Navigating the big picture: A qualitative study of burn nurse perspectives on goals of care for patients with burns.

Abstract

Clinical burn care engages several dimensions of life-limiting illness, including acute resuscitation, reconstructive surgery, and rehabilitation of disabilities. At the same time, little is known about how burn providers achieve goal-concordant care for their patients. The value of primary palliative care skills in surgical specialties has been increasingly recognized. We asked: What are currently observed practices and challenges of burn providers in addressing goals of care? This is a qualitative study within a single verified burn center in an urban setting. We conducted semi-structured interviews with registered nurses with at least one year of experience working in a mixed burn ward and critical care setting who were recruited by in-person snowball sampling. Interviews were recorded and transcribed; themes were generated iteratively using Braun and Clarke's thematic analysis and were coded via Dedoose software. 14 nurses were interviewed, who had worked an average of 5.4 years in the unit. Five broad themes emerged from interviews: (1) Burns decision-making; (2) Burns prognostication; (3) Communicating quality of life; (4) Nurse as patient advocate; and (5) Patient psychosocial situation. Navigating goals of care discussions for burn patients is often burdened by uncertainty and stagnation in their clinical trajectory, as well as effective communication of anticipated quality of life. Burn nurses contribute to goals of care discussions outside of formal provider interactions, where they frequently encourage families and patients to ask "big picture" questions and manage expectations of function and recovery. Ultimately, the challenges identified in this study in attaining goal-concordant care for burn patients serve as potential points of intervention in provider education to improve the quality of primary palliative care more broadly.