1

Prevention of Burns in the Elderly – Developing the framework

for an Education Package.

Alwena Willis 10566971

Registered Nurse

This thesis is presented in partial fulfilment of the requirement for the

Master of Health Professional Education

of the University of Western Australia

Education Centre

Faculty of medicine, Dentistry and Health Science

2010

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Declaration

Having completed my course of study and research towards the degree of

Master by Research (by thesis), I hereby submit my thesis for examination in

accordance with the regulations and declare that this thesis is my own

composition. All sources have been acknowledged and my contribution is

clearly identified in the thesis.

The thesis has been substantially completed during the course of enrolment in

this degree at UWA and has not been accepted for a degree at this or another

institution.

Alwena Willis

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Abstract

Introduction

Burns in the elderly are a challenging problem faced by many burn units

throughout the world. The effect of an ageing population on demand for burn

centres needs to be addressed. A 12-year retrospective study on burns in the

elderly recently conducted at Royal Perth Hospital showed there was an

increase of 14.9% in admissions during the last 4 year period of the study,

compared to the previous 8 years. Prevention through education can be

effective at reducing burns, and education should be targeted to specific

groups. Very few education campaigns are targeted at the elderly, and a

community assessment is an important first step to developing any education

program. Therefore, prior to developing an education programme, it is important

to ascertain the views and understanding of elderly members of the community.

The research aim is to develop the framework of an education package

targeting the elderly over 65 years who live independently in their own homes or

a retirement village and providing them with the education they need to prevent

burns in the home and to know the appropriate first aid should a burn occur.

To facilitate the development of the education package it is important to

ascertain the views and understanding of elderly members of the community

therefore a study in the form of a knowledge needs assessment was

undertaken to gather this information.

4

The research question is:

What do the elderly community aged over 65 years know of burn

injuries, burn first aid and preventative measures?

The findings of this study have been used in the development of a framework of

an education package designed to be disseminated by health professionals to

the elderly throughout the state including the country and metropolitan areas,

and differing cultural groups within our elderly community in Western Australia.

Participants

The group targeted was a convenience sample of elderly people over 65 years

who lived independently in their own homes or retirement village. A total of 165

participants were approached to complete a survey of knowledge of burns risks,

first aid and preventative measures, with a response rate of 41% (n=68).

Methodology

Mixed methodology was used, collecting data from quantitative/qualitative

surveys and qualitative focus group discussions. This approach facilitated the

retrieval of demographic information and definitive data on burns, and at the

same time allowed an in- depth view of the participants‟ knowledge of burn

injury, burn first aid and preventative measures. The survey questions were

analysed using SPSS v 17.0, using descriptive analysis for the dichotomous

and multiple-choice questions within the survey. The focus group interviews and

the unstructured survey questions were transcribed, reviewed and content

analyses used to code and identify keywords that linked into themes or

categories.

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Results

In categories considered high-risk activities for a burn injury, such as cooking

meals and making hot drinks 61.8% of the cohort still cooked their meals daily,

with 95.5% of them making two or more hot drinks a daily. Hot water tap

regulators were installed in 51.6% of the cohort‟s homes with 27.9% of the

cohort stating that they had received a burn injury in the last 20years.

Approximately 70% of the cohort stated that they had confidence that they

would know what to do if they sustained a burn injury, but according to the

survey, only a quarter of them actually have a reasonably good knowledge of

what to do in an event of a burn.

Conclusion

Even though 70.6% were confident that they would cope with a burn injury, Part

A of the survey contradicts this assumption and shows the need for education in

burns first aid for the elderly. The study identified the areas of concern for the

elderly in Western Australia and the results of the survey highlighted them.

However, the survey also showed that the elderly are open to learning burn first

aid and prevention measures, and can be more resilient than we often

anticipate. Ensuring that they know and understand the preventative measures

they can have in their homes to decrease the risk of them being burnt, and to

provide them with the knowledge, they need to implement correct first aid, will

give them the tools that they need to ensure that any burn injury they receive

will be minimised.

From this survey, an education package has been designed for the elderly in

our community using a social constructivism learning theory, taking into

consideration the ageing process, and the challenges involved in teaching the

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elderly over age 65 years. This package is designed to be disseminated by

health professional throughout the state in various country and metropolitan

areas.

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Acknowledgements

I would like to thank so many people for their support through what seems such

a long journey to me. It has been a challenging time, which has had me riding a

roller coaster of emotions, enthusiastic one minute, and in total despair the next,

but a worthwhile journey all the same.

My appreciation goes to all the wonderful teachers who have imparted their

knowledge to me along the way and have shown me nothing but support.

Everyone I have encountered within this course has been wonderfully

supportive, enthusiastic, and willing to help, so to the wonderful team of the

Masters of Health Professional Education course, I thank you.

I have been very fortunate with my supervisors and I appreciate and admire

them immensely.

To Dr Adrienne Huber our time together was short but during that time, I

learned so many things that have helped me along my way, so thank you for

starting me on my journey.

To Winthrop Professor Fiona Wood, I thank you for contaminating me with the

enthusiasm for improving burn care especially through education. Your

commitment to educating as many people about burn first aid as we can is

inspiring and I am grateful to be in the position of working with you. I thank you

for your support and all your help.

To Associate Professor Sandra Carr who saw me floundering and took me on

board and who has helped me in so many ways it is difficult to put in words.

Thank you for being patient and supportive for answering my endless questions

and for reassuring me when I felt overwhelmed. Your support of me during this

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time has been invaluable and without your help, I would not have completed this

journey. You have been an amazing help and I cannot express eloquently

enough how much I appreciate it.

To Associate Professor Annette Mercer who helped me finish the journey I am

immensely grateful for your help and support.

To all the team at RPH Burns unit and Telstra Clinic who have helped and

supported me along the way I thank you. You are an amazing group of people

to work with and I count myself lucky to be part of such a brilliant team. To the

McComb Research foundation for a grant to assist me with time to prepare my

Thesis, I thank you very much.

To my friends at Princess Margaret Children‟s Burn unit, I thank you for your

endless support and kind words and for being there for me.

To all my colleagues and friends from ANZBA who all have this wonderful

desire to improve all aspects of burn care, your offers of help and support have

been immensely heart-warming and appreciated.

To Aaron Berghuber who defies all the quotes of men not having any patience,

they had obviously not met you. Your help has not only been invaluable but

your calm manner and friendship have made tasks that seemed impossible,

reasonably easy. I thank you for always being willing to help and in such a

gracious way.

To my nephew Mel Griffiths, for his unstinting support and help, for giving up his

precious time to help me and for having someone in the family who understood

what I was going through. Your achievements inspire me. Thanks, Mel you are

wonderful.

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To my amazing children Sian and her husband David, Paul, Katrina, Adelle and

Thomas who support me in everything I do, who always believe I can achieve

what I set out to do even though at times I am unsure. I thank you all for your

love, your patience and support and for believing in me. You are my life and

everything I do; I do it for you. To my granddaughter Carys whom I love very

much, I thank you for just being part of my life.

My thanks would not be complete if I did not thank my Heavenly Father who

guides me in everything I do and has helped me to keep going by answering the

prayers of someone perhaps not always worthy. I thank you for your

unconditional love.

