Post-Traumatic Growth Among Patients Suffering From Burn: A Cross-Sectional Study

Background: Burn and wounds are one of the most serious hospital cases in all healthcare settings, both social and psychological support are needed to overcome all depressive and anxious feelings afterward the burns' incidence. This study aims to assess and evaluate all posttraumatic growth experiences from healthcare professionals after burns and wounds on selected patients with various degrees of burns


INTRODUCTION
Burn injuries, which occur frequently, are best treated through timely medical intervention and the implementation of suitable early therapeutic interventions 1 In Kingdom of Saudi Arabia (KSA) it is common for many burn victims to initially seek treatment at the emergency departments of general district hospitals, rather than being immediately referred to specialized burn clinics. 2 The situation is expected to exhibit similar characteristics in other nations as well.Individuals who have sustained burn injuries are expeditiously transported to the nearest emergency department to receive prompt medical intervention. 3Subsequently, if their condition has been stabilized at the location of the incident, they may be transferred to the closest specialized burn unit for comprehensive management.In instances where there are multiple casualties, hospitals provide triage and emergency care services to burn patients. 4Healthcare professionals employed within these geographical areas frequently receive requests to offer support to the teams present at the location. 5hey possess the capability to be deployed to offer aid in that particular area.Therefore, the proficiency and knowledge of the nursing personnel employed in these units are crucial factors in the effectiveness of burn treatment endeavors. 6auma can be described as the direct damage caused to bodily tissues, organs, and an individual's psychological state due to external environmental factors. 7The predominant factors consist of mechanical trauma, chemical trauma, and psychological trauma.Psychological trauma, as delineated within the domain of psychiatry, pertains to occurrences that transcend the boundaries of commonplace encounters. 8The traumatic events under consideration are distinguished by their abrupt and overpowering nature, resulting in a departure from the usual psychological state of individuals. 9The experience of trauma leads to significant psychological damage at a subconscious level, encompassing the loss of autonomy, communication, power, and individuality.Trauma can be conceptualized as an injury that symbolically expresses itself, signifying an underlying wound that becomes evident through recurrent reenactments. 10Therefore, it can be inferred that individuals who have undergone traumatic experiences are prone to re-enacting past traumatic events and consequently find themselves in a perpetual state of distress, wherein they are unable to regain control over their current circumstances. 113][14][15] Mild psychological trauma possesses the capacity for spontaneous resolution, while more severe trauma can precipitate the emergence of anxiety, depression, and, in extreme instances, Post-Traumatic Stress Disorder (PTSD) 9.As a result, individuals who undergo such traumatic experiences face an increased susceptibility to Secondary Traumatic Stress (STS), thereby presenting additional complexities in terms of mental well-being. 16It is important to acknowledge that healthcare professionals who specialize in burn care play a vital role in providing comprehensive support to patients throughout the entire continuum of trauma care, encompassing rehabilitation and posttraumatic therapy. 17rrently, there exists a dearth of scholarly inquiry pertaining to the frequency, determinants, and potential medical ramifications of posttraumatic growth (PTG) specifically in relation to the pandemic among healthcare practitioners. 12Positive Transformational Growth (PTG) is a term used to describe the positive psychological changes that individuals may undergo when faced with highly challenging life circumstances. 18Possible transformations may involve an increased state of awareness and the utilization of personal strengths, the development of deeper interpersonal relationships 19 , the identification of new opportunities for personal development, the enhancement of spiritual progress, and a heightened sense of gratitude towards life 15 .Although posttraumatic growth (PTG) can possess inherent worth, it is crucial to acknowledge that the existence of PTG does not automatically preclude the existence of symptoms related to posttraumatic stress disorder (PTSD). 14Indeed, these two phenomena frequently manifest in conjunction, and it is commonly noted that individuals exhibiting moderate symptoms of post-traumatic stress disorder (PTSD) tend to report the most pronounced levels of post-traumatic growth (PTG). 20Therefore, this study aims to assess and evaluate all posttraumatic growth experiences after burns and wounds on selected patients with various degrees of burns.

