Obesity is rapidly becoming the world’s largest health issue with no sign’s of moderating (National Health Service (NHS), 2007). Not only does obesity have significant human cost in relation to the onset of disease and early mortality but also constitutes a severe financial burden to the NHS. The cost of obesity to the United Kingdom (UK) NHS was estimated to be approximately £1 billion a year with an additional £2.3- £2.6 billion a year to the economy as a whole (Department of Health (DOH), 2007). Overall hospital admissions for obesity as has bariatric surgery with 2724 operations carried out between 2007 and 2008.
Attitudes to obesity are generally negative in the published literature but one study highlighted that nurses, in particular, hold negative attitudes towards this client group. This study will focus on obese patients’ perceptions of nurses’ attitudes towards them. A quantitative paradigm incorporating a descriptive survey design will be selected as the most appropriate approach. The sample will comprise members of the British Obesity Surgery Patient Association (BOSPA) who will be invited to complete, a structured online questionnaire on a protected part of the website. The sampling technique used will be purposive and a convenience sampling and data will be analysed statistically.
The focus of this study will be the obese patients’ perception of the attitudes of the nurses towards them. To gain an insight into and an understanding of this area of practice, the literature relating to obesity and bariatric surgery, the patient experience and nurses’ attitudes will be critically appraised.
Obesity is defined as an excessive fat accumulation that is a risk to health. This is identified according to international guidelines by a body mass index (BMI), where a person’s weight is divided by the square of their height. A person having a BMI of 30 or more is classed as obese.
Being obese is a major risk factor for a number of chronic diseases, including diabetes, strokes, hypertension, cardiovascular disease, musculoskeletal disorders like osteoarthritis, and some cancers (World Health Organisation (WHO), 2009). These conditions cause premature death and significant disability (WHO, 2006).
In England the prevalence of obesity has almost trebled in the last two decades, with nearly one in five adults currently classified as obese, (National Audit Office (NAO), 2001). Obesity is rapidly becoming the world’s largest health issue (NHS, 2007); it is on an upward trend with no signs of moderating. By 1998 the incidence of obesity had almost trebled, at present almost half of women and two thirds of men are either overweight or obese, meaning one in five adults in the UK are obese (NAO, 2001). Not only does obesity have significant human costs, contributing to the onset of disease and early mortality, but also has severe financial burdens on the NHS. It has been estimated that the cost of obesity to the UK NHS is approximately £1billion a year, with an additional £2.3billion-£2.6billion a year to the economy as a whole. If the current trend is not halted, it is estimated that by 2010 the cost to the economy alone could be £3.6billion a year (DOH, 2007).
Overall hospital admissions for obesity have increased, reaching 5,018 in 2007/08, a 30% rise in one year and almost a sevenfold increase in a decade. Increasing numbers of drugs are being prescribed by doctors for obesity with the number of items rising 16% in one year to reach 1.23 million in England in 2007 (Telegraph, 2009).
It is now said that Britain is facing an ‘obesity time bomb’ as the number of middle aged people dying as a result of being overweight has doubled in less than a decade (Telegraph, 2010). The statistics show that more than 190 under 65 year olds died as a direct result of their obesity last year compared to just 88 in 2000; deaths among those aged between 46 and 55 almost tripled. Obesity was a contributing factor in a further 757 deaths last year compared to just 358 in 2000. These death rates are said to continue to increase rapidly through the decades as the overweight youngsters of today become middle aged (Telegraph, 2010). IS THE TELEGRAPH A RELIABLE SOURCE? WHAT IS IT REPORTING FROM, A RESEARCH STUDY, GOVERNMENT FIGURES??
The government is committed to tackling the rising trend of obesity in the UK; in 2008 the DOH set out a strategy to enable everyone in society to maintain a healthy weight. The strategy focuses on five main areas the healthy growth and development of children, promoting healthier food choices, building physical activity into our lives, creating incentives for better health and personalised advice and support. In spite of these national efforts and incentives to support a reduction in problems associated with obesity, such as lifestyle, diet and exercise, bariatric surgery has become more common.