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Table of Contents

Page

Title Page 1

Declaration 2

Thesis Abstract 3

Acknowledgements 7

Table of Contents 10

Chapter One- Introduction 16

1.1Background 16

1.2Literature Review 18

1.3 Methodology 22

1.4 Results 23

1.5 Discussion 23

1.6 Health Education Framework 23

1.7 Conclusion 24

Chapter Two – Literature Review 26

2.1 Introduction 26

2.2 Search Strategies 26

2.3 Literature Reviewed 27

2.4 The Ageing Population 28

2.5 Burns in the Elderly 32

2.6 Burns first aid 40

2.7 Burn Prevention and Education 41

2.8 Elderly Education 45

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2.9 Social Constructivism 46

2.10 Research Methods 47

2.11 Community Nurses 48

2.12 Conclusion 48

Chapter Three- Methodology 51

3.1 Introduction 51

3.2 Recruitment 53

3.3 Sample 55

3.4 Data collection 56

3.4.1Survey 56

3.4.2 Survey Instrument Development 56

3.4.3 Reliability and Validity 60

3.4.4 Focus Groups 61

3.5 Analysis 63

3.6 Ethics 64

3.6.1 Confidentiality and Intellectual Property 64

3.7 Limitations of the Design 65

3.8 Conclusion 66

Chapter Four- Results 67

4.1 Introduction. 67

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4.2 Sample 67

4.3 Survey 68

4.3.1 Scenario Questions 68

4.3.2 Demographic data 69

4.3.3 Risk factors for burn 71

4.3.4 Fire Alert mechanisms 74

4.3.5 Knowledge of Burn first aid 75

4.3.6 Grandparents 79

4.3.7 Education 79

4.4 The Focus Groups 81

4.4.1 Focus Group One 81

4.4.1.1 Experiences of a Burn Injury 82

4.4.1.2 First Aid 83

4.4.1.3 What Burn Treatments they were 83

Taught when Young

4.4.1.4 Open Fires/Combustion Stoves 84

4.4.1.5 Back Burning on Property 85

4.4.1.6 Risk Factors 85

4.4.1.7 Smoke Alarms and Preventative Measures 87

4.4.1.8 Education 89

4.4.1.9 The Role Play 90

4.4.2 Focus group 2 92

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4.4.2.1 Experiences of a Burn Injury 92

4.4.2.2 First Aid 93

4.4.2.3 What Burn Treatment they were taught, when 94

Young

4.4.2.4 Grandchildren 95

4.4.2.5 Open Fires/Combustion Stoves 95

4.4.2.6 Risk factors 96

4.4.2.7 Smoke Alarms and preventative measures 97

4.4.2.8 Education 98

4.4.2.9 The Discussion 99

4.5 Comparison of the Focus Groups 100

4.6 Conclusion 102

Chapter Five – Discussion 103

5.1 Introduction 103

5.2 Discussions 104

5.2.1 Demographics 104

5.2.2 First Aid 106

5.2.3 Risk factors 108

5.2.4 Prevention measures 112

5.2.5 Education 113

5.3 Limitations of Study 115

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Page

5.4 Conclusions 115

Chapter Six- Health Education Framework 118

6.1 Introduction 118

6.2 Framework 118

6.3 Strategic Direction 119

6.4 Education Package 121

6.5 Conclusion 122

Chapter Seven – Conclusion 123

7.1 Burns in the Elderly 123

7.2 Literature Review 123

7.3 Methodology 124

7.4 Results. 125

7.4.1 Demographics 125

7.4.2 Survey 125

7.4.3. Risk factors 125

7.4.4 Prevention measures 126

7.4.5 Education 126

7.5 Health Framework 127

7.5.1 Rationale for Developing an Education Framework 127

7.5.2 Strategic Direction 128

7.6 Conclusion 128

8.0 References 130

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Appendix 1. Table.2.3 138

Appendix 2. Formal letter of Introduction 139

Appendix 3. Patient Information Sheet 141

Appendix 4. Consent Forms 145

Appendix 5. Survey Forms 147

Appendix 6. Healthcare Framework 162

Appendix 7. Education Package 163

.

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Chapter 1

Introduction

1.1 Background

Burn injuries are devastating, and when they occur in the elderly those injuries

can be overwhelming. Many factors can compound to make burn injuries more

severe such as inadequate, inaccurate, or the complete absence of first aid.

Consequently, this can affect the recovery process of the elderly person, which

is often complex and lengthy. Furthermore, burns in the elderly tend to be more

serious and take longer to heal and need extensive rehabilitation in comparison

to the younger adult age group, who have both physical and psychological

resources in their favour.1,2

The elderly frequently have deteriorating physical health, hearing and vision

loss, decreased mobility and loss of dexterity, all of which can result in slower

reaction times and risk assessment impairment. Together, these factors make

the elderly more vulnerable to a burn injury and more importantly, can influence

the length of hospital stay and survival. Additionally health issues such as

dementia, delirium, confusion and disorientation have a significant bearing on

the treatment, recovery and rehabilitation of the elderly person. This often

results in a complicated discharge due to their extensive rehabilitation needs,

with family members often unable to offer adequate support due to work

commitments, lifestyle or geographical distances, leading to a compromise in

the independence of the elderly person.3,4

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People are living longer and birth rates are declining, therefore, the population

of Australia over the age of 70 years is expected to double by 2051.5 This will

have a significant impact on the future social systems of the country and in

particular the health economy, with an expected increase in demand on

healthcare and support services.

To ascertain whether there was an increase in admission of burns in the elderly

to the State Adult Burn Unit in Royal Perth Hospital, a retrospective descriptive

study was conducted on burn injury in the elderly over the age of 70 years

between the years of 1995-2006. The study consisted of twelve years of data

divided into three four-year blocks, the last four-year block showing an increase

of admissions by 14.9% compared with the previous period.6 Consequently, this

increase means an increase in workload and resources for the State Adult Burn

Unit and Royal Perth Hospital. Unfortunately, documentation of burns first aid

administered at the time of the injury was often missing in the case notes, and

in those that were documented, the first aid was often incorrect or inadequate.

The findings from this study prompted further questions:

Are the elderly with a burn injury applying first aid prior to

hospitalisation?

What do the elderly know of burn injuries, burn first aid and

preventative measures?

Could increasing their knowledge in this area help prevent burn

injuries and reduce the number of elderly admitted into hospital?

This study reported in this thesis is an attempt to answer the research question:

What do the elderly population of Western Australia know of burn

injuries, burn first aid and preventative measures?

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The method used was to conduct a survey of a representative sample of people

over the age of sixty-five years of age who live independently in their own home

or a retirement village in Western Australia. The aim of the research is:

To determine the baseline knowledge of the elderly in burn

preventative measures

To determine the baseline knowledge of the elderly in burns first

aid knowledge

To determine if cost is a factor for lack of preventative measures

such as smoke alarms, first aid training, hot water temperature

gauges.

To determine if the elderly have any cultural beliefs regarding

burn first aid.

To determine if the elderly feel an education and prevention

campaign would be of benefit

To use the outcomes of the study to develop an education

package on the subject of burns first aid and preventative

measures

1.2 Literature Review

Chapter 2 discusses the literature reviewed in the undertaking of this study,

which includes articles concerning the elderly, the ageing process, burns, and

teaching the elderly. Following is a summary of the review of the literature.

In the burn literature reviewed, the definition of elderly is variable, with ages

ranging from 55 years to 75 years. Research shows that age is a major

influence on morbidity and mortality in the elderly; this makes comparison of

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these research papers difficult.4 Geographical differences such as climate can

also have a major effect on morbidity and mortality in this age group, as

countries with hot climates and mild winters have less house fires and therefore

less flame and inhalation burn injuries that entail a higher risk of mortality.

Similarly, countries can have different cultural issues that contribute to burns

such as type of clothing worn, and means of heating and cooking, all of which

impact on the epidemiology of burns within those countries. Although these

factors made comparison of burns in the elderly a complex undertaking, many

similarities were found within the studies reviewed.

