A Study Protocol for the Implementation and Evaluation of a Self-management Support Program in Burns Aftercare for Burn Survivors in the Netherlands

The primary outcome measure is self-management skills, assessed using the revised Partners in Health (PIH) scale. This 12-item questionnaire measures self-management behavior and knowledge, with scores on a 9-point Likert scale (higher scores indicate better self-management). Two subscales are identified in the Dutch PIH: 1) knowledge and coping, and 2) recognition and management of symptoms, adherence to treatment. Higher scores reflect better self-management skills. The PIH scale has good construct validity and reliability, with Cronbach's alpha ranging from 0.82 to 0.86. Test-retest reliability, as measured by the intraclass correlation coefficient, ranges from 0.77 to 0.818 across different language versions. While no data on responsiveness is available, the PIH consistently provides valid evidence of self-management skills in patients with chronic conditions.

To determine reach, participant demographics will be compared to non-participants using the Dutch Burn Repository R3. We will compare the following characteristics: sex (m/f), age (years), total body surface area burned (%), operation (yes/no), and length of stay (days).

Adoption at staff level will be assessed by comparing the total percentage of participating healthcare professionals to the total percentage of healthcare professionals who were invited to participate, which will be quantified in percentages. Participation is defined as the completion of the three training components (i.e., e-learning, face-to-face training, follow-up training).

To gain insight into the intervention fidelity to the core components, healthcare professionals will be asked to document in patient records when they have used certain components. A convenience sample will be taken by assessing patient records to investigate how often the core components were used, which will be described using descriptive statistics.

To gain insight in the implementation fidelity to the implementation strategies, each burn center will be asked to keep track of the completion of the implementation plan, including the staff attendance to training plan and their e-learning completion rate. Implementation fidelity will be quantified using descriptive statistics.

Maintenance will be assessed by the healthcare professionals' self-report of continued use using the Provider REport of Sustainment Scale (PRESS). The PRESS measure is a brief, reliable, and valid three-item measure of sustainment that is both pragmatic and useable across different evidence based practices (EBPs), provider types, and settings. The PRESS captures frontline staffs' report of their clinic, team, or agency's continued use of an EBP. It is measured on a 5-point Likert scale, with higher scores indicating better maintenance.

Setting-level maintenance will be assessed via the Clinical Sustainability Assessment Tool (CSAT). The CSAT is a brief and reliable instrument consisting of 35 items within seven domains to assess an institution's capacity for sustaining a clinical practice. These domains include Engaged Staff & Leadership, Engaged Stakeholders, Organizational Readiness, Workflow Integration, Implementation & Training, Monitoring & Evaluation and Outcomes & Effectiveness. Each domain includes five items that are scored on a 7-point Likert scale, where 7 indicates an individual believes their institution has that domain to a great extent. Each domain has a min-max value of 5-35, with higher scores indicating better maintenance.

Self-regulation skills will be measured with the Self-Regulation Assessment (SeRA). The SeRA consists of 22 items that assess four domains of self-regulation: 1) Insight in own health condition, 2) Insight in own capabilities, 3) Trust on self and apply self-regulation, 4) Organisation of help. Answers are given on a 5-point Likert scale. Mean scores are calculated per domain, with a min-max score of 0-40. A higher score on the scale indicates a better level of self-regulation skills.

Participation will be measured with the Measure of Experiential Aspects of Participation (MeEAP). Participants will be asked if they participate on four different life domains: 1) employment, 2) mobility, 3) sport, and 4) exercise. The response options will be used to assess both participation in the activity (yes vs. no) and the individual's satisfaction with the level of participation

Participants will be asked if they are capable of performing their daily activities. Daily activities will be measured with one question from the 5-level EuroQoL-5D (EQ-5D-5L). Answer options are presented on a 5-point Likert scale, with a higher score indicating better capability of performing daily activities.

Participants will be asked if they are capable of performing self-care. Self-care will be measured with one question from the 5-level EuroQoL-5D (EQ-5D-5L). Answer options are presented on a 5-point Likert scale, with a higher score indicating better capability of performing self-care.

Participants will be asked if they are dependent on other people. Dependency will be assessed with a newly formulated question. Answer options are presented on a 5-point Likert scale with a min-max value of 1-5, with a higher score indicating less dependency on other people.

Return to work or school will be measured with the Adjusted International Consortium for Health Outcomes Measurement. Participants will be asked about their daily occupation, with the following response options: 'I work 36 hours or more per week' (1), 'I work 35 hours or less per week' (2), 'I am job searching' (3), I do not have a paid job (I go to school or am studying)' (4), I do not have a paid job (retired, volunteer, stay-at-home occupation' (5), 'I cannot work because of my burn injury' (6), 'I cannot work due to other health issues' (7). Furthermore, they will be asked if their job has been adjusted since their burn injury (e.g. physical adjustments or reduced working hours), with 'yes' or 'no' as response options. Lastly, they will be asked, if suitable, how long after their burn injury they have started working or studying again.

Overall experience of the received care will be assessed using the Dutch translation of the subscale 'patient-centeredness' of the American Consumer Assessment of Health Plan Survey (CAHPS). Participants will be asked if they feel listened to by their healthcare professional, if sufficient time is dedicated to their concerns, if they feel healthcare professionals take them seriously, if the healthcare professionals are able to appropriately explain things, and their level of trust in the healthcare professional's competence. Answers are measured on a 4-point Likert scale resulting in min-max values between 0-20, with higher scores indicating higher satisfaction.

To evaluate the cost-effectiveness of the intervention, the complete 5-level EuroQol-5D questionnaire will be used to measure the effectiveness for patients compared to the control and intervention group. The EQ-5D questionnaire consists of five dimensions: mobility, self-care, daily activities, pain/discomfort and anxiety/depression. The EQ-5D L also consists the EQ visual analogue scale (VAS). Answer options are given on a 5-point Likert scale.

Self-management support skills of participating healthcare professionals will be measured with the Self-efficacy and Performance in Self-management Support (SEPSS-36). The SEPSS is a 36-item questionnaire divided over 6 subscales, using a 5-point Likert-scale. Higher mean scores (overall and for subscales) indicate a higher level of self-efficacy or performance in self-management support. Min-max values for the subscales range from 0-24, and the overall min-max value range from 0-144.

Need-supportive counselling will be measured using two separate taxonomies. The first taxonomy is the Coding and Observing Need-Supportive Counselling in Chronic Care Encounters (COUNSEL-CCE). The COUNSEL-CCE consists of 44 items divided into nine scales of behavioral approaches. Response options are based on a 5-point Likert scale range from 'never observed' (0) to 'all the time observed' (4). Min-max values range from 0-24, with higher scores indicating better need-supportive counselling.

To explore healthcare professionals' perspectives on adoption, implementation, and maintenance, we will conduct Consolidated Framework for Implementation Research (CFIR)-informed interviews with all participating healthcare professionals. These interviews will be used to provide working hypotheses to explain the degree of adoption, to explain implementation success or failure, and to explain the degree of maintenance.

The second taxonomy to assess need-supportive counselling is the Nurse-Child Interaction Taxonomy (NCIT). The NCIT consists of 16 items divided over 3 subdomains, scored on a 7-point scale, with higher scores indicating better need-supportive counselling.