The incidence of burns has significantly increased over the last decades. Although there is an extensive amount of literature on burns related injuries in Kenya, there is no evidence of studies which have examined barriers to quality nursing burn care in public health facilities in the country.
To examine factors hindering quality nursing burn care at Moi Teaching and Referral Hospital.
Material and Methods
Six variables were assessed namely nurse age, nursing responsibility, availability of consumables, pre and post-operative care, staffing and the equipment which is always working and in good condition.
Availability of consumables negatively predicted barriers to quality nursing care among nurses who were currently working in the burn unit (t = -2.37; p = 0.02). And a positive predictor among those who had worked in the burn unit before (t = 2.00; p = 0.05). Equipment always working and in good condition was a positive predictor among nurses who had never worked in the burn unit (t = 2.38; p = 0.02).
Staffing, proper working equipment and availability of consumables are major barriers to the provision of quality nursing for burn patients.
The incidence of burns has significantly increased over the last decades (1). Developing countries alone, account for nearly 95% of all documented cases, with the majority of the cases being reported in the poorest and remote areas in these regions (2,3). The stack reality is that it is becoming a major public health problem (1).
Unfortunately, these regions lack a surmountable amount of resources to reduce the incidence and the severity of injuries attributed to burns (3–5). These include a lack of trained staff and advanced equipment to manage burn injuries (4,5).
The distribution of burn injuries may differ significantly with gender, income and age groups (6,7). However, the majority of these cases occur in domestic settings where cooking takes place (8). Fuels for lighting, heating and cooking are listed as the main contributors (9).
In Africa, burns remain a public health concern due to their high incidence and the inability of the region to manage the cases (1). It is estimated that 6.1 per 100,000 burns related deaths occur annually in Africa (10). Apart from death, other poor outcomes include long recuperation time and even paralysis (11,12).
About 32,633 burns were recorded in Kenya in 2010 (13). Although there is an extensive amount of literature on burns related injuries in the country, there is no evidence of studies which have examined barriers to quality nursing burn care in public health facilities.
2.0 Materials and Methods
2.1 Study Design
The study was cross-sectional in design.
2.2 Study Site and Participants
The site was Moi Teaching and Referral Hospital (MTRH) the second-largest and the only national referral health facility outside the Kenyan capital, Nairobi. The 800-bed hospital has a 21bed burn unit. There were 23 patients admitted to the unit at the time of the study. The study targeted all the nurses who had been employed at the time on a full-time basis. A total of 195 nurses were randomly selected to participate in the study.
2.3 Data Collection Procedure
A semi-structured questionnaire was used to collect data. Four research assistants were recruited, trained, and engaged in administering the questionnaire. Data was conducted from May 2016 to December 2016.
2.4 Data analysis
Hierarchical regression was used to predict barriers to quality nursing burn care among nurses who were currently working in the burn unit, those who had previously worked in the unit and those who had never worked in the burn unit. Six variables were assessed namely nurse age, nursing responsibility, availability of consumables, pre and post-operative care, staffing and the conditions of the equipment.
2.5 Ethical Consideration
Moi University and MTRH Institutional Review and Ethics Committee (IREC) reviewed and approved the study. All nurses who participated in the study consented verbally and without coercion.
3.1 Characteristics of the Nurses
Majority of the nurses were females (n = 124; 63.6%). The proportion of male and female nurses who had never worked in the burn unit differed slightly (47.3% vs. 49.0%). Most of the nurses who previously worked in the burn unit were males (n = 24; 64.9%) and vice versa for those currently stationed in the unit (n = 43; 62.7%).
A large proportion of nurses reported having undergone in-service training in burn management (n = 171; 87.7%). However, about half of those who had undergone such training had never worked with burn patients before (n = 93; 47.7%). Interestingly, most of these nurses were approaching the legal retirement age (62.0%). See Table 1.
Table 1: Characteristics of the nurses
3.2 Condition of the patients in the burn unit
Close to two-thirds of the patients in the burn unit were adults (n = 17; 73.9%). About 60.9% (n = 14) of the patients were males. Most of the injuries were either work-related (n = 11; 47.8%) or due to domestic violence (n = 8; 34.7%). The majority of the injuries were third-degree burns caused by electric faults, open fire, scalds and corrosive substances (n = 16; 69.6%). Overall, scalds were the main cause of the burns (n = 13; 56. 5%). The mean hospital stay was 34.4 days. The majority of the patients rated their condition as improved (n = 16; 69. 6%).