METHODOLOGY
For this investigation, a cross-sectional descriptive study was carried out.The study specifically recruited adult participants who had experienced burn injuries.The injuries were assessed and categorized according to severity and penetration of the burns.The assessment of burn extent was conducted using Pulaski and Tennison's rule of nines 21 , A technique that computes the ratio of burned areas on the body in relation to the overall surface area of the body.
The inclusion of individuals with severe burns was determined and chosen according to certain criteria.The requirements required second-degree burns covering more than 25% of the body surface area or third-degree burns affecting the face, neck, and joints.The classification of the treatment phase was derived by calculating the average length of hospital stay for individuals with third-degree burns from 2018 to 2020 22 Patients in the acute phase, excluding those who got emergency treatment, were defined as persons who were admitted to the hospital within about two months after the emergency phase.The mean period of time elapsed since the burn occurrence for those in the acute phase was 64 days.Patients in the rehabilitation phase who were discharged from the hospital participated in outpatient visits.During the period of their hospitalization, patients received physiotherapy services in the rehabilitation department, underwent various clinical interventions, or were admitted to the plastic surgery department for the purpose of undergoing reconstructive surgical procedures.The average period of time elapsed after the burn incidence for people in the rehabilitation phase was 185 days.Individuals who were unable to engage in effective communication or who exhibited cognitive impairments were susceptible to being marginalized or excluded.In addition, the survey questions were orally presented by one of the researchers, and the responses of people with physical impairments caused by burns, such as eye impairment or hand injuries, were reported.The study's data were gathered from a sample of persons who were seeking medical care from Burns Hospitals in Dubai, encompassing both outpatients and inpatients.The period of data collection extended from March 11th to May 3rd, 2023.The survey was conducted over a period of approximately 15 minutes, during which data was primarily collected from the outpatient clinic or counselling room of the hospital.The researchers employed the G*Power 3.1 software to determine the most suitable sample size for their investigation [23][24][25][26] The minimum required sample size was calculated to be 98, taking into account a worth level (p-value) of 0.05 and an influence (1-β) of 0.79.The study had a group of 97 individuals in the acute period and 94 individuals in the rehabilitation stage.A total of 191 surveys were distributed.
The general features encompassed five particular variables: age, gender, educational attainment, financial challenges, and personality traits, specifically extroversion and introversion.The evaluation of burnrelated characteristics encompassed four components: the measurement of burn severity by a healthcare professional (%), the evaluation of burnrelated pain using a numerical rating scale, the identification of burn locations (such as upper and lower extremities, face, torso, anus, genitals, etc.), and the acknowledgment of challenges in daily activities resulting from the burn injury.
The study employed the Beck Depression Inventory-II 27 as a tool for assessing and quantifying depression symptoms.The research instrument employed in this study comprises a total of 21 items, with each item being assessed on a four-point Likert scale that spans from 0 to 3. The cumulative scores span from 0 to 63, with higher scores indicating a more pronounced manifestation of depressive symptoms.The scoring scale spans from 0 to 63, with scores falling between 0 and 13 being categorized as within the normal range.Scores within the range of 14 to 19 are suggestive of a mild level of depression, whereas scores within the range of 20 to 28 indicate a moderate level of depression.Scores ranging from 29 to 63 are indicative of severe depression.The Cronbach's alpha coefficient achieved during the instrument's developmental phase was 0.85, whereas, in the present study, it was determined to be 0.92.
The variable being examined was assessed using the Social Support Scale, which was first created in the Korean language by Lee 28 .The utilization of factor analysis was employed as a means to evaluate the construct validity of the scale under investigation.The analysis yielded the identification of several domains and their corresponding items.These domains cover emotional support, which includes aspects such as love-intimacy, trust, interest, encouragement, empathic listening, and understanding.Another domain is evaluative support, which comprises items pertaining to fair evaluation, praise, talent recognition, respect for personality, respect for opinion, and value increase.Additionally, there is information support, which consists of items addressing problem solving, adaptation, decision-making, recommendation, advice, and guidance in times of crisis.Lastly, material support includes items encompassing money, direct and indirect assistance, lending of goods, services, time, and work.The scoring of each item is determined using a Likert scale consisting of five points, which span from 1 (representing "strongly disagree") to 5 (representing "strongly agree").The scoring system implemented in this study permits a potential score range spanning from 25 to 125.Higher scores are indicative of elevated levels of social support.The present study obtained reliability coefficients, as measured by Cronbach's α, of 0.81 for emotional support, 0.82 for assessment support, 0.79 for information support, and 0.88 for material support.The Cronbach's α coefficient acquired during the developmental phase was 0.92, and it maintained a consistent level of dependability at 0.92 in the current investigation.The Posttraumatic Growth Inventory, which was developed by Tedeschi and Calhoun 29 , is widely used in research and clinical settings.In the present study, we employed the inventory version that was translated and adapted to the specific cultural context of South Korea by Song et al 30 .The instrument comprises four distinct categories, namely alterations in interpersonal relationships, shifts in self-perception, exploration of new possibilities, and heightened spiritual and religious inclination.In this study, the items within each category consist of a total of 16 elements.These elements are assessed using a Likert scale with six points, ranging from 0 (representing the absence of any experience of the change) to 5 (representing a highly significant experience of the change).The cumulative scores span from 0 to 80, with higher scores indicating a higher level of positive posttraumatic growth experiences.The Cronbach's α coefficients reported in the studies done by Tedeschi and Calhoun 29 , Song et al 30 , and the current investigation were 0.90, 0.91, and 0.92, correspondingly.
This investigation was steered after the necessary agreement from the official examination panel of Al-Ain University, with which the author is affiliated.The participants were given comprehensive information pertaining to the research's objectives and methodologies.The participants voluntarily participated in the study after providing written consent that indicated their comprehension of the study's objectives and methodologies.The participants were presented with information that explicitly stated the absence of any adverse repercussions linked to their non-participation or withdrawal during the study.Furthermore, participants were provided with the information that the surveys would be assigned distinct numerical identifiers to safeguard their anonymity.It was explicitly communicated that the data gathered would be exclusively employed for the objectives of this research and subsequently discarded.The data was securely stored in a vault.
The data was analyzed using SPSS Statistics 24.0.A descriptive data analysis was conducted to evaluate the general characteristics and variables connected to burns.The chi-square test and t-test were utilized to measure two groups' effects.Additionally, the study assessed the association of social support, depressive symptoms, and posttraumatic growth.The Pearson correlation coefficients were also used to evaluate the relationships between these variables and the regression analysis was used to ascertain the factors linked to posttraumatic growth.

