The Medical Social Worker, A Neglected Ally in The Management of Burn-Injured Patients
Ogundipe Kolawole Olubunmi1, Kadiri, Innih1, Etonyeaku Amarachukwu Chiduziem2, Aduloju Tolulope3
1 Plastic and Reconstructive Surgical Unit, Department of Surgery, Ekiti State University / Ekiti State University Teaching Hospital, Ado- Ekiti, Ekiti.
2 General Surgery Unit, Department of Surgery, Obafemi Awolowo University & Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti.
3 Department of Social Work, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State.
Correspondence to: Dr. Ogundipe Kolawole Olubunmi. Email: email@example.com. Tel: +2348060186037
Background: Burn injuries comes with enormous challenges. It is a very devastating injury for anyone who sustains it. The consequences become worse when multiple members of a family are involved. Social supports are necessary, especially where health financing is mainly through out-of-pocket expenditure. The utilization of Medical Social Workers (MSW) in burn care in our region is limited, or their roles poorly or inadequately reported.
Objective: This study appraises the role of the MSWs in the multidisciplinary management of burn patients. Methods: We reported the management of an impoverished family of five who sustained varying degrees of burn injuries, and the role played by the MSWs in their care. Results: Beyond being a routine discharge planner, the MSWs provided social support, psychotherapy and rallied community support which translated to an improved outcome for the patients.
Conclusion: Involving the MSWs in burn care is of great benefits to the patients. Burn surgeons are therefore encouraged to utilize the added value of the MSWs on their teams.
Keywords: Burn, Injury; Medical Social Worker; Healthcare Financing.
Ann Afr Surg. ****; **(*):***
Conflicts of Interest: None
© 2020 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.
Burn injury is one of the most devastating injuries anyone can sustain and remain alive (1), though with widespread and debilitating consequences. Its sequelae include morphological changes, psychological and functional impairments, as well as social stressors like post-traumatic stress disorder, pain, shock, sepsis, and altered physiological function in the immune and emergency response systems (2, 3). Even at the time of discharge, the burn model system of Fauerbach et al. (3) reveals that there could be clinically significant psychological distress in a third of patients who sustained major burns which becomes more worrisome when more than one person in a family is affected. The psychosocial, financial, mental, and physical consequences can far outweigh the resolve of the burn-injured patients to cope. In particular, the costs associated with the management of burn injury are often high. Chris and Peter (4) put the cost for the management of an average adult burns patient at US$73,532. Procurement of burn care is, therefore, a big challenge in Nigeria where the living wage per individual is US$119 per month (5), the gross domestic product is US$2,028 (6), and a significant population earn US$50 per month (`minimum wage`). In furtherance, the unemployment rate has been estimated at 23.13% third-quarter 2018 by the National Bureau of Statistics (7). These are issues of concern in Nigeria, where out-of-pocket expenditure (OPE) has been the principal mode of financing medical care, up to 65% in some studies (8).
For the best outcome, management of burn injuries requires a multidisciplinary approach (9). The burn team will not be deemed complete without the medical social worker (MSW). Atanesian of the North Carolina Jaycee Burn Center highlighted the roles of the MSW to include social support and counselling to patients and their family, suggestion of appropriate services, addressing problems or concerns as they arise throughout hospitalization, facilitation of patient's release from the hospital, assistance with reintegration into the community and provision of tools and resources for the patient to reclaim life once again. (10).
In the management of burn injuries in our facility, the social workers were only called upon to facilitate patients' release from the hospital and recover unpaid bills. They were hardly involved in the management of the burn-injured patient. However, following the presentation to us of a family of five with varying degrees of burn injuries, the devotion of medical social workers came handy in facilitating the total care.
This study is a descriptive report of the role played, over two months, by the medical social workers in the management of five patients who sustained varying degrees of burn injuries and whom we admitted into our facility, Ekiti State University Teaching Hospital (EKSUTH), in South-West region of Nigeria. We obtained informed consent from the father on behalf of the patients before we included them in this study. The Hospital Ethics and Research Committee's approval was also sought for and obtained before commencement of the study (ERC No. 2019/09/0018). We retrieved the records of the patients` biodata (including name, age, sex, place of work and abode, religion), history of presenting complaint, clinical profile, and treatments up to discharge and entered them into a spreadsheet. There are two certified Medical and Social Workers (MSWs) in the hospital, assisted by four clerical assistants, and they have access to a shuttle bus and a standby driver. The involvement and record of the activities of the MSWs and their impact on care were also recorded. We employed the core competency areas of the medical social workers' services as described by Atanesian (10) in evaluating the extent of involvement as well as the completeness of services given by the MSWs to the patients.