3.3 Barriers to the provision of quality burn care
The hierarchical regression predicted a significant portion of barriers to quality nursing burn care among the three categories of nurses (r2= .68 for the nurses currently working in the burn unit, r2 = .63 for those who have ever worked in the burn unit and r2 = .45 for those who have never worked in the burn unit).
Nursing responsibility, specifically post-operative care, was a consistent barrier to the provision of quality nursing burn care. Pre-operative care positively predicted barriers to the provision of quality nursing burn care among nurses who had never worked in the unit. After controlling for nursing responsibility, staffing consistently predicted barriers to the provision of quality nursing burn care across the three categories.
The influence of the nurses’ level of education across the three categories was less consistent. It was affected by the nurses’ ages which were highly correlated with barriers to the provision of quality nursing burn care (r2= 0.68, p < .05for nurses who are currently working in the burn care, r2 = 0.56, p < .001for those who have ever worked in the burn unit and r2 = 0.60, p < .001 for those who have never worked in the burn unit).
A hierarchical regression with and without the age of the nurse revealed that age was not a suppressor variable. It was therefore removed from the model. Thereafter, staffing positively predicted barriers to the provision of quality nursing burn care. Availability of consumables negatively predicted barriers to quality nursing care among nurses who were currently working in the burn unit (t = -2.37; p = 0.02). And a positive predictor among those who had worked prior in the burn unit (t = 2.00; p = 0.05). Equipment always working and in good condition was a positive predictor among nurses who had never worked in the burn unit (t = 2.38; p = 0.02).
Table 2: Hierarchical regression without nurses’ age for predictors of barriers to quality burn care
* p < .05, ** p < .001
As the study was ongoing, a section of the media reported overcrowding in the MTRH wards (14). The study observed the same in the burn unit which had an excess of two patients. And this could be attributed to the large catchment area of the hospital which spans 23 counties and the neighbouring countries in East and Central Africa (15).
However, sharing a hospital bed is a health risk as it may be a precursor to nosocomial infections. It is also demeaning as it denies the patients their needed privacy. And for this reason, the hospital should take necessary measures to ensure the unit is decongested.
One way to do this is to increase the burn unit bed capacity and if need be, refer non-critical cases to other facilities. Prevention of scalds at household levels could prove more helpful. As scalds are the leading causes of burn injuries among burn patients seen at the facility and this was also reported by Lelei et al. (16) and Odondi et al. (17).
However, the number of injuries attributed to scalds was lower in our study compared to the two studies (16,17). This may be attributed to the differences in the studied population. Unlike this study whose primary focus was on the patients admitted to the burn unit, the two studies targeted burn patients in both the outpatient and inpatient departments.
In terms of staffing, the study observed that the same number of nurses assigned to the 21 patients was managing the additional patients. This increased patient-nurse ratio leads to job dissatisfaction (18). It is also a recipe for burnout and prolonged recuperation (18,19). And contribute to increasing mortality (18). Ultimately, this may prolong in-hospital stay as was seen in the study. And which was longer than that reported by Lelei et al. (16) and Odondi et al. (17).
In order to safeguard against burnout, staffing is critical as it may also offer a multi-specialized team to cater for different levels of nursing (19). This may be easy to achieve in MTRH as it has a high number of nurses who have been trained in burn management. However, most of these skills remain underutilized. And most probably, may go to waste considering that most of the trained nurses were approaching the legal retirement age.
Lastly, post-operative care has a significant impact on the recovery of a burn patient after surgery (20). But this is a demanding task that needs specialized treatment equipment and which should be in good working conditions (21). And this calls for their maintenance to enable them to function well throughout their lifespan. However, the cost of doing so should be low and cost-effective (19). Alongside the equipment, the availability of consumables such as dressing materials must be taken into consideration. Otherwise, all these may affect the quality of burn management.
The study observed that staffing, proper working equipment and availability of consumables are major barriers to the provision of quality nursing for burn patients.
- Wong JM, Nyachieo DO, Benzekri NA, Cosmas L, Ondari D, Yekta S, et al. Sustained high incidence of injuries from burns in a densely populated urban slum in Kenya: An emerging public health priority. Burns J Int Soc Burn Inj. 2014 Sep;40(6):1194–200.
- Sasor SE, Chung KC. Upper Extremity Burns in the Developing World: A Neglected Epidemic. Hand Clin. 2019 Nov 1;35(4):457–66.
- Ahuja RB, Bhattacharya S. Burns in the developing world and burn disasters. BMJ. 2004 Aug 21;329(7463):447–9.
