Emotional impact of clinical practice in Burns Unit among nursing students: a qualitative study.

BACKGROUND AND AIM OF THE WORK: In Burns Units, the long professional relationship with patients suffering from intense physical pain and psychological distress, which cannot be completely resolved or minimized, exposes nurses to very intense emotions and stressful experiences. Learning to care for patients with such medical conditions can arouse many emotions also in nursing students, that can be both positive and negative. The goal of this study was to describe the emotional impact experienced by nursing students in a Italian Burns Unit.
METHODS: A qualitative research was implemented among 16 undergraduate nursing students, before and after clinical practice in a Burns Unit, through a semi-structured interview.
RESULTS: Strong and conflicting emotions from nursing students were reported in the preliminary stage of the internship. Their enthusiasm and curiosity for a new opportunity countered their fear and anxiety of not feeling able to deal with the clinical situation. The internship experience ranged from emotions of joy at the healing of patients to impotence and frustration at not being able to alleviate intense and lasting suffering. All students reported that the internship was experienced as an important opportunity for personal and professional growth.
CONCLUSIONS: In light of the results, we highlight that nurse trainers should support students to take full advantage of this training, helping them to express their emotions and, in the same time, to learn to manage them profitably.

Introduction

Caring is considered the foundation and the essence of nursing. In fact nursing’s assistance which adopt caring is associated to a better quality and safety in treatment, as well as better satisfaction in patients (1, 2). The caring competences development must be considered one of the main aims in nursing education and the role of clinical placement is recognized as fundamental in this regard (3-5).

Learning possibilities about caring abilities from nursing students are influenced by the quality of the learning environment (5, 6) and by the training in clinical practice which increases a humanistic vision of caring from both theoretical and practical knowledge (7). The expressive component of caring performs an essential professional requirement of the future nurse, as the knowledge of care it feeds not only on knowledge and practical experience but also, and mostly, on soft skills which precede and overcome the limits of technically oriented act. Inevitably, those who choose by profession to create helping relationships offer themselves to other by showing everything they are (8), aware that emotional echo is the basis of the care relationship, whose essence is sharing with the other. Empathy and communication skills, respect, attention, motivation, resilience are just some emotional skills that a care professional must strive to achieve (9-12). Educating in emotional skills is not only about ability to accept other’s emotions, but also practice listening to one’s own.

The scientification of medicine risks fueling an idea of anonymous and aseptic care, which often leads to neglecting the development of affective-relational skills in the training of health professions, focusing mainly on the training of technical aspects (9, 13).

This constitutes a fragility factor for professional, which will have to learn alone and with effort to accept their own weakness, to tolerate frustration, to give hope. Nurses who are in daily contact with fragility and precariousness of life, like in ITU (intensive therapy unit), realize that scientific competence is not enough to face pain and they fell the need to find places, time and instruments to elaborate their own feelings (9, 14).

The responsibility to deal with live and the intensity of interpersonal relationship with patients and their relatives can expose the nursing team to psychosocial risk factors.

In high specialized units, like Burns Units, long relationship with patients in deep emotional and physical pain, which cannot be solved or minimized by nursing, exposes nurses to intense emotions, which can boost up the stress experience (15, 16). In the care to burn patients, nursing team need to face with a big work routine, pain and death, uncertainties due to the burn’s consequences and other many factors, not just related to patients but also their relatives (17). It has been noticed that taking care of a burn patient is connected to many stress factors, and it’s considered extremely exhausting and it can cause changes in nurses health (17, 18). A cross-sectional study conducted among Israeli clinicians has found that care of burn survivors can lead to burnout, compassion fatigue, and vicarious trauma (19). Learn to care and help patients involves different emotions that could be both positive and negative. Also, clinical training can cause strong emotional reactions in students, even if they provide big learning opportunities (20). As suggested Shapiro, healthcare students need to learn how to manage their own emotions as well as the emotions of their patients (21). High-complexity units like Burn units could expose nursing students to emotionally demanding situations that often challenge confidence in their professional skills and may weaken student’s determination to pursue a career in this type of unit.

There are few studies about nurses’ emotional involvement in burn units, and about their stress management. We don’t know enough about how students experience these situations, how they receive support and what they learn from these experiences (17, 18, 20, 22).

It seems very important for nursing education to investigate these issues in order to obtain useful data for updating training opportunities.

So, the main goal of this study was to understand the emotional impact experienced by nursing students in a high complexity Burns Unit.