A family of five sustained varying degrees of burn injury following a cooking gas explosion at their home, a two-bedroom apartment in a block of flats. They had suffered the injury while the mother was attempting to light a gas cooker in their kitchen, unaware there was a gas leak from the system. The resultant explosion primarily affected her and her three children who were with her in the kitchen. Her husband sustained burn injury while trying to rescue her and the children.
The mother, a 38-years old female petty caterer, sustained 20% mixed thickness burns to the face, both upper and lower limbs. First child, a 10-year-old girl, had 27% mixed thickness burns involving the head and neck, both upper and lower limbs, with an inhalational injury. The second child, an eight years old boy, sustained burns to the head and neck, both upper and lower limbs, with estimated total burn surface area (TBSA) of 17%. The four-year-old youngest child had 27% burns involving the head and neck, both upper and lower limbs and part of the trunk, with an inhalational injury. The father, a 48-year-old launderer, had partial-thickness burns involving the face and the right upper limb with TBSA of 9%.
The family lived and worked at Mowe in Ogun State about 100km from Lagos, the economic capital of Nigeria. Our facility, also located in South-West Nigeria, is about 268.4km from Mowe. They were initially managed consecutively at two private hospitals before they were referred to our facility, on the father's request, on the fourth-day post-injury because they could not finance the needed care at the referral hospital. We managed the father on an out-patient basis while the others were admitted. By the 17th day of admission, they were discharged home and followed up in the clinic. However, they were lost to follow up after a few clinic sessions.
Role Played by the Social Workers
On presentation, the family had no funds with which to procure treatment and as such the initial access to care was supported by the hospital's policy of providing care without any hindrance in the first 24 hours of admission. By the following day, we (the plastic, burn and reconstructive surgery unit) invited the medical social works department to co-manage the patients: given the socio-economic and psychological straits they were passing through; having lost their home and without funds to access care. The MSWs on evaluation discovered that the husband had no living relative and that the wife, too, had been long ostracized by her own family. The index family lived far and detached from their community and thus had a poor connection with their home community.
The MSWs were immediately handy to provide social support for the patients. They sought a donation of items of clothing for the patients as they had presented to our facilities without any extra clothing. They assisted the patients to obtain food, aside from the provision from the hospital kitchen, and to procure toiletries and similar items.
On the third day of admission, the MSWs facilitated transportation for the father to visit his home community and seek for financial support. When contacted, the traditional ruler of the community referred the MSWs to the community's progressive union, a body that provides an avenue for mutual aid, contributory welfare, security and leadership within the town. The latter, called for donations, in both cash and kind, from the members of the community. The MSWs were the liaison between the patients' host community and the hospital, ensuring a constant flow of fund for the patients' management. Later on, the MSWs secured a sum of money from the Ekiti State Government through its periodic health financing intervention program to needy patients.
Following the death of the youngest child from severe pneumonia on the third day of admission, the MSWs provided psychotherapy and counselling for the parents. Subsequently, the MSWs participated in the clinical meetings and briefings held on behalf of the patients and occasionally joined the ward rounds. On discharge, the MSWs took up the barge of the discharge planner and facilitated the joining of social support groups by the patients.
