Understanding the Barriers and Enablers for Seeking Psychological Support following a Burn Injury

Round 1

Reviewer 1 Report

Many thanks for the opportunity to review this interesting work which reports on barriers and facilitators regarding the usage of psychological support for burn survivors. Please see the comments below for your consideration: 

1. The introduction can be improved to include state-of-the-art literature regarding psychological issues post-burn. There is a plethora of literature in this regard and must be included to clearly conceptualize the phenomenon in-depth. For instance, are there any factors that influence how psychological issues develop? How are existing psychological services supporting burn survivors and their families warrant a study that seeks to examine the barriers and facilitators that they experience? Are there gender variations regarding the occurrence of psychological issues post-burn? How is the current study situated in the wider peer-reviewed burn care literature regarding mental health issues post-burn? 

Further to the above, the service context needs to capture the current services offered and how they are organized. The notion of self-referral is interesting to note albeit it remains unclear on what basis the patient needs to undertake this self-referral. The authors mention that "...at any point for burn-related psychological difficulties" (page 2, line 62). I find this rather vague as it remains unclear how the patient would know that if their psychological issue is related to the burn? 

2. The study aims are well articulated. 

3. Regarding the methodology, the authors state that they used the thematic analysis methodology with reference to Braun and Clarke's approach. I find this rather confusing as Braun and Clarke did not describe the thematic analysis approach as a methodology. Instead, it is a method of data analysis: "TA is a method for systematically identifying, organizing, and offering insight into, patterns of meaning (themes) across a dataset" (Braun & Clarke, 2012, p.2). Please rectify this point and indicate exactly the qualitative methodology that was employed. 

4. As a minor comment, was the interview guide piloted before use? 

5. The section on "Credibility checks" should be changed to "trustworthiness or methodological rigor". This is important as quality in qualitative research is not judged only based on credibility. Aspects such as transferability and dependability need to be included as well. 

6. The participant demographics may need to include how many years post-burn prior to the invitation to participate in the study. 

7. The results, discussion, and recommendations are well-raised. Well done to the authors. 

8. As a matter of curiosity, this study is a full research work, I wonder why the authors consider it as a project evaluation report instead. 

Author Response

See attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the privilege of reviewing this manuscript. Overall, very well done. A few comments: Please expand on the subject selection. Were they required to have been previously admitted to a burn center with a burn? Were people with trivial burns excluded? Did the subject access psychological care support themselves?  Please expand on how peer support was addressed and differentiated from psychological care during the interviews.

Author Response

See attached

Author Response File: Author Response.pdf

Reviewer 3 Report

Thank you for the opportunity to review this interesting paper. I think this is a subject that is worthy of exploration, and necessary for psychological recovery of burn patients. Overall, I think this paper can be accepted for publication and is well written. Well done so far. I have added my thoughts below about the themes for you all to consider, and to make changes or not following your internal discussion within the team of aurthors.

I have no changes to suggest for the abstract, introduction and method sections.

Result section:

Overall themes look reasonable. Here are some thoughts to consider about the themes.

3.1.1. Communication between patient and service

missed opportunities:

the quote about being ‘just normal for the hospital’ (lines 157-8) seems to be that this patient is asking for the need for psych support to be destigmatised

Poor communication:

what does they ‘have to go through stress’ actually refer to within the text? Is this about 1) the process of accessing support being stressful or 2) that the patient sees this as a necessary criteria for seeking support?

Thus, are the above two quotes. about communication (3.1.1) or about beliefs (3.1.2)?

3.1.4 Fostering hope:

               encouraging positivity (lines 305-6) and inner strength (lines 325-340)

These themes/sub-themes reflect the principles of posttraumatic growth after burn – of which hope is an important part.

However, I am not sure about the inclusion of Clinician Care as a subtheme under the Fostering Hope theme. The interactions of patients with the HCPs are important to foster hope, but also not to create shame (lines 300-302). I feel that perhaps the ‘clinician care’ subtheme could be more of an overarching theme instead to prioritise their role in psychosocial care. The MDT as a whole could be encouraged to take a more holistic approach to burn recovery, so they can normalise the impact of the burn on mental wellbeing, destigmatise the use of supportive psychosocial services, and encourage patients to access these at all stages of the patients’ postburn journey. It can be hard to predict at what stage an individual will need help, therefore specifying a fixed timepoint post-burn to screen patients can easily miss those who require support.

Discussion

line 392 – is this a definition of cultural humility? if not please state a definition or, if yes, clarify it is one

lines 410-413 these patient characteristics are all aspects of posttraumatic growth after burn – please add comment in text

line 414 – emphasises the importance of clinician’s care as well – should this be a theme?

4.1 Service recommendations and rationale

Table 3

·        if the recommendations are based on the literature as well as these study findings then please add references.

·        Resources supplied should be developed with patients so that they address the patients’ needs such as the use of language, acceptable layout and presentation, patient stories, quotes and anecdotes.

·        Staff education around patient experiences, psychosocial support, how to encourage and motivate patients.

·        It reads as thought the recommendations made are all about written materials placed in the vicinity of the patient without personal face-to-face interaction of the clinical psychology team, and without the clinical psychology team being a present and integrated part of the burns MDT.

·        Is it possible for the clinical psychologist to have a physical presence on ward rounds, in the ward, MDT meetings as well as in the outpatient clinic etc?

Limitations

please comment about not reaching saturation (unless you did – in which case please state in the methods section)

Conclusion

Please, add a statement that captures the main themes as being important from a patient perspective.

Well done for exploring this, it is wonderful that your patients have the opportunity to seek support via self-referral and something that your burns MDT clinicians should be promote as a marker of service excellence. You talk very little about your service capacity though, which is alluded to in the recommendations and the conclusions, but I suspect might be a barrier to your general presence in the clinical areas of the burns ward and opc. I understand it is outside the scope of the exploration of this study, but more information will add contextual information around the subject.