High percentages of the Western Australian elderly population live in their own

homes with or without a partner and continue to attend to their own cooking

needs. It is well documented that cooking and home-related accidents are a

leading cause of preventable injury in the elderly.2,6 In a study by Ho 2 of 94

burn patients over the age of 60 years, it was shown that 90.4% of the burn

admissions were due to domestic accidents. Likewise, in a study of 20 burn

admissions over the age of 65 years, Redlick 7 stated that the home was the

most common place of injury for the burn admissions examined, with the

kitchen being the predominant place of injury. Undoubtedly these activities can

be hindered by age related diminished functions and a reduced capacity to

manage everyday activities, which make the elderly more vulnerable to burn

injuries. 2,3,6, 7

The review of the literature revealed that first aid prior to hospitalisation in the

elderly is frequently excluded for exploration, however, one of the few studies

that include this information regarding burn first aid is the study by Ho.2 In their

study of 94 elderly patients admitted with a burn injury, they found that more

than one third of their patients had received no first aid, with 43% of patients

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having received inappropriate first aid. These factors were considered

contributory factors to prolonged hospital stays and increased mortality. By

contrast, a study by Chang 8 did not consider burn first aid in relation to

outcomes, but rather focused on outcomes related to total body surface area,

burn aetiology, inhalation injury and gender differences.

Similarly, other retrospective studies into burn outcomes that took into account

variables and their effect on outcomes, were reviewed.9-11 As with the Chang 8

study, burn first aid and its possible effect on outcomes were not discussed in

these studies. Consequently, the questions of whether first aid is being

administered, whether it is adequate and appropriate and whether it does have

an effect on burn outcomes is difficult to ascertain. This gap in the literature is

significant, as in the elderly age group, effective first aid administered at the

time of the injury can have a major influence on patient outcomes and

mortality.12, 13 With correct burn first aid, involving cooling the burn under

running water for approximately 20 minutes, pain levels are decreased, the heat

is removed and progression of the burn is prevented.12, 13

Advanced surgical techniques, silver dressings, and superior skin cultures have

revolutionised burn treatment. However, these advancements have not been

reflected in the prognosis of elderly patients, which continues to be relatively

poor compared to those in the younger adult age group.7 Many factors

contribute to poor prognosis in this age group and many studies have been

conducted to ascertain the main factors involved. The Pomhac 14 study on

predictors of survival related to age, found that there is a considerable

difference between burn injuries in the 60 years age group compared to the 80

years age group, due to co-morbidities and declining physiological reserve.

However, it was also found that there has been an improvement in survival in

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the 80 years age group compared to historical controls. Similarly, the study by

Rao9 found that co-morbidities did influence the outcomes of burns in the

elderly, and that total body surface area (TBSA) and inhalation injury have a

significant effect on mortality in this age group when compared with younger

age groups.

Research has shown that many of the burn injuries in the elderly occur within

the home, and could be prevented with an education program specifically

directed at the elderly population, tackling the issues that are relevant to them.

Studies related to burn prevention and to the design and developing of

education programs were reviewed. Tan15 implemented the burn prevention

campaign of a perspective study of elderly groups over 60 years who attended

a „Burn Prevention Education Seminar‟. It was found that there was a significant

increase in burn prevention knowledge after the multimedia campaign and

community presentations with the preferred method of education within the

campaign being the community presentation.15

Cutilli 16 states that due to the many changes that occur during the ageing

process both physically, and more importantly cognitively, education of the

elderly needs careful consideration, and there is a need to understand the

education strategies that take into account these changes, which is often a

challenging process. Articles related to the education of the elderly were

reviewed.

Participants in an education session can include people with different

educational levels and differing health issues. It is therefore important that

educational programmes for the elderly should be connected to the participants

of the group, their experiences and interests.17

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Because of the learning needs of the elderly, the education program detailed in

this study was designed using the theoretical framework of Social

Constructivism, incorporating a diversity of strategies to aid the potentially wide

variety of learning styles.

A review of the literature on Social Constructivism found limited scientific

research, with most articles consisting of interpretations of Social

Constructivism by the author. A variety of views were documented, with Hein18

stating that learning is a social process when people are engaged in any form of

social activity, and that all social activity is in fact a learning process. He then

went on to emphasise the importance of cultural background and personal

experiences in the process of learning, especially in the elderly population.18

Social Constructivism allows the elderly learner to participate in the learning

process, with the health educator facilitating the learning process in a social

environment such as senior citizen centres or retirement villages, to help them

learn about burn first aid and preventative measures.

1.3 Methodology

Chapter 3 discusses the methods used in the study and the advantages of the

mixed methodological approach used.

The research design consisted of a mixed methodology community survey with

a focus group component. The mixed methodology allowed the use of different

approaches to answer the research questions, using both quantitative and

qualitative data. The study consisted of a survey designed to help gain an

understanding of what burns first aid knowledge the target population have, and

to provide the demographic information and data needed. Furthermore, the

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study examined the insights on preventative measures the elderly have already

implemented, and their views on burn first aid and prevention measures.

The focus groups were conducted in order to gain a deeper perspective of their

concerns about burn injury, first aid and prevention.19

1.4 Results

In Chapter 4, the results of the study are discussed. The survey questions were

analysed using SPSS v 17.0, (http://spss.en.softonic.com/), using descriptive

analysis for the dichotomous and multiple-choice questions and using a nominal

scale, with the results divided into tables, and figures.

By contrast, the notes from the focus group interviews and the non-structured

questions in the survey were transcribed and reviewed using content analysis to

code and identify keywords, which linked into themes and categories.19 The

issues identified in the study have been used in the development of the

framework of an education package

1.5 Discussion

Chapter 5 contains a discussion of the results of the study and the implications

of them in the development of the educational framework.

1.6 Health Education Framework

Chapter 6 consists of the strategic directionof the framework for an education

package for the elderly population of Western Australia. This education package

will be designed to be delivered by various health workers around Western

Australia, including Community Nurses, Burn Specialist Nurses, Aboriginal

Health Workers and General Practitioners.

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In considering the ageing population and the need to identify strategies to

ensure the health service are able to cope with the expected increase in burns

in the elderly; other education packages designed for the elderly in Western

Australia will be reviewed. The elderly population in Western Australia is a

growing population, and consists of many diverse groups, which include the

indigenous population, Australian born, and the elderly from various

multicultural backgrounds. Amongst them, there is much diversity both

economically, and socially, all of which will need to be considered in the

development of an education package.

Teaching the elderly involves many considerations such as how they learn, their

incentive to learn and the cognitive changes that occur with the ageing process.

These cognitive changes according to Cutilli16 involve four main functions:

sensory function

processing speed

working memory and

inhibition

Some or all of these functions may be diminished to some degree in the elderly.

Consequently, these are important considerations in the development of the

education package to enable the needs of all of Western Australia‟s elderly

population to be met.

Another factor to consider is that not all of the cognitive changes in the elderly

are losses, and along with increased age comes the benefit of experience.

Therefore, one way to teach the elderly is to use the experiences they have

accumulated in their lives to help them learn the things they need to know now,

and social constructivism utilises those experiences in the learning process.

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Older adults often have a wealth of knowledge and life experience that they

have gained over the years that they can draw upon and relate to the learning

experience, but the elderly must also see the importance for the learning

experience in the first place and agree that the topic is relevant to them.17

1.7 Conclusion

Chapter 7 consists of the conclusions of the study and contains an overview

and assessment of the findings of the research study aims.

The long-term objective of this project is to reduce the number of elderly people

presenting to Royal Perth Hospital‟s State Adult Burn Unit with a burn injury,

therefore the conclusion and summary will discuss the results of the study

related to the questions to be addressed.

The conclusion will also address what direction needs to be taken next, such as

further research or further development of the framework and the delivering of

an education package.

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Chapter Two

Literature Review

2.1 Introduction

This chapter provides a review of the literature, with the search strategies

employed in obtaining the relevant literature identified, including a summary of

the keywords used. An overview of studies relating to the ageing population is

presented, before an examination of the literature concerning burns in the

elderly. An overview of the published information on the impact of first aid

measures is also presented, as is a summary of the literature concerning elderly

education. Social Constructivism theory is examined, before the chapter

concludes with a review of the literature relating to the study‟s methodology.