Burn injuries are quite devastating and debilitating injuries requiring multidisciplinary care in a burn center since no single specialist can manage the multisystem injuries that arise following burn injury. The management, which is not limited to the medical or surgical care, also involves a psychological assessment of the patient and the family (11). Survivors of burn injuries deal with psychosocial issues like adapting to physical limitations and permanent changes, coping with grief and loss, traumatic stress, anxiety, pain, sleep disturbance, depression, body image concerns among others (12). Given the psychosocial issues above, one cannot underestimate the role of the medical social workers in the care of burn patients. Thornton & Battistel (13) illustrated the significance and the responsibilities expected of the social workers in a study wherein they suggested that the social worker could assist in the psychosocial adjustment of burn patients during hospital admission, both in the acute and rehabilitating phases. Suggested approaches included a case-management style and the establishment of support groups. Blakeney et al. (14) observed that increased likelihood of physical survival had led to more significant concern for potential psychological morbidity for the burn survivor, and therefore devised a philosophy of psychosocial rehabilitation for patients with severe burns. Waqas et al. (15) noted that social support played a significant role in maintaining the physical and mental health of patients with burn injuries. Patients tend to heal quickly with shorter treatment duration when families are present and provide the necessary assistance, as burn treatment and recovery can still be long and arduous, even with family support. In a study on psychosocial adjustments of patients after burn injury, interdisciplinary cooperation between plastic surgeons and psychosomatic specialists could optimize early intervention with patients exposed to social maladaptation (16). Waqas et al. (15) further noted that burn patients reported lower scores on social support from their significant other, family, and friends than their healthy counterparts. Our patients did not even have any family, friends, or others to lean on to for support. The support given by the social workers lessened the would-have-been negative health outcome for them. The MSWs offered psychotherapy and counselling to the father and mother after the loss of one of their children. It is not unusual to erroneously consider children as minors who may not yet understand the implication of a loss of a sibling. As such, the other siblings did not receive the psychotherapy.
These patients' management was not the first time the MSWs were involved in the management of patients. However, the knowledge of their established roles in burn patient's management is deficient. As Linton et al. remarked (17), the social workers are mostly wearing the discharge planner hat. It is therefore not unusual for us to call upon them to help plan a patient's discharge, recover unpaid bills and assist with the reintegration of the patient to the society. We rarely called upon them to be involved in the care of burn patients from the outset of management (in the acute phase of care). Barrett (18) had recommended referral of burn patients to social work as soon as possible after admission (at least within the first 24 hours). Early referral of these patients had ensured that appropriate psychosocial crisis care and support were provided to the patients and that their immediate practical needs addressed as soon as possible. The medical social workers obtained financial support for the patients, thus ultimately lowering the cost of care. The financial support was obtained mainly by engaging the patient's home community. Fraser et al. (19) in their review of studies reported ten studies where social workers engaged community resources on behalf of patients and their families and noted that seven of those studies demonstrated findings favoring integrated care. Without financial support, access to healthcare would have been impossible for the patients, thereby increasing their potential morbidity and mortality, and escalating the attendant cost of care. Steketee et al. (20) in their study had noted that interventions involving social workers, whether through sole delivery, team leadership, or core membership on interprofessional teams, had positive effects on health outcomes and were less costly than usual care that did not include substantial social work services. Invariably the MSWs were still required to wear the discharge planner hat, but they equally assisted the patients
to join a social support group. Establishment of social support group provides avenues for burn survivors and their families to discuss subjective experiences, as well as the dissemination of various coping techniques (21).
We utilized the Atanesian core competence area for social work assistance to families (10) in assessing the completeness of the role of MSWs in this study. The MSWs showed thoroughness in the discharge of their duties to the patients. These duties also cut across the five essential domains of social work, as illustrated by Browne et al. (22). At some point in the discharge of their duties, they had touched on increasing screening and prevention, addressing economic and environmental stressors in health care, improving care management and coordination, promoting interventions tailored for vulnerable populations, and facilitating successful care transitions. These are models of health social work that can leverage health care systems to address social and community factors shaping health outcomes (22). Marino et al. (23) worked on the development of a conceptual framework that was to guide the implementation of a large-scale calibration study that will provide a computerized adaptive test for monitoring the social impacts of burn injuries during recovery. The intervention of the MSWs can then better be tailored against such established social impacts when such monitoring tools are available, rather than carrying them out empirically.
The medical social worker's responsibilities go beyond psychosocial support, planning for discharge, and debt recovery. The MSW is a mobilizer who assist in rallying community support for burn patients, even in clients from disjointed families. This study had shown the beneficiary participation of the MSWs in the multidisciplinary care of burn-injured patients. With more pieces of evidence suggesting improved outcome for patients, families and communities in integrated patient care and the added value of social workers on such health care teams (19, 22, 24), there is a need for burn surgeons in similar settings as ours to get more participatory involvement of the medical social workers in their practice.
Conflict of interest
The authors warmly acknowledge and appreciate the roles played by Mrs C. O. Omole of the Department of Medical Social Services of the Ekiti State University Teaching Hospital, Ado-Ekiti.
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