RESULTS
The study included 191 participants, with a mean age of 42.2 years (standard deviation = 9.79).Out of the total sample size (N = 191), 50.8% (N = 97) were identified to be in the acute phase, while the remaining 49.2% (N = 94) were categorized as being in the rehabilitation phase.Homogeneity was observed across various demographic and clinical characteristics, including age, gender, educational attainment, degree of burns, pain severity, number of burn areas, and challenges in daily functioning, throughout all stages of treatment (See Table 1).).There was a substantial difference in the average scores of depressive symptoms between the two phases, as indicated by a statistically significant t-value of -3.611 (p = .000).
The inquiry unveiled the correlation between posttraumatic development and other variables during various stages of treatment.A substantial negative connection was seen between posttraumatic growth and depressive symptoms in patients during both the acute period (r = −0.2134,p =.005) and the rehabilitation phase (r = −0.213,p <.000).The results of this study, as shown in Table 3, demonstrate a substantial and favorable association between posttraumatic growth and social support among patients in both the acute period (r = 0.331, p =.000) and the rehabilitation phase (r = 0.412, p .000).The verification of the regression assumptions' analysis for the independent variables involved the identification of multicollinearity, examination of residuals, and assessment of singular values.In examination of the variables linked to posttraumatic growth among individuals with severe burns during the acute and rehabilitation stages, it was determined that social support exhibited a statistically significant relationship during the acute phase (β = 0.14, t = 2.71, p = .000).This association accounted for 12.9% of the observed variance (F = 4.174, p = .000).The results of the study indicate that there is a significant negative relationship between depressive symptoms (β = −0.11,t = −1.31,p = .00)and posttraumatic growth during the rehabilitation phase.Additionally, there is a significant relationship (positive) between social support (β = 0.129, t = 3.78, p < .000)and posttraumatic growth.These two variables, depressive symptoms and social support, collectively account for 19.1% of the variance in posttraumatic growth (F = 19.12,p < .000).