Methods

This study uses a qualitative design. It consists in qualitative data collection in two different steps during nursing students’ internship in a Burn Unit. Data collection tool consists of semi-structured interview, conducted before and after internship. The consolidated criteria for reporting qualitative studies (COREQ; 32-item checklist) was followed for reporting results (23). The study was conducted from year 2015 to year 2018.

Setting

The study was performed in a Nursing School in a Northern Italian University. The Burns Unit is one of the most specialized in Northern Italy. It’s a specialized center with intensive and semi-intensive therapy unit for adults and children, and the head office of the regional skin bank.

Participants

The participants were nursing students, at third year, that had the possibility to make their training in high complexity wards. In this University, only few students ask to make their training at Burns Unit (8 out of 70 third year students per year), and un to 10% of these give up during the training period; this represents one of the biggest dropout school rates in front other Units. Furthermore, about 10% of third year students makes a specific request to not make his training in Burns Unit, because of personal problems that make them believe they’re not ready for this assignment. Therefore, we recruited third year students of Nursing, who attended the Burns Unit from 2015 to 2018. Invitation to participate in the project was given to all students entering the internship in the Burns Unit in that period.

Data Collection

Students, allowing to take part in the project, were subjected to two interviews each. The first interview concerned about a set of questions about emotions and feelings they were living and about the strategies that they thought they could apply to cope with these emotions. The same questions were asked at the end of the internship. Again, at the second interview, were asked to students to share with the group a moment that had particularly touched them emotionally. Interviews were conducted by an expert nurse in qualitative interview and a graduated nurse, properly prepared.

Data Analysis

Interviews, made before and after internship, were coded before and then wrote down verbatim. On the written text has been make thematic analysis according to Braun e Clark method (24). We focused the analysis on emerging themes but also on emotions and meanings that the professionals attributed to their statements.

Ethical considerations

Study participation was optional. All data were handled anonymously, confidentially and consent was obtained from all students participating in the study. Management cleared the study before it was conducted.

Results

In total, 16 students took part of study and each of them was submitted to interview before and after training.

1. Before training

Strong and contrasting emotions and feelings

The students, before practical training, had strong and contrasting feelings. Different participant answers showed coexistence of emotions even ambivalent, for example: happiness sensation and joy associate to fear and anxiety.

“I feel curious but at the same time I’m afraid and anxious to be not qualified” (cod.2, pre);

“I find in myself a sense of ambivalence which I think is normal in this kind of situation” (cod. 5, pre).

Joy and curiosity

Deepening emotions dimension, these included joy and curiosity. These emotions are connected to practical training, which represents an opportunity to personal and professional improvement for students. This is further supported by the fact that Burns Unit is an high specialized center, and patients have different needs compared to patients in more traditional wards.

“I feel joy because I think that this experience can help me to grow”(cod. 3, pre);

“I’m really enthusiastic about this internship because I think that I could obtain a lot emotionally”(cod. 9, pre);

“I’m enthusiastic and excited because this Unit is completely different from others where I’ve been already” (cod. 5, pre).

Moreover, joy was also associated to “privilege/honor” to log into this training opportunity in Burns Unit. In fact, because of caring and psychological complexity, internship in this Unit is allowed only to third year nursing students.

“I feel privileged, it’s a new experience that few people have the chance to live” (cod. 1, pre).

About the second emotion mentioned, students expressed a deep curiosity toward a reality beyond the most traditional and knew units, feeding enthusiasm and willingness to face new challenges, even if they don’t anticipate what they could deal with and how they will react to certain situations.

“I’m happy because difficulties are not synonymous of bad experience, considering that I faced small and big mountains during all my scholastic route and at the end these brought me to breathtaking views. I can’t wait to see what is waiting me! I can’t wait to meet so many stories” (cod 12, pre).

However, at the same time, inability to image what he could face and how he will respond to this type of patient, produce also fear, and alarm in their different meaning, whit focus on anxiety.

Fear and anxiety

For some students and mostly for those who the Burn Unit represents the first critical experience, fear and anxiety were connected to care complexity that awaited them.

“I’m definitely afraid of the ward because of the patients… or for not being able to face emergency situations”(cod. 6, pre);

“It’s an emotion full of anxiety connected to all the thing I will have to pay attention, to complexity of welfare activities and the burns patient” (cod. 12, pre).

Another aspect which causes anxiety is the impact with the burns body of the patient. Students fear the burn itself and they are aware of all the care needs of those patients. Students are not sure if they can touch wounds and to be able to care this type of patients. The typical smell of this wounds is another difficulty factor. On the other side, besides problems connected to the physical care of the patient, other fears arose from the think to cannot deal properly the emotional aspect and leave that technical components of their duties darkened the relationship with patient as well as his psychological needs.

