Alette De Jong, a registered nurse and nurse researcher, has been involved in burn care at the Burn Centre of the Red Cross Hospital in Beverwijk, the Netherlands, since 1985. After completing her nursing qualifications Dr De Jong went onto study nursing science at the University of Wales in Cardiff, United Kingdom, and obtained her PhD in 2013. Dr De Jong initiates, performs, and coordinates research in the field of burns nursing at the Red Cross Hospital and for the Association of Dutch Burn Centres to improve the quality of nursing care. Her research interests include pain measurement and pain management following burn injury. You can follow her on Twitter @AletteEEdeJong.
Dr De Jong sat down with Lincoln Tracy, a research fellow from Monash University, Australia, at the 43rd Annual Scientific Meeting of the Australian and New Zealand Burns Association Annual Scientific Meeting, which took place on October 15-18, 2019, in Hobart, Australia. Dr De Jong discussed her journey to become the first nurse researcher in burns care in the Netherlands, the importance of accurate pain measurement, and the challenges in implementing clinical change based on research findings. Below is an edited transcript of their conversation.
What was your path to becoming a burns nurse?
When I left high school, I didn’t know what to study. There were several options available to me—such as physiotherapy, nursing, and occupational therapy—but I’d been advised to study nursing. While it wasn’t my first choice, I followed the advice I’d been given and pursued nursing. I started my on-the-job training at the Red Cross Hospital in Beverwijk in the Netherlands. There was a burns centre in this relatively small hospital, but as nursing students we weren’t allowed to work there because it was too complicated. The on-the-job training was a combination of working in daily practice and studying. You went to school for one week per month and the rest of the time you spent working on the wards in the hospital. It was hard to balance the study and the shifts.
I was very curious about the burns centre. I discussed the possibility of working in the burns centre with the head of the nursing studies in the hospital on multiple occasions. He eventually spoke with the manager of the burns centre and asked whether it would be possible for me to work day shifts during the summer, when they were very busy and short on staff. The head of nursing studies eventually convinced the manager, and I spent the last year of my studies working in the burns centre. Over that summer, I really got the impression that this was the place for me.
What did you find so interesting about working in the burns unit?
The diversity of patients was one thing that was interesting—we saw patients of all ages and backgrounds. We also saw patients that we called “accident prone”, so lots of psychiatric, addiction, and elderly patients. Because the patients would stay in the burns unit for quite a long time, we got to know them very well. The technical parts of the burns unit—such as wound care—was also interesting to me. The nurses in the burns unit were also quite independent, which I was not used to from working on the normal wards.
How did you make the transition from working clinically to getting involved in research?
When I graduated from my nursing studies in 1984, getting involved in research was never an aim. But after I started working on the wards, I had the impression that I had to do something related to research. Luckily, there were a few examples I could follow. I got the opportunity to help some of the doctors with the basic research they were doing on the ward, which I found quite interesting. I also had a colleague at the Burn Centre in Rotterdam who had previously studied nursing science, and she was a real inspiration for me.
But one of the real turning points was seeing a so much pain in the patients who were in the burns unit. I thought I had to do something about it, because so much of the pain was poorly managed. I wanted to understand why, so I think the idea of using nursing science to find a solution to the problems you see in daily practice was really appealing to me. After my graduation as a nurse scientist in 2000 I created a role as a research nurse, as this role didn’t exist at the time. I was a pioneer at the time, and I like to still think I am.
As a nurse researcher I was responsible for the whole process of research, all the way from fundraising to publication and presentation of the results. Once I had a couple of presentations my supervisor said, “Maybe you could put it together as a thesis?” In the Netherlands, you write your thesis first and then defend it orally. I had never officially been a PhD student; it just happened, like a lot of other things in my life. But I’m glad it worked out that way.
Why is it important for nurses to be involved in research? Do you have any advice for nurses who are interested in research?
There are many reasons why this is important. First, it makes the profession stronger by founding daily practice on research, rather than habits. Most of the older nurses justify some of their daily practices by saying that “we’ve done this for ages, and it’s always been okay”—and this is not always true. Getting involved in research is also good for the positioning of the profession. Nurses used to obey doctors without question. But if you are familiar with the latest research you can develop a level of autonomy and potentially overrule the doctors by saying “Okay, I’ve read this article—or even wrote it myself—which is the latest evidence. So, we are going to do it this way, and not the way you suggest.”
If you are interested in undertaking research as a nurse you need to make that very clear to your management, because usually they aren’t very interested in nursing research. In many cases they put greater importance on having nurses bedside, which is important for daily practice. So, you really must convince them that this is important. You may also need to find a mentor or have someone to guide you if you are new to the research. In retrospect I was very lucky, as I had great mentors earlier in my career but didn’t realise it at the time.