DISCUSSION
The aim of this research was to examine the variability in levels of depressive symptoms, social support, and posttraumatic growth among individuals who have experienced severe burns, with a specific em-phasis on the various phases of treatment.The research entailed categorizing the participants into two distinct stages, specifically the acute phase and the rehabilitation phase.This study also aimed to ascertain the factors that are associated with posttraumatic growth.The purpose of this study was to collect essential data that can be utilized in the development of clinical nursing interventions that specifically target the psychosocial dimensions associated with severe burns.
The initial year following a burn incidence is critical for patients with severe burns due to their heightened vulnerability to psychological discomfort or worry associated with the requirement for outpatient therapy and surgery subsequent to hospital discharge.Jain et al31 posit that individuals frequently encounter elevated levels of depression due to secondary stressors linked to the necessity of adapting to daily routines, recalling traumatic events, and facing financial challenges.Hence, it is crucial for clinical nurses to proficiently evaluate the psychological states of patients in accordance with their stage of treatment and subsequently administer appropriate care.
No statistically significant difference was found between the two groups in terms of social support levels.However, a study revealed that individuals undergoing rehabilitation generally displayed greater levels of social support in comparison to those in the acute phase, encompassing various subcategories.
The aforementioned findings may be ascribed to the prolonged period of hospitalization and treatment encountered by individuals with acute burn injuries.There was no statistically significant difference observed between the two groups in terms of overall posttraumatic growth.The user's text is empty.Nevertheless, it is crucial to emphasise that a statistically significant disparity was noted in the alterations in self-perception.
The subcategory concerning self-perception assessed the patient's capacity to surmount obstacles and cultivate enhanced openness, optimism, and psychological fortitude.The present situation exhibits similarities to the encounters of individuals suffering from depression, both during the acute stage and throughout the process of rehabilitation.Jeschke et al32 posit that individuals who are in the acute phase of their medical condition and have received prompt intervention for their physical injuries progress into the subsequent stage of recovery.As a result, individuals cultivate an elevated appreciation for existence and demonstrate unwavering resolve in overcoming obstacles.
Nevertheless, individuals in the rehabilitation phase, subsequent to the acute phase, encounter limitations as a result of repeated interventions, which subsequently give rise to emotions of disillusionment and demoralization, ultimately culminating in the formation of adverse self-perceptions33.Therefore, it is crucial to administer nursing interventions to patients during the rehabilitation phase that promote their participation in self-help groups, improve their self-perceptions, and encourage effective communication with nurses.
A notable statistical correlation was also detected for both depressive symptoms as well as the posttraumatic growth in individuals in acute and rehabilitation phases.Teodorescu et al34 conducted a study wherein it was observed that all participants reported varying degrees of posttraumatic growth, with a minority of 31% indicating a higher level of growth.The study's results suggest that a significant percentage of the patients, specifically 80%, exhibited posttraumatic stress symptoms that surpassed the predetermined threshold.Moreover, a significantly large proportion of 93% of participants indicated the presence of depressive symptoms that reached a clinically significant threshold.The construct of posttraumatic growth exhibited the most significant influence on the model, surpassing the impact of posttraumatic stress symptoms and depressive symptoms.The research revealed that individuals who encountered stressors subsequent to their migration, such as unemployment, limited social connections, and difficulties in social integration, exhibited a moderate adverse correlation with posttraumatic growth and overall quality of life.Moreover, these stressors exhibited a positive correlation with symptoms of psychopathology.The findings of the study indicated that a substantial percentage of the individuals receiving outpatient care, specifically 60%, were classified as unemployed.
Refugees who have undergone multiple traumatic experiences and are seeking treatment at outpatient clinics have reported the manifestation of psychopathological symptoms, alongside the emergence of posttraumatic growth subsequent to their exposure to these traumatic events.A negative correlation has been identified between indicators of psychopathology and the overall level of quality of life.Furthermore, there is a notable correlation between psychopathological indicators and post-migration stressors, including but not limited to unemployment, a limited social network, and inadequate social integration.A notable correlation was observed between posttraumatic growth and quality of life, suggesting a positive association.In contrast, an inverse relationship was identified between posttraumatic growth and post-migration stressors.The findings from the hierarchical regression analysis indicated that posttraumatic growth accounted for a greater proportion of the variability in quality of life in comparison to posttraumatic stress symptoms, depressive symptoms, and unemployment.Hence, it is imperative to consider both favourable transformations and psychopathological indicators during the evaluation and management of outpatients with a refugee background who have experienced numerous traumatic events.
The shared factor among both groups was identified to be the presence of social support.Based on the findings of a study conducted by Farzan et al35, Research has shown that people who suffer burns that cover 80% or more of their entire body surface area during the initial phase have a higher likelihood of surviving if they have a strong social support system.According to Michalczyk et al. 36, individuals diagnosed with breast cancer who endure physical changes resembling those seen in burn victims are more likely to develop a feeling of life connection and undergo posttraumatic growth.The likelihood of this outcome is higher when individuals maintain supportive and positive relationships with their loved ones, a finding that is consistent with the results of the current study.Martin et al37 assert that the phenomenon of posttraumatic growth in patients is subject to the influence of various internal and external factors.The process of personal growth is influenced by both internal and external factors.Internally, an individual's motivation to seek personal strength contributes to this growth.Externally, the presence of social support also plays a crucial role in facilitating personal growth.Due to the aforementioned influences, individuals undergo heightened levels of positivity, cultivate a more profound comprehension of others' suffering, and acquire the requisite selfassurance to surmount obstacles.The provision of increased social support to burn patients has been observed to result in reduced levels of physical pain and shorter recovery durations, attributed to the facilitation of enhanced rehabilitation endeavours.Therefore, it can be argued that social support plays a crucial role as an external factor for individuals undergoing the rehabilitation process.In the context of patients undergoing rehabilitation, a positive correlation has been observed between the severity of depressive symptoms and the occurrence of posttraumatic growth.Individuals who have experienced significant burn injuries are expected to develop a cognitive understanding of the subsequent events that occur following the injury.Participating in these introspective cognitive processes holds the capacity to yield posttraumatic growth.In addition, it is crucial for clinical nurses responsible for the care of patients suffering from severe burns to provide comprehensive care through the establishment of a support system that facilitates access to self-help groups.This approach ensures the provision of both psychological and treatment support.This methodology al-lows individuals to develop an ample level of selfawareness and self-esteem.