- Atiyeh B, Masellis A, Conte C. Optimizing Burn Treatment in Developing Low- and Middle-Income Countries with Limited Health Care Resources (Part 1). Ann Burns Fire Disasters. 2009 Sep 30;22(3):121–5.
- Stokes MAR, Johnson WD. Burns in the Third World: an unmet need. Ann Burns Fire Disasters. 2017 Dec 31;30(4):243–6.
- Blom L, Klingberg A, Laflamme L, Wallis L, Hasselberg M. Gender differences in burns: A study from emergency centres in the Western Cape, South Africa. Burns. 2016 Nov 1;42(7):1600–8.
- Ali SA, Hamiz-ul-Fawwad S, Al-Ibran E, Ahmed G, Saleem A, Mustafa D, et al. Clinical and demographic features of burn injuries in karachi: a six-year experience at the burns centre, civil hospital, Karachi. Ann Burns Fire Disasters. 2016 Mar 31;29(1):4–9.
- Sadeghi Bazargani H, Arshi S, Ekman R, Mohammadi R. Prevention-oriented epidemiology of burns in Ardabil Provincial Burn Centre, Iran. Burns. 2011 May 1;37(3):521–7.
- Sharma NP, Duke JM, Lama BB, Thapa B, Dahal P, Bariya ND, et al. Descriptive Epidemiology of Unintentional Burn Injuries Admitted to a Tertiary-Level Government Hospital in Nepal: Gender-Specific Patterns. Asia Pac J Public Health. 2015 Jul 1;27(5):551–60.
- World Health Organization. A WHO plan for burn prevention and care [Internet]. World Health Organization; 2008 [cited 2022 Apr 29]. 23 p.
- Weissman O, Weissman O, Farber N, Berger E, Grabov Nardini G, Zilinsky I, et al. Hypoglossal nerve paralysis in a burn patient following mechanical ventilation. Ann Burns Fire Disasters. 2013 Jun 30;26(2):86–9.
- Stiles CE, McLawhorn MM, Nosanov LB, Paul JL, Shupp JW. Burn Injuries in Patients with Paralysis: A National Perspective on Injury Patterns and Outcomes. J Burn Care Res Off Publ Am Burn Assoc. 2017 Dec 27;39(1):15–20.
- Knbs KNB of S, Council/Kenya NAC, Programme/Kenya NAC, Sanitation/Kenya M of PH and, Institute KMR. Kenya Demographic and Health Survey 2008-09. 2010 Jun 1 [cited 2022 Apr 29]
- Otieno J. The Star [Internet]. Report lays bare mess in country’s referral hospitals. 2019 [cited 2022 Apr 30]. Available from: https://www.the-star.co.ke/news/2019-05-10-report-lays-bare-mess-in-countrys-referral-hospitals/
- MTRH. Moi Teaching and Referral Hospital [Internet]. 2018 [cited 2022 Apr 30]. Available from: http://www.mtrh.go.ke/about-us
- Lelei LK, Chebor AK, Mwangi HR. Burns injuries among in-patients at Moi Teaching and Referral Hospital, Eldoret, Kenya. Ann Afr Surg [Internet]. 2011 [cited 2022 Apr 30];8.
- Odondi RN, Shitsinzi R, Emarah A. Clinical patterns and early outcomes of burn injuries in patients admitted at the Moi Teaching and Referral Hospital in Eldoret, Western Kenya. Heliyon. 2020 Mar 20;6(3):e03629.
- Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital Nurse Staffing and Patient Mortality, Nurse Burnout, and Job Dissatisfaction. JAMA. 2002 Oct 23;288(16):1987–93.
- Bettencourt AP, McHugh MD, Sloane DM, Aiken LH. Nurse Staffing, the Clinical Work Environment, and Burn Patient Mortality. J Burn Care Res Off Publ Am Burn Assoc. 2020 Aug;41(4):796.
- Ll S. Postoperative nursing care of the burn patient. Semin Perioper Nurs [Internet]. 1997 Oct [cited 2022 Apr 30];6(4).
- Bittner EA, Shank E, Woodson L, Martyn JAJ. Acute and Perioperative Care of the Burn-Injured Patient. Anesthesiology. 2015 Feb;122(2):448–64.
Our gratitude goes to all the nurses who participated in the study.
All the authors participated in the writing of the manuscript. The three authors formulated the study, collected, and analyzed the data.
The author has no competing interests.
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Copyright (c) 2022 Jared Otieno Ogolla, Joice Ballidawa, Vivian Chemurgor Rono