2.2 Search Strategies

The literature for this study was gathered from a variety of sources to provide a

comprehensive review of the literature. The following websites were searched:

Databases:

Ebsco CINHAL

Ovid Medline

ERIC

Google Scholar

UWA Library search

Specific journals:

Burns

Journal of Burn Care and Research

27

Government sites

Western Australian Department of Health and Ageing

Department of Health – Injury Prevention Branch

Australian Bureau of Statistics

Healthinfonet

The search was refined using specific journals such as „Burns‟ and „Journal of

Burn care and Research‟ which were then individually examined for relevant

burn articles.

2.3 Literature Reviewed

For this study, 135 articles or websites covering the different elements of the

study were reviewed. The keywords used in the search were as follows:

Burns, Elderly, Aged 65years and over, Geriatrics, Demographics, Elderly

Education, Ageing, Geragogy, Prevention, Risks, Injury, Health education,

Health Promotion, Health Prevention, Health Frameworks, Constructivism,

Learning theories, Social Constructivism, mixed methodology, Coding,

Qualitative Research, Focus Groups, Surveys: Ageing Population, Population

Statistics, Australia, Western Australia, Adult learning, Teaching, Adult

Education, Community Nursing, Burns first aid

The majority of literature reviewed consisted of Burns in the Elderly and Burn

Prevention followed by Education of the Elderly, Ageing and Research. These

five categories constituted 75% of all the literature reviewed while Education

Packages, Social Constructivism with Education Burn First Aid and Community

Nurses made up the remainder.

28

The number of articles reviewed consisted as tabled below.

Table 2.1 Articles Reviewed

Categories Number of Articles

Burns in the Elderly 35

Burn Prevention 26

Elderly Education 16

Education 7

Health Education 11

Research 12

Ageing 12

Community Nurses 4

Burns First Aid 4

Constructivism 8

2.4 The Ageing Population

Because people are living longer and birth rates are declining, the population is

ageing and by 2013, 2.6 million Australians will be over the age of 70 years,

with this figure expected to double by 2051.5 People over 65 years of age in

Australia constitute 13.3% of the population. Western Australia‟s growth in the

elderly age group has increased 3.7% from June 2008 to June 2009.5 This

increasing population age is not unique to Australia, which fares well when

compared with other countries. For example, Sweden has 18.3% of the

population over the age of 65 years, and the United Kingdom has 16.6%. New

Zealand and the United States of America are similar to Australia in terms of an

ageing population, with both countries having 13% of the population over 65

years.5

29

The ageing population is likely to have a considerable impact on the future

social systems of Australia and on the health economy in particular. It is

expected that as the population ages there will be subsequent increases in

demand on healthcare and support services. Consequently, the Australian

Government has responded to this by introducing health education and

promotion strategies to encourage active independent living.20 Strategies aimed

to achieve active independent living in older Australians by promoting good

health and healthy ageing, as well as by encouraging the reduction of health

risk factors such as smoking, obesity and inactivity. The Health and Ageing

Working group lists preventative health as one of their five main priorities, and

although the focus is on reducing the burden of disease, preventative measures

in all fields are considered of benefit to the overall health economy.20

In Madrid in 2002, the Second World Assembly on Ageing held by the United

Nations put forth a political declaration known to most as the „Madrid plan‟,

which has three main priority directives, including objectives and actions

intended to aid in their implementation.

Those priority directives are:

1) Older persons and development;

2) Advancing health and well being into old age; and

3) Ensuring enabling and supportive environments.

The Australian Government has stated its commitment to the „Madrid Plan‟ and

have already commenced implementation of it.20

Butler 21 in his paper on „Population ageing and health‟ states that one of the

reasons people are living longer is due to improved nutrition and the inroads

30

into disease prevention and cure that medical research has achieved. He

argues that the ageing population as a group has had greater exposure to

toxins such as high fat diets and smoking, and therefore will suffer the

accompanying related health effects, such as heart disease and stroke.21

Because of these factors, Butler 21 expresses concern that governments are not

being proactive enough in their preparation for the anticipated increase in

healthcare demand. Furthermore, Butler 21 states that the responsibility for the

ageing population should involve everyone, including the people themselves,

and that governments should encourage them to contribute in taking care of

their own health and well-being.21

Geriatric medicine and research along with investment in health promotion,

education and prevention, would enable the elderly to gain the knowledge they

need to be proactive in their health and well-being. 21 Differing to Butler

however, Getzen 22 in his paper on „Population ageing and health‟, argues that

the projected health economic increase is not simply due to the aging

population but is more likely due to the high cost associated with the

development of the technology now used through medical research, a

development which has occurred concurrently with population growth.

In contrast, Coorey 23 in his paper on „Ageing and healthcare costs in Australia‟

suggests that Australia should be well placed to cope with the changes

expected in the health care system due to the ageing population, and that

concerns of the expected increase in demand on our future health care services

is overly bleak. Coorey 23 further states that acknowledging this would improve

government policy making decisions concerning the ageing population, and

suggests that as society changes and health issues such as the number of

31

people smoking decrease, the result will be an overall decrease in related

illness and its associated health costs.23

Andrews 24 suggests in his article on „Promoting health and function in an

ageing population‟, that health education and promotion are essential to help

benefit the well-being of the elderly in the coming decades, and that education

should be designed to cater for all social aspects of this population. The

Western Australian Health Promotion Strategic Framework 2007-2011 25

supports this view by suggesting that a framework for comprehensive health

promotion should include a broad range of activities such as education, skill

development programs, mass media campaigns, legislation, and community

action. One of their key strategic approaches is to target populations such as

the elderly, with the aim of reducing morbidity and premature mortality by

decreasing chronic disease and injury.25

Although much of the literature examined differ in opinion on ageing and the

future of health care costs, they all conclude that the ageing population should

have a greater responsibility in their own health and well-being and that

educational campaigns in health matters are beneficial to aid this. Regardless of

the debate on whether the cost of health care system will or will not increase

due to the ageing population, research have shown that the number of elderly

people admitted to the State Adult Burn Unit of Royal Perth Hospital is

increasing.6 This is likely to have an impact on the cost and resources of the

State Adult Burn Unit and therefore Royal Perth Hospital, and is likely to result

in more pain and suffering from burn injury for an increasing number of our

elderly.

32

2.5 Burns in the Elderly

Studies have shown that although survival from burn injuries continues to

improve across almost all age groups, this is not the case with the elderly. Even

though the elderly often make up only a small proportion of the burn population,

with an ageing population, that proportion of burn injuries will increase.7, 26 In

recent years, there have been many advances in burn treatments, with

improvement in surgical techniques and scientific technological advancements

such as artificial dermis and cultured epithelial cell spray. In addition, there have

been other advancements such as nanocrystalline silver dressing products and

the introduction of nutritional support, all of which have helped improve the rate

of survival in burns patients.1, 26 For many reasons, including the psychological

and physical features of the ageing process, the prognosis for our elderly

patients do not always reflect these advancements. Prognosis for the elderly

with a burn injury continues to be poor when compared to the younger adult

population, and studies have shown that in the elderly, the greater the

percentage of total body surface area burnt, the greater the likelihood of

mortality.1, 2, 27

Directions in Injury Prevention, 28 a report by the National Injury Prevention

Council states:

„Severe burns have an enormous impact on the victim and their family,

they are very costly, and they present particular problems for acute care

and rehabilitation‟. (p.24)