What are some of the challenges in researching pain measurement and management?
If you want to manage pain appropriately you need to be able to measure it. Without accurate measurements you won’t know if your management is effective or not. But when I wanted to jump in and start pain management, I soon realised that we had no idea of how to measure it. So, we had to start from square one and investigate adult patients who can provide us with self-reports about pain. When we started researching some of the instruments and measures, we found that we were analysing how much pain adults were able to self-report.
Then you realise that there are other patient groups who are not able to provide self-reports—in these cases, you need structured pain behaviour scales. I started investigating research in children under the age of four who were unable to provide a numeric rating of their pain. We then set out to test the existing scales to determine if they were usable in our specific setting. Burn pain is different from post-operative or chronic pain—it is long-lasting, fluctuating, and unpredictable. We found that having the nurses observe patients in a structured way was much more accurate at measuring pain compared to when they give their own interpretation of what pain they thought the patient was experiencing.
I’m also looking at pain measurement in patients who are admitted to the ICU and ventilated, as these are another group who are unable to self-report. And while there are existing behavioural scales, they have never been tested for burn care. Many of these scales rely on facial expressions as part of their measurement. However, burns patients often have facial burns, or have bandages on their face that make it difficult to determine their facial expressions. We aren’t sure if the traditional scales work in this population.
Has your research led to any changes in clinical practice?
Yes, based on some of the research I have been involved with we now ask an additional question when assessing their pain. We ask patients to provide a rating of their pain, like normal, but now we also ask whether that rating is bearable or not. This came about because we were seeing that while some patients feel that pain that is eight out of ten is bearable, while others were saying that a two out of ten was unbearable. If the patient feels that the pain is unbearable, then you need to adapt your pain management strategies. If the pain the patient is experiencing is bearable, then you can discuss the possibility of decreasing the use of certain medications.
And while a small change like this sounds very easy in theory, it was challenging to implement this in daily practice. We needed to convince the IT department to adapt the electronic patient file to make room for the additional question. We had to educate nurses and doctors, because we had to convince the doctors to ask the nurses in the multidisciplinary team meetings about the pain scores for each patient and if they were bearable. Implementation is always ongoing and difficult, but we managed to get it done in the end.
How important is it to take a multidisciplinary approach to pain management in burn patients?
It all starts with the burn care nurses, because they are responsible for measuring the pain and informing the rest of the team about how the patient is feeling. They are also heavily involved with pain management and liaise with the doctor or sedation specialist—an anaesthesiology nurse who can give sedation to patients. We have these nurses in our hospital, which is a very good development. But the important thing is that the team utilises non-pharmacological pain management as an extra and not as a replacement for pharmacological pain management. We have a working group that focuses on collected a range of evidence-based interventions we can offer to our patients, and we are now in a stage where we want to investigate which intervention suits individual patients the best.
Outside of work, what do you like doing with your spare time?
I used to run a lot but had to give that up because of pain issues in my back and knees. So, I started cycling instead. Initially I was just doing spin classes in the gym, but then I heard about a planned on-road tour. It was about a 60-kilometre ride close to where I live, yet it took me to places I had never seen before. It was all so nice and beautiful in the open air—I was surprised by how much I liked it! I also enjoy Netflixing when I have the time. I’m currently watching the last season of ‘The Fresh Prince of Bel Air’—I love it. It’s so funny to go back to the 80’s and watch how Will Smith develops as an individual and an actor.
Lincoln Tracy is a researcher and freelance writer based in Melbourne, Australia. He is a member of both the Australian Pain Society and the Australian and New Zealand Burns Association. You can find him on Twitter @lincolntracy
Nursing Research Opportunity
Alette De Jong is a current Fellow of the Leadership Mentoring in Nursing Research 2.0 program. Over a two-year period, Fellows aim to help develop leading researchers in nursing science on a national and international scale. The overall goal is to obtain international funding for collaborative nursing research.
Initial steps have already been taken, with collaborations between Belgian burns centres, the University Hospital Bergen (Norway), and the Universities of Tasmania, Adelaide, and Western Australia already in place.
These international collaborations have great potential, such as focusing on nursing-sensitive quality indicators relating to pain, procedural anxiety, delirium, sleep, and much more. Once a method for reliably assessing these indicators has been developed, the next step would be connecting these indicators with nurse-led protocols to improve patient care.
If you are interested in taking part, or would like to learn more about this fantastic opportunity to educate the next generation of nurses and invest in nursing research, please do not hesitate to contact Alette via Twitter (@AletteEEdeJong) or email. She would love to hear from you!