantitative research as focusing
on discrete and measurable areas in a study, while qualitative research
facilitates an understanding of an individual‟s viewpoints and experiences which
can have a significant impact on a study. Combining the two methods in a
research project can allow a broader and more comprehensive understanding
of the research questions. Burke Johnson 59 suggests that there are similarities
between the two methods as both use empirical observations and have
safeguards to minimise bias. Furthermore, as today‟s health research is often
conducted within a multidisciplinary forum, an understanding and blending of
both methods to facilitate communication between various disciplines is
necessary. Although combining both methods can be a complex task, which
requires a comprehension of both quantitative and qualitative research, it
provides a richer context to the research.60 This research study mixes the
quantitative and qualitative methodologies, although is predominantly qualitative
nature.
3.2 Recruitment
The decision of where to recruit participants was influenced by the proposed
target groups for the education programme, and therefore it was determined
that Senior Citizen Centres within the Perth metropolitan and country areas
would provide the most suitable populations. Twelve Perth metropolitan centres
were chosen randomly by the researcher, using the White Pages to select the
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Senior Citizen Centres, and they were invited to participate in the study.
The presidents of Senior Citizen Centre committees were contacted by
telephone and asked to consider participation in the study, with most agreeing
to discuss the issue at their next committee meeting. The Senior Citizen
Centres, which declined to participate, cited disinterest in the study generally, or
disinterest due to a higher percentage of older seniors with physical disabilities
such as deteriorating eyesight and dexterity within their centres. Of the twelve
centres contacted, six agreed to participate in the study, and an information
pack containing a formal letter of introduction, and an information sheet on the
study was distributed to them. (Appendices 2 & 3) Four of the six centres who
agreed to participate were within the Perth metropolitan area, with two centres
in the country areas of Geraldton and Busselton.
Four weeks from the initial contact with the Senior Citizen Centres, a second
mail out was conducted for the six senior centres, consisting of twenty surveys,
consent forms and information sheets for the study. Of the six Centres, five
responded to the second mail out. (Appendices 3- 5) A follow up with the sixth
centre by phone, resulted in an agreement that they would return the surveys,
though this was not achieved by the closing date of the survey.
As only six centres had agreed to participate, it was determined that the
invitation would be extended to five Retirement Villages and one church group
randomly chosen from around the Perth metropolitan area. Telephone or
personal invitations to participate in the study were extended to these five
retirement villages and the church group. Two retirement villages and the
church group accepting the invitation. Consequently, these groups were sent
the information pack containing the formal letter of introduction, the information
sheet on the study. In the follow up mail out one week later, each of the
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retirement villages were provided with 20 surveys, information sheets and
consent forms, while the church group received only five of each due to only
five people meeting the inclusion criteria. (Appendices 3-5)
Two centres agreed to participate in the focus groups, one country Senior
Citizen centre and one Church group.
3.3 Sample
A convenience sample of one hundred and sixty five people over the age of 65
years participated in the study, with a response rate of 41% (n=68), with five
surveys excluded as they failed to meet the age criteria. Of this figure, thirteen
people participated in the focus group discussions. Convenience sampling is a
non-probability sampling methodology, which does not claim to represent the
wider population. Therefore, the findings of this study may not be generalised to
the main population due to the limitations of the method of sampling and the
small size of the study.65
The surveys, which were distributed by the researcher, the Senior Citizen
Centres, or the Retirement Village chairpersons, and included a stamped
addressed envelope to enable the participants to complete the survey in their
own time and return them to the researcher. The participation of the country
centres provided a broader perspective of the knowledge Western Australian
elderly concerning burn first aid and preventative measures, which will allow the
education package to be better targeted to all elderly people throughout
Western Australia.
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3.4 Data collection
Data was collected using a survey and conducting focus groups. This section
discusses the purpose of the survey and the development of the instrument tool
with a table summarising the research survey tool. Reliability and validity are
discussed, as are aspects of the focus group discussions.
3.4.1Survey
The title of the survey was „Developing an Educational Framework for Burn
Prevention and First Aid in an Elderly Population: The role of beliefs,
knowledge, understanding and practices‟ (Appendix 5). The purpose of the
survey was to gather demographic data such as age, marital status, and living
arrangements and to gain a comprehensive picture of the knowledge and views
of the elderly concerning burn first aid and preventative strategies.
3.4.2 Survey Instrument Development
The survey items were designed to help gain an understanding of the burns first
aid knowledge of the target population and included two parts with part A
consisting of four case scenarios relating to a burn injury situation, with five
multiple-choice answers from which to choose. The questions were adapted
from those used in previous research at Royal Perth Hospital and redesigned to
assess current practices and beliefs of the elderly concerning burn first aid and
are representative of burn injuries seen at the State Adult Burn Unit.40, 66
. Part B consisted of four multiple-choice questions relating to demographic
information and 24 structured and unstructured dichotomous and multiple-
choice questions with the use of some contingency questions, the unstructured
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questions were designed to obtain more in depth knowledge from the
respondents on a particular topic.
The remainder of the questions were divided into four sections, with the majority
of questions consisting of dichotomous and multiple-choice questions with the
use of some contingency questions for further information. The four focal areas
related to firstly, activit