33

Burn injuries in the aged are associated with a higher degree of morbidity and

mortality, take longer to heal, and tend to require an extended recovery period

and more intense rehabilitation than for other age groups. Furthermore, the

elderly often have pre-existing medical problems, which can contribute to the

length of their hospital stay and their chances of survival.3, 7, 29 In addition, the

elderly population may have disabilities such as failing hearing or vision,

decreased mobility and dexterity, as well as declining reaction time and aptitude

for risk assessment, all of which impact on their ability to manage everyday

activities. 3, 7, 29

During hospitalisation, the elderly may have less tolerance to medication and

surgical procedures, be more susceptible to infection, and may suffer from

delirium and confusion, all of which are contributory factors to longer recovery

and rehabilitation.4, 14, 30, 31 To maintain independence, this age group requires a

high level of input, which is often complicated due to inadequate family

support.3

This review of the literature found the majority of research pertaining to burns

and the elderly are retrospective, descriptive studies conducted at various

centres, which focus on morbidity, mortality and burn prevention. Many of these

studies cite flame as the most frequent aetiology of burns, with differing

mortality rates. Scalds was cited as the second most frequent aetiology with the

exception of four studies which found scalds to be the most predominant

agent.2, 6, 7, 32

Alden‟s 33 retrospective case control, observational study conducted on burn

injury in patients with dementia was the only study from the United States of

America (USA) of burns in the elderly that showed scald as the predominant

34

agent. Wibbenmeyer 29 retrospective descriptive study on predicting survival

rates in the elderly with a burn injury, found that of the 308 patients admitted

with burns over the age of 60 years, flame was the most prevalent cause of

burn at 69% with a mortality rate of 30.2%. Likewise a retrospective review by

Lionelli 26 in 2005 on factors affecting mortality in burns in the elderly, showed

that of 201 patients over the age of 75 years, flame was also the prevalent

cause of burn injury at 73.6%, with a 47% mortality rate. However, studies that

have stratified ages into age groups have shown that age differences play a

major role in mortality, the significant difference in the mortality rates between

these two studies may be the result of age difference.

In a retrospective descriptive study considering the effects of pre existing co-

morbidities on mortality in the elderly aged 55 years and over conducted by

Lundgreen 4 in 2009, it was found that flame was the most predominant cause

of injury, with a mortality rate of 18.5%. Significantly, when these rates were

stratified to age they found the mortality rates varied in the stratified age groups

as follows:

Table.2.2

Age Groups Mortality Rates

55-64 years 9.7%,

65-74 years 16.5%

75 years + 32.7%

Lundgreen 4 concluded that age rather than co-morbidities was the deciding

factor in regards to mortality in the elderly.4 Similarly, a retrospective descriptive

35

study of a cohort over 55 years of age by Pham 27 in the USA of the

epidemiology and outcomes in the elderly with a burn injury, concurred

Lundgreen‟s 4 finding that flame was the predominant causal agent, showing

that mortality rates increased as age increased. Most other studies also concur

with the findings that increased age leads to increased mortality, with some

studies aiming to identify if treatment has an effect on mortality rates.23,24.

A retrospective review in Birmingham, England by Rao 9 on the aetiology and

outcome of burns in the elderly, showed that in the 65 years and over group,

flame was the predominant agent at 49.2% with a mortality rate of 34%.

Furthermore, the study aimed to see if early surgical intervention reduced

mortality, however, the findings showed no significant difference in the timing of

surgical intervention and mortality and concurred with most studies that

mortality was significantly related to age, total body surface area (TBSA) and

inhalation injury.9

In contrast, the Khadim 34 retrospective descriptive study based on Rao‟s 23

study on mortality estimates in the elderly burn patients in their unit compared to

the Birmingham unit, showed that early aggressive therapy, which included

early surgical intervention and the use of intensive Care Units (ICU), did reveal

a correlation to better survival in the elderly. They stated that their mortality rate

of 12.6% was significantly lower than the Rao 23 study of 34%. However,

Khadim 34 states that in their study, the cohort had fewer burns in the over 50%

TBSA category, which is known to have an effect on mortality rates in this age

group, and this factor may have been significant

By comparison, Keck‟s 35 2009 review of the current literature in burn treatment

for the elderly, argues that early surgical intervention is controversial in the

36

elderly and cites studies that both support and oppose it. Keck 35 concurs with

others that age and TBSA play the major role in mortality, and state that

although lower than the general adult population, survival in this age group has

still improved since the 1970‟s. Keck 35 argues that because of this, there is a

need for increased rehabilitation facilities to ensure as optimum a return to

normal as possible.35

A retrospective descriptive study by Baux36 in 2008 of 37 elderly burn patients

aged 70years and over who had presented to their unit showed flame burns as

most common at 65.3% with a mortality rate of 30.6% and also showed that

78.1% of burns in this age group were from domestic accidents such as cooking

and bathing accidents.36

The 2010 retrospective descriptive study by Yin 37 on the characteristics of

elderly burns in Shanghai, also showed that flame was the predominant agent

of burn at 52.7%, but found a mortality rate of only 8%, which is considerably

lower than most centres. They also found that domestic burn injuries were high

at 73.6%, which was attributed to the change in the social structure in Shanghai

where family life is changing from a traditional one, consisting of different

generations living together in one family home, to one where the elderly now

often live alone. Yin 37 states that although the living standards have improved

in Shanghai, this is not always the case for the elderly. Furthermore, Yin 37

concludes that domestic injuries could be prevented with appropriate education

campaigns. This phenomenon of the changing family life is not exclusive to

Shanghai, and social structures around the world are changing resulting in

increasing numbers of the elderly finding themselves living alone, often with a

reduced income and a decreased standard of living.6, 35, 37

37

The studies reviewed with scald as the predominant agent revealed different

overall results concerning mortality, which exposes a different view of burns in

the elderly. A retrospective descriptive study by Ho 2 in 2001 of the evaluation of

the epidemiology and outcome of 94 patients aged 60 years and over found

scalds to be the predominant agent at 62% with a mortality rate of 7.4%. This

was one of the few studies that gave figures for first aid prior to hospitalisation,

showing that 34% of those surveyed did not receive first aid prior to admission

and 30.6% presented with inappropriate first aid such as toothpaste, herbal

ointment, soy sauce and cigarette ash, with a further 35.4% unaccounted.2 A

follow up retrospective descriptive study of Ho‟s study by Wong 38 in 2007 on

an elderly burn prevention revealed similar figures, with 64% scalds and a

mortality rate of 6.8%, with two thirds of the burn injuries occurring at home.

First aid given was also reviewed and showed only 12% received appropriate

first aid with 88% having no first aid or inappropriate first aid.38

A retrospective descriptive study at Royal Perth Hospital of elderly patients over

70 years conducted over a twelve-year period to evaluate trends in morbidity

and mortality found the predominant cause of burn was scald at 49%, with a

mortality rate of 11%.6 Like the Hong Kong studies, first aid administrations was

reviewed, with the study showing that first aid was administered in 30% of the

cases, inappropriate first aid in 2%, and no first aid was administered in 11 % of

the cases. Unfortunately, first aid had not been documented in 57% of the case

notes presenting an obstacle in ascertaining whether first aid was administered

at all, and whether or not it was adequate. This is significant as effective first aid

can have a major influence on patient outcomes and including mortality in the

elderly.6

38

Like the Hong Kong and Perth studies, the Redlick 7 cross sectional study of

2002, a survey of risk factors for burns in the elderly and prevention strategies,

and Klosovά 32 retrospective descriptive study of burn injury in senior citizens

over 75 years of age, state that scalds are the predominant cause of injury,

although it is difficult to correlate a congruence of the four studies for numerous

reasons. Climate, culture and age all differ in these studies with each

influencing the overall results of the studies to some degree, making the studies

difficult to compare.

The retrospective descriptive study conducted by Klosovά 32 in 2005 showed

that scald was the predominant agent of burn at 43%, but with a mortality rate of

27%. This mortality rate is considerably higher than the Willis or Wong 6,38

studies, potentially due to the Klosovά 32 study age range of 75 years and over.