“My biggest fear is that I could lost key moments on the relationship nurse-patient, focused myself only on his body and how to managed it” (cod. 8, pre).

Another aspect of the fear was the one to be inadequate and unable to face the situation emotionally, not be able to overcome situations totally new and become emotionally very involved. At the same way, the fear to injure the patient produces also a great anxiety; students think that they cannot overcome such a concern.

“I’m afraid that once in front of the patient I will not be able to pass what that I really want… that I will not be able to do or say the right thing for the moment” (cod. 3, pre);

“I feel fear and anxiety because I think that I will not overcome what I will see or feel, not only from a practical point of view but mostly emotional. I don’t think I will be able to manage so much pain” (cod. 2, pre);

“I’m afraid to become stiff in front of some situations. I’m scared of behaving embarrassing” (cod. 12, pre).

2. After training

Same emotions as the pre, but faded and new emotions

Most quoted emotions are placed on the emotions emerged in the pre-training, and there are some new. It’s interesting to see, however, that recur feelings were less emphasized after they performed internship.

Fearand doubts/uncertainties

During first weeks of practical training, students still reported fear and doubts connecter to their lack of knowledge of this type of patients. Some students affirmed:

“I didn’t know how to get closer to patient and at the beginning I felt out of place” (cod. 10,post);

“In the first days I felt intimidated and inadequate in front of sick people” (cod. 5, post).

From fright to sadness

Like before practical training, students feared to hurt patients during care procedures, and this caused sadness and deep distress after ward’s experience. Participant, many times, show this sadness which born from perceived inability to relive the pain of the patient.

“I felt really sad because I saw patients suffer and I didn’t know how to relieve their pain” (cod.4, post);

“During wounds medication I remember the look of that man, which seemed beg us to stop and his body that, exasperated, revealed an unimaginable pain. That day I had to stop for a moment, I could not carry on” (cod. 8, post).

This sensation led student to an inner analysis and allowed him to understand the lasting impact that burns have for the patients, not only in their body but also in their interiority. The participants express their sense of powerlessness in front of such a suffering patient:

“I was and I am sad to see physical scars that don’t disappear and leave big psychological impact on the patients” (cod. 9, post).

“I was in the follow-up clinic. Patients come back to checks also few years from accident. A child came with her parents. I invited her to sit on the hospital bed and show me her burned area. I never realized how embarrassing could be this simple request. She was ashamed. […] At the end of the visit she asked to the doctor if scars would last forever. I felt powerless. I don’t know if I was feeling empathy and I don’t expect to give a name to that emotion. However, in that moment I understand that the burn lives with you forever” (cod. 2, post).

Difficulties to confront with deep patient pain

Face up to patients’ pain has been described as difficult, because it often left the trainee speechless

“The main difficulty in this unit, that I have ever felt so strong, is connected to the deep scar that patient wear, a wound that usually does not heal with time…a wound in the soul. The traumatic event which caused burns keeps to be alive in patient every time that he looks at his own body.Why me? Why I allowed that this happened? I’ve been reckless.” I found difficult to find an answer to these questions” (cod. 8, post).

Emotions so far expressed in the post featured mainly the first part of practical training. Over the time and with acquisition of a role in the team, students became safer and more independent, mitigating their fears and leaving space to new satisfaction emotions.

Joy and satisfaction

All the students admitted to feel joy both towards the patient and themselves. An important part of this sensation was connected to improvement of clinical conditions of patients, raising student from pain and uncertainty, triggering a sense of happiness and success. On the other hand, this sensation is referred also to the same students. They felt joy to achieve their own progress and for the opportunity to learn something new every day.

“Professionally I felt joy because every day I was going home aware to have learn something new and because I was able to confront myself with such a critical patient and this strengthened my professional self-esteem” (cod. 3, post).

When students discovered an inner resource, of which they were not aware, their self-esteem has grown, making them feel proud of themselves to not having interrupter the practical training, despite difficulties.

Professional growth

At the end of internship, students agreed that this experience has provided them a great professional and personal growth. They were aware that the ward and the patients met have a strong impact on them and changed them forever. For some of them has been another confirm that this was the right way and encouraged them to maintain enthusiasm to keep growing like professional.

“I realized that this is more than a job. I realized that every day passed in these units, between these people, has more to do with my identity and the person I will be, rather than become a professional” (cod. 12, post);

“This ward changed my, it helped me to grow not only like a nurse but also like a human” (cod.1, post);

“When I arrive in Burns Unit, like often happened, I didn’t understand how deeply this experience would influence me. Only at the end of the experience I understand that something inside me changed” (cod. 12, post).