CONCLUSION
The present study revealed that social support exerted a noteworthy influence in promoting posttraumatic growth among individuals belonging to the acute phase group.On the other hand, it was observed that individuals belonging to the rehabilitation phase group demonstrated posttraumatic growth as a result of reduced depressive symptoms and the availability of social support.The participants in the acute phase group displayed indications of mild depression in relation to its intensity.On the other hand, the cohort undergoing the phase of rehabilitation demonstrated a moderate degree of depression and a reduced perception of positive selfimage.
The results of this study suggest that the implementation of specific strategies tailored to each phase of treatment is imperative in psychosocial interventions.Therefore, it is advisable that individuals with severe burn injuries be provided with an extended period of counselling intervention and support.During the early stages of the severe burn's crisis, the clinical realm is employed for the identification and treatment of depressive symptoms.Nevertheless, the results of this study indicate that healthcare professionals tend to overlook the potentially exacerbated severity of depressive symptoms that may arise during the rehabilitation process.Therefore, it is crucial for healthcare professionals to establish a comprehensive framework that effectively addresses the management of depressive symptoms in individuals experiencing severe burns, thereby ensuring their access to suitable psychosocial interventions within the community setting.Furthermore, it is advisable for nurses to utilize a holistic approach that integrates psychological support and nursing interventions to facilitate the enhancement of patients' posttraumatic growth by fostering the cultivation of suitable self-awareness and self-esteem.It has been observed that there is a need for further research in the United Arab Emirates to enhance the clinical data pertaining to the primary experiences of healthcare professionals in managing burn and wound cases, as well as other infectious disorders in patients.

Table 1 :
Burn-related characteristics and demographic data

Table 2 :
The mean score differences in the study

Table 3 :
The Correlation among the posttraumatic growth and constructs

Table 4 :
Factors linked to posttraumatic growth