As other studies have shown that this age group have a higher mortality rate,

this may be the factor affecting the difference between the studies.6, 32, 38

Redlick 7 found that although scalds were the predominant cause of burn injury,

there was also a high mortality rate of 46%, which is comparable to studies

where flame is the main cause of the burn injury. The Redlick 7 study

concentrated on preventative measures rather than on the actual burn cases

making it difficult to assess the reason the mortality rates found were higher

than the Willis and Wong 6, 38 studies. Whether the differences are due to the

treatment approaches or the age differences in the studies or other factors is

hard to say.6, 7, 38

Climate may also be a defining issue between burn aetiology and consequently

mortality rates. Both the Wong and the Willis 6,38 studies were conducted in

countries that experience a warm climate, which might result in lower incidence

39

of burn injuries caused by house fires and heating sources. By comparison, the

Redlick and Klosovά 7,32 studies, are from countries with a colder climate

(Canada and the Czech Republic respectively), and consequently it is possible

that a higher incidence of house fires were a significant factor compared with

the Hong Kong and Perth 2, 6, 38 studies. There is a higher component of

inhalation injuries in house fires, which leads to a higher mortality rate, and this

is likely to be a defining issue in the difference between mortality rates in the

studies from the four countries.6, 7, 32, 38

The main factor to be considered, however, is that the age group defining the

elderly is not uniform between the studies, with the cohort‟s ages varying from

55 to 75 years of age. This makes comparing the studies accurately difficult, as

a discrepancy of 10 to 20 years can make a significant difference in burn

outcomes as the Lundgreen and Pham4, 27 studies illustrate with their age

stratification.

The other significant factor is the difference in aetiology of the injury where

flame injuries may also have had an inhalation component. This increases

mortality, making it difficult to compare this group of studies.

Table 2.3, shows an analysis of eighteen articles that have been reviewed

which includes the study, their most frequently cited aetiology, mortality rates,

age group, cohort size and mean TBSA percentage. This table helps to identify

the differences between age groups, aetiology and mortality rates, all of which

combine to make comparison of these studies difficult.

Table 2.3 Appendix 1.

40

2.6 Burns first aid

Lack of published information concerning first aid measures used prior to

hospital admission makes it difficult to study its effect. Only three studies Ho2,

Wong38 and Willis6 had this important information, indicating that there is

relatively little literature on burn first aid knowledge in the elderly. Despite many

burns studies neglecting to factor in first aid administration, it is known that

effective first aid can have a major impact on the patient outcome. Therefore, an

important question is whether a lack of first aid administered at the time of the

injury has a significant impact on morbidity and mortality.

In a study in Perth on minor burn injuries in adults presenting to the regional

burns unit in Western Australia, 39 only 39% of the 227 cases had received

appropriate first aid and 61% received inadequate, inappropriate or no first aid.

Inappropriate first aid included application of ice or applying topical agents such

as honey or toothpaste.

Another study assessed the knowledge of Burn first aid in 462 HealthCare

workers and 180 engineering students, where the respondents were asked to

comment on four scenario type questions, with only 18.8% providing correct

responses, indicating that burn first aid knowledge is poor in the general

community.40 A knowledge of and administration of prompt first aid prior to

hospital admission is essential to achieve the best outcome for the injured.12

Adequate and correct burns first aid improves the outcome for the burn patient,

and leads to a decrease of admission into a burns unit, and a decrease in

severity in the burns of those needing to be admitted.12, 40

41

2.7 Burn Prevention and Education

Smoke alarms are a proven intervention that can help reduce the incidence of

house fires and consequently burn injuries.41 In Australia, legislation in every

state makes it compulsory to install smoke alarms in all new properties and

renovated homes. However, socioeconomic factors such as cost could preclude

the elderly from having smoke alarms in their homes.35, 41-43

Hot water is a major cause of burn injury in Australia with scald injuries common

in the elderly, who are more vulnerable to scalds. These injuries represent 49%

of hospitalised burn admissions at the State Adult burn unit, Royal Perth

Hospital in Western Australia.6 There is now Australia wide legislation to ensure

hot water temperatures in new residential or renovated homes are not greater

than 50oc. Unfortunately, many of our elderly live in older homes that do not

have this safety feature and cost could be a deterrent for many elderly in

safeguarding their homes by installing them.43, 44

In 2007, Alden 45 conducted a retrospective review of hot water tap burns to

assess socioeconomic factors related to them. The study found that 97% of

burn injuries occurred within the home, with 98% of the cohort having pre-

existing co-morbidities. Furthermore, the study concluded that the elderly were

often limited by income in buying and installing safety devices such as

expensive anti scald devices.45

In a prospective observational study by Stone 46 in 2000, hot water

temperatures were tested in 14 residential homes and 25 randomly picked

homes of elderly people, which showed that most of the residential homes

conformed to the government legislations. Unfortunately, half of the private

42

homes had water temperatures of over 60 degrees as not all of the homes had

fail-safe thermostatic devices installed in order to prevent scalds.46

The retrospective descriptive study conducted in New South Wales by Boufous

on the epidemiology of scalds 30 in 2005 concurred with the Stone 46 study, and

found that as the elderly live in older homes which are not subject to hot water

tap regulations, more work needs to be achieved to aid the elderly in this area.

Scald is the most predominant cause of burns in Western Australia; therefore,

education of the elderly on the benefits of installing fail-safe thermostatic

devices in their homes is important in order to reduce the risk of a scald.

Furthermore, education on topics such as first aid treatment, burn hazards and

prevention, would be beneficial to the elderly, as research has shown that many

of the burn injuries in the elderly that occur within the home can be prevented.47,

48

McMurdo‟s 48 2000 review of healthy old age, found there was a lack of health

education for the elderly. Grant 47 2004 in his article on burn prevention,

suggests that before designing a burn prevention program, there should be a

community assessment to ascertain what is relevant, in order for the education

to be targeted effectively. To minimise or prevent an injury, the elderly need to

be aware of burn preventative strategies, and burn first aid knowledge as

informing the elderly will empower them in regards to their health and well-

being.47, 48

Grant 47 states that advanced practice nurses should help in the prevention of

burns by actively participating in health promotion programs in fire and burn

injury prevention. However, he also states that there is little evidence on the

efficacy of prevention programmes, and that most evidence comes from the

43

efficacy of passive strategies such as smoke alarms, fail safe thermostatic

devices and the use of less flammable materials in clothes, such as nightwear.

Grant 47 suggests that prevention comes in three phases:

Primary - legislation and burn awareness education;

Secondary - the teaching of burns first aid; and

Tertiary – This includes the rehabilitation and recovery of a burn survivor,

in order to promote the maximum level of function and to minimise any

disability.

The Pomhac 14 2006 retrospective descriptive study on „Predictors of survival

related to age‟, found that there was a considerable difference between burn

injuries in the 60 year old age group compared to burn injuries in the 80 year old

age group. However, Pomhac14 conceded that their study was small and that

there was a need for multi-centre studies to understand the broader picture in

education of the elderly.

The Redlick 7 2002 cross sectional study administered a multiple-choice survey

to a group who had already sustained a burn injury about the circumstances

that led to their injury and burn injury risks, with a cohort group of uninjured

elderly people. When the data were compared, it was found that 85% of those

who had sustained a burn injury felt that their injury was preventable. Although

few participants had changed their habits post injury, 95% stated that a burn

prevention program would be useful. However, it was found that the cohort

group were at a higher risk for a burn injury, but that they took more burn

preventative measures, which were effective. Because of the study, a

prevention program for the elderly was designed, involving a multimedia

campaign and community education sessions.7 Tan 15 followed through and

44

developed the burn prevention campaign and conducted an evaluation study in

which an elderly group over 60 years of age attending a „burn prevention

education seminar‟ were surveyed. It was found that there was a significant

increase in burn prevention knowledge after the multimedia campaign and

community presentations, and that the community presentation was the

preferred method in the educational campaign. Additional surveys were

conducted 4 to 6 weeks after the education, but they considered it was too soon

to determine whether the information could be retained long term, a factor that

could determine how frequently the education should be repeated.15 Judkins 49

review of burn prevention and rehabilitation in 1998 argues that short one off

programmes seems to achieve little and that any education programmes

undertaken should be long term.

