The experience of wearing compression garments post-burn injury: a qualitative study of patient perspectives and recommendations for practice

Background: Burn injuries most often result from catastrophic events, leaving the individual with multiple impairments that require intensive and extensive medical treatment and rehabilitation (Elsherbiny, Salem, El-Sabbagh, Elhadidy, & Eldeen, 2011; Kornhaber, Wilson, Abu-Qamar, & McLean, 2014; Sliwa, Heinemann, & Semik, 2005).  Burn injuries can lead to a broad range of physical and psychological changes for the individual patient, including the development of hypertrophic scarring.  Hypertrophic scars appear different to surrounding healthy skin in that they can be raised, and have a different texture and colour (Tredget, Levi, & Donelan, 2014). If hypertrophic scarring is untreated, the collagen fibre deposition undergoes reorganization, which can cause skin contractures and scar related problems such as movement restrictions, itch and heat intolerance (Ladak & Tredget, 2009). Patients are requested to adhere to lengthy, at times painful, and intensive rehabilitation programmes to manage hypertrophic scars.Compression garments have been used since the 1970s as part of an intensive rehabilitation programme for the management of hypertrophic scars (Atiyeh, El Khatib, & Dibo, 2013; Bloeman et al., 2009; Macintyre & Baird, 2006; Van den Kerckhove et al., 2005). Compression garments rely on a firm fit and prolonged wear (23 hours per day) to ensure that sufficient pressure is applied to inhibit scar growth and optimise scar management (Atiyeh et al., 2013; Bloemen et al., 2009; Ladak & Tredget, 2009; Macintyre & Baird, 2006; Tredget et al., 2014; Williams, Knapp, & Wallen, 1998). The aim of compression garment wear includes direct influence on hypertrophic scar tissues as well as improvements in physical limitations including skin contracture and itch.  Compression garments have been reported to reduce hypertrophic scar growth in 60-85% of patients (Atiyeh et al., 2013; Reno, Grazianetti, & Cannas, 2001; Yagmur, Akaishi, Ogawa, & Guneren, 2010).  The use of compression garments, however, can cause increased pain, heat intolerance, and skin breakdown for some patients (Johnson, Greenspan, Gorga, Nagler, & Goodwin, 1994; Macintyre & Baird, 2006; Ripper, Renneberg, Landmann, Weigel, & Germann, 2009; Stewart, Bhagwanjee, Mbakaza, & Binase, 2000).  Adherence to compression garment wear has been reported as low as 41% (Johnson et al., 1994). With evidence suggesting positive scar and physical outcomes associated with wearing compression garments, it is important to understand why intensive wear might be difficult. Limited literature is available to explain the patient experience of wearing compression and what experiences make wearing compression difficult. Therefore, it is essential to investigate the patient experience of wearing compression garments and the influence of certain experiences on patients’ ability to continue wearing compression garments.Aims: The first aim of this research study was to gain an in-depth understanding of the patient experiences associated with wearing compression garments post-burn injury and identify potential reasons why patients remove their garments. A second aim was to identify what changes could be made to improve the experience of wearing compression garments post-burn injury.Method: A qualitative research design was used, with interpretive description as the methodological approach.  Using purposive sampling, 15 burn patients (aged between 24 and 61 years, 8 men and 7 women) were recruited to the study. Eleven patients were recruited over a twelve-month period for interviews, while a further four burn patients were recruited from the hospital burns support group to participate in a focus group. Five occupational therapists currently working within the burn unit participated in a second focus group. Data analysis was undertaken using the six stages of thematic analysis described by Braun and Clarke (2006) to identify themes.Results: Five significant themes were identified from the burn patient and occupation therapist data. The first three themes were derived from burn patient data only and described the burn patients’ experiences of wearing compression garments and included the physical and emotional experiences of wearing compression garments, the experience of being a patient within the burns service, the impact of wearing compression garments. Themes four and five, patient strategies and recommendations for service provision, were built from data from burn patients and occupational therapists. These themes highlight potential modifications to service provision to improve the experience of wearing compression garments, including increased education options, peer support and shared decision making.Conclusion: The findings of this research contribute to an increased understanding of patient experiences associated with wearing compression garments post-burn injury and point towards a number of recommendations to improve these experiences. With such understanding and potentially enhanced service provision, burn patients may be able to wear compression garments more consistently to achieve optimal scar outcomes. With optimal scar management and subsequently improved physical and psychological outcomes, enhanced patient adjustment to life post-burn injury is possible.