Discussion

Caring for burn patients can be a unique learning experience which can induce profound professional changes in nurses and in all other healthcare professionals. The emotional aspects of inexperienced nursing students approaching Burns Unit for the first time is an open topic. While it is recognized that nursing duties in intensive care units often go beyond the technical tasks for caring for patients’ physical needs, not much recognition is given to preparing students –as well as experienced professionals– on training for the more transversal skills such as empathic communication and stress management (22, 25). Although this experience can promote effective learning by itself, the emotional impact of highly complex Burns Unit on nursing students should be better evaluated. In interviews conducted prior to clinical experience, students reported experiencing strong but also ambivalent emotions and feelings. In line with the literature, our students found the experience attractive, but, at the same time, stressful (26). Many participants expressed fear and anxiety about the complexity of care that they feared might divert their attention from human and emotional needs of patients. Another fear consisted in not feeling able to bear the emotional impact of such a painful condition due to the excessive emotional involvement in the sufferance of people cared for (25, 27). Emblematic was the statement of a student who literally reported “I don’t think I can manage so much pain”.

Although unpreparedness in facing complex situations in a high-complexity unit may cause stress repeatedly throughout a nurse’s career. These aspects were relevant especially for younger inexperienced nurses who attended the Unit, as in our case, among whom fear was a prevalent feeling, as reported in another study (28).

Differently to experienced nurses, who have gained confidence through years of nurse-patient interaction, students let themselves be overwhelmed by fear. In the medical fields, emotions accompany the learning process (18, 25) and the emotional impact varies based on the context. When facing setting of high assistive complexity yielding a high emotional impact, the emotional answer has a relevant effect, so it becomes fundamental to make a pondering experience. The pondering experience should be transversal to all the contexts to train the student to express his/her emotions and it should be sustained by constant and well-structured tutorial support. The pondering on the experience becomes a key tool to make students aware and provide them the tools to cope with new situations. These findings are in line with the study by Bayou et al. (18) that underline how there is a need to establish structures that can encourage burn care nurses to verbalize their feelings.

Given the emotional impact student experience in working in a high complexity unit, we believe being able to analyze one’s feelings to be able to name them appropriately and sharing them is a skill worth teaching and that could be implemented in the future development of students training programs even with simulation (29). In nursing education, technical preparation must be accompanied by the development of emotional intelligence which represents the “ability to recognize our and others’ feelings, to motivate ourselves, and to positively manage our emotions, both internally and in the social relations” (11). At the same time, the participants recognize the privilege of being placed in a very formative clinical context for their future professional career and express their enthusiasm and curiosity for a strong learning opportunity. As highlighted by other authors, what made the internship in the Burns Unit attractive was the novelty of the learning, skills and experiences the interns acquired (26).

At the end of the internship, the students talk about the emotional impact mainly due to the inability to relieve the physical pain of patients and the feeling of helplessness experienced in the face of profound psychological suffering. The burn was experienced as a permanent event, which remains forever in the patient’s history, even after years with its scars and the shame to show them. Students during the internship experiences tended to empathize with the patient as observed in a recent Iranian study: “The horrible appearance of the patients and other physical and psychological problems imposed on them all make the students feel empathic and perform care services empathetically” (26). At the same time, the joy for the improvements in the patients’ conditions was also a strong emotion when students attended a Burns Unit.

With the passage of time in Burned Unit, students reported a metamorphosis in their attitudes since they felt more confident and independent in caring for patients with a reduction of their fears and a greater satisfaction for their professional growth. At the end of the internship all participants agreed that this experience had helped them to professionally and personally grow.

Since a purposive sampling was used, therefore we cannot generalize our results to the population of nursing students. The strength of the present study is represented by the report of theemotional feelingsexperienced by nursing students in a such stressful clinical context as Burn Unit using a qualitative approach. These results can encourage trainers to improve this experience, learning from care for burn patients.

Conclusions

This qualitative study reports the emotional impact experienced by Italian nursing students who attended a Burns Unit.

In the preliminary phase of the internship, strong and conflicting emotions were reported by nursing students who experienced enthusiasm and curiosity countered by fear and anxiety due to emotionally involving feelings in the clinical situation. The internship in Burns Unit led them to experience emotions of joy for the recovery of patients, but also helplessness and frustration of not being always able to alleviate the patient’s sufferance that can be profound and lasting.

All students reported that the internship was experienced as an important opportunity for personal and professional growth. Considering that students experienced strong and ambivalent emotions, it is considered very important that nurse trainers support students in order to take full advantage of training, helping them to express and learn managing their emotions in a profitable way.