In their 2007 retrospective descriptive study, Wong 38 stated that there have

been some successful burn education/prevention programmes aimed at

children, particularly in scald prevention, but very little for the elderly. Spalleck 50

conducted an evaluation study of the campaign, „Hot water burns like fire‟, a

scald campaign targeted for children, which involved testing the tap water

temperatures at selected homes and schools and assessing scald admissions

prior to and post the education. They found that the average hot water tap

temperature in the surveyed homes after the campaign was higher than prior to

the campaign, and scald admissions had increased. This, they reasoned was

due to the way the data was gathered pre and post campaign, which involved

two different research groups using different methods. Furthermore, they went

on to suggest that there is little evidence to prove that educational campaigns

affect change in behaviour and maintain that passive strategies such as

45

promoting smoke detectors are more effective than campaigns designed to

encourage behavioural change.50

The American Burn Association has a comprehensive package for burn

education for various groups including the elderly on their website. However,

the literature search did not reveal any studies of the effectiveness of this

education or any centres that had adopted this education package.51

2.8 Elderly Education

In a clinical review in 2008, Cutilli 16 states that due to the many changes that

occur during the ageing process both physically and cognitively, education of

the elderly needs careful consideration, and an understanding of education

strategies is needed in view of these changes. All adults are individuals and

possess many differing characteristics that can affect how they learn and all of

these factors should be taken into consideration when planning and choosing

the correct learning theory for an education package for the elderly.52

Malcolm Knowles, considered the founding father of Adult learning, stated that

there were differences between adult learning (Androgogy) and the learning of

children (Pedagogy), and that adults were autonomous and self-directed with

their learning.53

Zemke 54 went on to suggest that adults are most motivated to learn if the topic

is relevant and useful to them and the subject interesting.54

Lieb 53 in his 1991 article „Principles of Adult Learning‟ concurred that adults

are more committed to learn when the learning has a meaning in their lives, and

that it is life experiences that have taught adults to be autonomous and self-

directed. An elderly learning group could include people with different

46

educational levels; some may have left school early to gain employment, and

therefore received a lower formal education with others having gained a tertiary

education. Furthermore, the groups are often predominantly women and may

have health problems, therefore any educational programmes should be

designed to consider these factors and appeal to the experiences and interests

of the group.17

Imel 55 states that learning is achieved best in an informal environment, and that

teaching in small groups is an effective method in adult learning, which allows

the educator to become the facilitator and allows the group to take a more

active role. As a result, small group learning can be more effective and

productive than large group learning with members of the group all having a

chance to contribute their experiences and strengths to the process.55

Hein 18 1991 states that learning occurs when people are engaged in any form

of social activity, whether it is with family, at school or any social group, and that

all social activity is in fact a learning process. Therefore, this emphasises the

importance of cultural background and experiences in the process of learning

especially in the elderly population

2.9 Social Constructivism

Due to the learning needs of the elderly, this education program has been

designed using the theoretical framework of Social Constructivism. Review of

the literature on Social Constructivism revealed limited scientific research. Most

articles located were interpretations of Social Constructivism by individual

authors with every author seeming to have a different interpretation of the

theory, although the basis of the theory remained unchanged.

47

Social Constructivism is believed to have originated with Jean Piagets „stage

theory‟, which describes the four stages of development.56 Social constructivists

believe that learners actively construct knowledge, that their learning is based

on their previous experiences, and that they create meaning through the

interaction with their environment as well as social interaction with each other.56,

57

2.10 Research Methods

This study used a mixed method approach including both quantitative and

qualitative data collection methods. Martin 58 (2000) describes qualitative

research as understanding the person‟s views and experiences which have

bearing on a study, while quantitative research focuses on discrete and

measurable areas in a study. The mixed methodology applied in this study

allowed the use of different approaches to answer the research questions.

Combining the quantitative and qualitative data collection methods facilitated an

understanding of the knowledge of burn first aid and preventative measures that

the elderly have from a comprehensive viewpoint. Burke Johnson 59 2004 states

that both quantitative and qualitative methods use empirical observations and

have safeguards to minimise bias. In today‟s research, many disciplines

conduct differing types of research relevant to their field of expertise within a

specific area. All of this research is relevant to the overall understanding of the

topic, so it is of benefit for researchers to understand both methods, as this will

help to facilitate a greater understanding of the topic studied.59

The data collection methods consisted of a community survey with focus group

discussions. Barbour 19 states that any group discussion can technically be

classed as a focus group with the difference between a discussion and a focus

48

group discussion being, the participation of the researcher as moderator and

actively encouraging the discussion. The use of the focus groups allowed a

more personal perspective of burns first aid and preventative measures to be

attained.19

Punch 60 and Creswell‟s 61 books on research comprehensively discuss the

different areas of conducting research such as mixed methodology, sampling,

coding qualitative data and analysis, and were used extensively as a reference

for all aspects of the research in this study.

2.11 Community Nurses

Nurses, General Practioners and Aboriginal Health Workers will participate in

the delivery of the education package to the elderly community. Runciman 62

2006 stated that health promotion was an important part of the role of the

community nurses, and is often embedded in their daily work. Abbott 63 states

that Aboriginal Health Workers have an important role as educators and health

promoters within their communities. The role of doctors, nurses and aboriginal

health workers in health education within the community is an important one, as

they are often the only source of appropriate health messages, and are held in

high esteem by the community.

2.12 Conclusion

This chapter provides a review of the literature, and identifies the search

strategies employed and an overview of studies relating to the different aspects

of the research question. Areas covered included the ageing population, and

although much of the literature examined differs in opinion on ageing and the

future of health care costs, they all conclude that the ageing population should

49

have a greater responsibility in maintaining their own health and well-being.6, 21,

24

Examination of the literature concerning burns in the elderly, studies shows that

although survival from burn injuries continues to improve across almost all age

groups, this is not the case with the elderly. For many reasons, including the

psychological and physical features of the ageing process, the prognosis for our

elderly burns patients does not always reflect this improvement.1, 2, 27

Comparing studies is difficult due to many factors, the main factor being that the

definition of elderly is not uniform between the studies, with the cohort‟s ages

varying from 55 to 75 years of age. This makes comparing the studies

accurately difficult, as a discrepancy of 10 to 20 years can make a significant

difference in burn outcomes as the Lundgreen and Pham 4, 27 studies show with

their age stratification.

In addition, an overview of the published information on the impact of first aid

measures and a summary of the literature concerning elderly education were

discussed. It is known that effective first aid can have a major impact on the

patient outcome.40 Therefore, an important question is whether a lack of first aid

administered at the time of the injury has a significant impact on morbidity and

mortality. It is disappointing that many studies do not factor in first aid

administration into their research. Due to the many changes that occur during

the ageing, process educating the elderly needs careful consideration. Their

individual and differing characteristics can affect how they learn and all of these

factors should be taken into consideration when planning and choosing the

correct learning theory for an education package for the elderly.18

50

Social Constructivism theory was examined, and was found limited in scientific

research. Most articles located were interpretations of Social Constructivism by

the author with every author seeming to have a different interpretation of the

theory, although the base reasoning was the same. Social constructivists

believe that learners actively construct knowledge, that their learning is based

on their previous experiences, and that they create meaning through the

interaction with their environment as well as social interaction with each other.56,

57

Literature on research methodology particularly mixed methodology was also

reviewed and Burke Johnson 59 2004 states that both quantitative and

qualitative methods have safeguards to minimise bias and use empirical

observations. Many disciplines conduct different types of research relevant to

their field within a specific area. All of this research is relevant to the overall

understanding of the topic, so researchers benefit in understanding both

methods.59

51

Chapter Three Methodology

3.1 Introduction

Burns in the elderly are complex, severe, take longer to heal, and need

extensive rehabilitation compared to the younger adult age group.2, 7, 26

Community assessment is an important first step to designing and developing

any educational program and therefore it is important to ascertain the views and

understanding of burn injuries, first aid treatment, and preventative measures in

an elderly population within the community.47

The research aim is to develop the framework of an education package

targeting the elderly over 65 years who live independently in their own homes or

a retirement village. This will provide them with the education they need to

prevent burns in the home and to know the appropriate first aid should a burn

occur and the following research question was considered.