I recommend that this paper is accepted with some minor changes following the consideration of the points above. Good luck, and I am happy to re-review if required.

Author Response

See attached

Author Response File: Author Response.pdf

Reviewer 4 Report

This quality improvement study seeks to inform the implementation of access to psychological services in a burns inpatient and outpatient hospital setting using a qualitative research design.

I have two major suggestions for consideration:

1)  More clearly identify the qualitative research design (e.g., phenomenology) and approach in the study. For example, the authors state they used purposive sampling, but then describe an approach that sounds like consecutive sampling Ii.e. quantitative methodology) in lines 89-92. Also, terminology of superordinate and subordinate themes aligns with interpretive phenomenology approach, yet Braun & Clarke (2006) is referenced for thematic analysis. 

2) Linkages with the underlying framework (COM-B) and interpretation of the data could be clearer. The authors may like to consider - to really inform implementation learnings - that it would be helpful to link the COM-B findings to the related Behaviour Change Wheel that sits alongside COM-B. This could be done as deductive analysis using the themes derived from the current inductive approach. I would also suggest that the example provided in line 365-371 speaks to opportunity (not capability) and line 372-380 speaks to motivation (not capability) - please review. A useful reference may be http://dx.doi.org/10.1136/emermed-2015-205461 

Minor corrections required for:

> include interview questions as Additional File 1

> Section 2.6 is part of results, not method

> present quotes in italics, with evidence trial after the quote not before (e.g., P4). Consider reducing the number of quotes to improve readability.

> line 439 speaks to generalisability (not transferability)

> repetition in lines 74-75 and 449-450 can be removed without loosing impact

Author Response

See attached

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Many thanks to the authors for thoughtfully addressing all the comments raised. Really, well done to the authors.

A minor concern remains regarding the choice of qualitative design. Indicating phenomenology adds another layer of complexity as the authors will need to justify whether it is descriptive or interpretive/ hermeneutic.  Going through the study, I think the nature and scope of the study, as well as the analytical procedures, fit within the domain of qualitative description (An approach by Sandelowski). May I invite the authors to consider this further? 

Author Response

Thank you for taking the time to read this paper. In line with your feedback we have removed the word 'phenomenology' in line with your comment below.

A minor concern remains regarding the choice of qualitative design. Indicating phenomenology adds another layer of complexity as the authors will need to justify whether it is descriptive or interpretive/ hermeneutic.  Going through the study, I think the nature and scope of the study, as well as the analytical procedures, fit within the domain of qualitative description (An approach by Sandelowski). May I invite the authors to consider this further? 

Reviewer 2 Report

Comments addressed.

Author Response

Thank you for taking the time to read this paper.

Reviewer 3 Report

These are all changes that have added positively to your paper and I am happy to suggest that this is now able to be accepted for publication. Well done

Author Response

Thank you for taking the time to read this paper.

Reviewer 4 Report

The authors have responded thoughtfully to the feedback provided by the four peer-reviewers. My main ongoing concern is in regard to methodological coherence and integrity, which I think can be resolved with some relatively simple revisions. I have aimed to describe my rationale and suggestions below:

> Given your research questions are about understanding perceptions of barriers & enablers (Q1), gaps (Q2) and develop practical and feasible service recommendations (Q3), codebook thematic analysis (TA) is appropriate as a tool for mapping data. However, I would suggest that your rationale for the value of TA was to capture shared topics (not patterns of meanings as you have stated in line 101). This would be more methodological coherent with the approach described in Table 1.

> the language of superordinate and subordinate themes (Table 1, step 5) is incompatible with codebook TA. Methodological coherence would require the language of overarching themes (i.e., the four themes identified) and sub-themes (i.e., the 15 sub-themes identified). Section 3.2 also needs to be revised to ensure this wording is consistently used throughout the manuscript.

The following reference may be of assistance if these suggestions need further clarification: Braun V, Clarke V. Is thematic analysis used well in health psychology? A critical review of published research, with recommendations for quality practice and reporting. Health Psychology Review. 2023 Jan 6:1-24.https://doi.org/10.1080/17437199.2022.2161594 

My other request would be the authors re-read abstract (line 15, re burns psychological): is there a word missing here?

Author Response

Dear reviewer 4,

Thank you again for your helpful amendments. I have addressed these in italic below:

The authors have responded thoughtfully to the feedback provided by the four peer-reviewers. My main ongoing concern is in regard to methodological coherence and integrity, which I think can be resolved with some relatively simple revisions. I have aimed to describe my rationale and suggestions below:

> Given your research questions are about understanding perceptions of barriers & enablers (Q1), gaps (Q2) and develop practical and feasible service recommendations (Q3), codebook thematic analysis (TA) is appropriate as a tool for mapping data. However, I would suggest that your rationale for the value of TA was to capture shared topics (not patterns of meanings as you have stated in line 101). This would be more methodological coherent with the approach described in Table 1.

We agree with your feedback and changed the language (we have removed 'patterns of meaning' and included 'key topics'). 

> the language of superordinate and subordinate themes (Table 1, step 5) is incompatible with codebook TA. Methodological coherence would require the language of overarching themes (i.e., the four themes identified) and sub-themes (i.e., the 15 sub-themes identified). Section 3.2 also needs to be revised to ensure this wording is consistently used throughout the manuscript.

We agree and changed the language from superordinate to 'overarching theme', and subordinate to 'sub-theme'. 

My other request would be the authors re-read abstract (line 15, re burns psychological): is there a word missing here?

We agree and have included the word 'care'. 

Thank you once again for your helpful amendments and taking the time to read this paper.