What do the elderly population of Western Australia know about know of burn

injuries, burn first aid and preventative measures?

The aims of the research are:

To determine the baseline knowledge of the elderly in burn

preventative measures

To determine the baseline knowledge of the elderly in burns first

aid knowledge

To determine if cost is a factor for lack of preventative measures

such as smoke alarms, first aid training, hot water temperature

gauges.

52

To determine if the elderly have any cultural beliefs regarding

burn first aid.

To determine if the elderly feel an education and prevention

campaign would be of benefit

To use the outcomes of the study to develop an education

package on the subject of burns first aid and preventative

measures

The target group for the education program was the independent elderly aged

65 years and over living in their own home or a Retirement Village. These

participants are most at risk of receiving a burn injury due to their independent

living, and would be the most able to participate in the education program and

implement the burn prevention strategies.

A cross sectional descriptive study design was used, with data collected using

surveys featuring both quantitative and qualitative items and focus group

discussions.

This method was used as it is a simple descriptive or observational study that

can be conducted on a representative sample of a population, and are useful to

gather information on health-related aspects of people's knowledge, attitudes,

and practices which is the aim of this study. This was chosen as many studies

have been conducted to measure the efficacy of such programs as family

planning, anti-smoking measures, and other public health and health-promotion

interventions and therefore is a suitable method for this study.

64

The data collection methods facilitated the retrieval of demographic information

and definitive data on the participant‟s knowledge of burn injury, prevention, and

practices concerning burn first aid. Data collected included factors important for

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understanding their learning needs, the beliefs of the participants, and the

teaching strategies that will need to be developed.

Quantitative research is mainly used to test a hypothesis or theory, while in

contrast, qualitative research facilitates gaining a greater understanding of the

topic being researched.60 Martin 58 describes quantitative research as focusing

on discrete and measurable areas in a study, while qualitative research

facilitates an understanding of an individual‟s viewpoints and experiences which

can have a significant impact on a study. Combining the two methods in a

research project can allow a broader and more comprehensive understanding

of the research questions. Burke Johnson 59 suggests that there are similarities

between the two methods as both use empirical observations and have

safeguards to minimise bias. Furthermore, as today‟s health research is often

conducted within a multidisciplinary forum, an understanding and blending of

both methods to facilitate communication between various disciplines is

necessary. Although combining both methods can be a complex task, which

requires a comprehension of both quantitative and qualitative research, it

provides a richer context to the research.60 This research study mixes the

quantitative and qualitative methodologies, although is predominantly qualitative

nature.

3.2 Recruitment

The decision of where to recruit participants was influenced by the proposed

target groups for the education programme, and therefore it was determined

that Senior Citizen Centres within the Perth metropolitan and country areas

would provide the most suitable populations. Twelve Perth metropolitan centres

were chosen randomly by the researcher, using the White Pages to select the

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Senior Citizen Centres, and they were invited to participate in the study.

The presidents of Senior Citizen Centre committees were contacted by

telephone and asked to consider participation in the study, with most agreeing

to discuss the issue at their next committee meeting. The Senior Citizen

Centres, which declined to participate, cited disinterest in the study generally, or

disinterest due to a higher percentage of older seniors with physical disabilities

such as deteriorating eyesight and dexterity within their centres. Of the twelve

centres contacted, six agreed to participate in the study, and an information

pack containing a formal letter of introduction, and an information sheet on the

study was distributed to them. (Appendices 2 & 3) Four of the six centres who

agreed to participate were within the Perth metropolitan area, with two centres

in the country areas of Geraldton and Busselton.

Four weeks from the initial contact with the Senior Citizen Centres, a second

mail out was conducted for the six senior centres, consisting of twenty surveys,

consent forms and information sheets for the study. Of the six Centres, five

responded to the second mail out. (Appendices 3- 5) A follow up with the sixth

centre by phone, resulted in an agreement that they would return the surveys,

though this was not achieved by the closing date of the survey.

As only six centres had agreed to participate, it was determined that the

invitation would be extended to five Retirement Villages and one church group

randomly chosen from around the Perth metropolitan area. Telephone or

personal invitations to participate in the study were extended to these five

retirement villages and the church group. Two retirement villages and the

church group accepting the invitation. Consequently, these groups were sent

the information pack containing the formal letter of introduction, the information

sheet on the study. In the follow up mail out one week later, each of the

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retirement villages were provided with 20 surveys, information sheets and

consent forms, while the church group received only five of each due to only

five people meeting the inclusion criteria. (Appendices 3-5)

Two centres agreed to participate in the focus groups, one country Senior

Citizen centre and one Church group.

3.3 Sample

A convenience sample of one hundred and sixty five people over the age of 65

years participated in the study, with a response rate of 41% (n=68), with five

surveys excluded as they failed to meet the age criteria. Of this figure, thirteen

people participated in the focus group discussions. Convenience sampling is a

non-probability sampling methodology, which does not claim to represent the

wider population. Therefore, the findings of this study may not be generalised to

the main population due to the limitations of the method of sampling and the

small size of the study.65

The surveys, which were distributed by the researcher, the Senior Citizen

Centres, or the Retirement Village chairpersons, and included a stamped

addressed envelope to enable the participants to complete the survey in their

own time and return them to the researcher. The participation of the country

centres provided a broader perspective of the knowledge Western Australian

elderly concerning burn first aid and preventative measures, which will allow the

education package to be better targeted to all elderly people throughout

Western Australia.

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3.4 Data collection

Data was collected using a survey and conducting focus groups. This section

discusses the purpose of the survey and the development of the instrument tool

with a table summarising the research survey tool. Reliability and validity are

discussed, as are aspects of the focus group discussions.

3.4.1Survey

The title of the survey was „Developing an Educational Framework for Burn

Prevention and First Aid in an Elderly Population: The role of beliefs,

knowledge, understanding and practices‟ (Appendix 5). The purpose of the

survey was to gather demographic data such as age, marital status, and living

arrangements and to gain a comprehensive picture of the knowledge and views

of the elderly concerning burn first aid and preventative strategies.

3.4.2 Survey Instrument Development

The survey items were designed to help gain an understanding of the burns first

aid knowledge of the target population and included two parts with part A

consisting of four case scenarios relating to a burn injury situation, with five

multiple-choice answers from which to choose. The questions were adapted

from those used in previous research at Royal Perth Hospital and redesigned to

assess current practices and beliefs of the elderly concerning burn first aid and

are representative of burn injuries seen at the State Adult Burn Unit.40, 66

. Part B consisted of four multiple-choice questions relating to demographic

information and 24 structured and unstructured dichotomous and multiple-

choice questions with the use of some contingency questions, the unstructured

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questions were designed to obtain more in depth knowledge from the

respondents on a particular topic.

The remainder of the questions were divided into four sections, with the majority

of questions consisting of dichotomous and multiple-choice questions with the

use of some contingency questions for further information. The four focal areas

related to firstly, activit