Weight loss surgery is available for people with a BMI of 40 or more (the morbidly obese) and could be an option for people with a BMI of 35 to 40, who have life threatening cardiopulmonary problems, obesity related heart disease or diabetes (NHS, 2007). Weight loss surgery is usually only available on the NHS where there is a clear clinical need for surgery, and other treatment options have been tried but failed (NHS, 2007).
The three most widely uses techniques in weight loss surgery are gastric band surgery, gastric bypass surgery and intra-gastric balloon. Gastric band surgery involves a surgical procedure to fit a band around the upper part of the stomach to limit the amount of food a person eats. Each operation costs between £8,000 and £10,000. Gastric bypass surgery is a similar procedure which uses a band to decrease the stomach pouch, but differs to the gastric band surgery as the smaller stomach is re-routed to the small intestine, bypassing the rest of the stomach. It costs in the region of £10,000 to £12,000 (NHS, 2007). Finally, intra-gastric balloon surgery comprises implantation of a soft silicone balloon into the stomach, which aids weight loss as it takes less food to stop a person feeling hungry and costs between £3,500 and £4,500 (NHS, 2007).
As bariatric surgery is classed as major abdominal surgery, post-operative care is of high importance. Management of patients following surgery includes oxygenation, pain management, mobilisation, wound care, nutrition therapy, education and emotional support (Harrington, 2006). The major topics highlighted in bariatric postoperative treatment plans include; pulmonary, cardiovascular, fluid and electrolytes, pain and discomfort, activity/ambulation, skin and wound, gastrointestinal, psychosocial and safety (Harrington, 2006).
In 2007/8 there were 2,724 finished treatments categorised as bariatric surgery the majority in women, compared with 1,951 the previous year, (Telegraph, 2009). Pressure is mounting on the NHS to increase its capacity to handle weight loss surgeries, but it currently does just 46% of the desired obesity surgeries (BOSPA, 2009). As a result a number of people from the UK go abroad for weight loss surgery.
An attitude is an abstraction or theoretical construct used to indicate and summarise psychological tendencies (Brown, 2005). They are one way of describing differences between people with regards to their differing likes and dislikes. Attitudes are enduring thoughts, beliefs and feelings that people have about an issue, people or events (Cormack, 2000). Attitudes consist of three aspects; an emotional or evaluative component, a belief or cognitive component and an action or behavioural component. The emphasis based placed on all three components varies greatly on in both attitude theory and research (Cormack, 2000). A belief is the thoughts and cognitions that people hold, they show a general correspondence to whether something is positively or negatively evaluated (Cormack, 2000).
Nurses are required to adhere to the standards set by the Nursing and Midwifery Council code which states that they must not discriminate in any way against those in their care and that people must be treated kindly and considerately (NMC, 2009).
Many studies that have focused upon attitudes of nurses towards obesity in the literature found that there is a negative attitude towards the obese patient and obesity as a whole, examples include ‘Management of obesity in primary care; nurses’ practices, beliefs and attitudes’ (Brown, Stride, Psarou, Brewins & Thompson, 2007), ‘Female nurses’ perceptions of acceptable body size’ (Wright, 1997), and ‘Challenges in caring for the morbidly obese: differences by practice setting’ (Drake et al, 2008).
A study also found that nurses feel uneasy about assessing and talking about weight management (Wright, 1997). Only one study out of the six explored in the literature review rejects the view that nurses have negative attitudes towards obesity and the obese patient (Zuzelo & Seminara, 2006).
Lansing, McGuire, Palmersheim, Baird and Twedell (2009) propose in their piece of research that bariatric patients often encounter challenging physical environments and sometimes encounter negative attitudes from health professionals when seeking care. Equipment, environment, education and resources are important to providing sensitive, respectful, safe and high quality patient care. According to the National Association of Bariatric Nurses (NABN), the nurse-patient relationship is of great importance and attitudes, emotions and moods can affect this relationship.
The DOH developed a patient experience definition after a great deal of research; the outcome was that an ideal NHS should meet both physical and emotional needs of patients, which means getting good treatment in a comfortable, caring and safe environment which is delivered in a calm and reassuring way. People must be given information so they are able to make choices, and feel confident and in control; they should be talked to and listened to as an equal and should be treated with honesty, respect and dignity (DOH, 2007).
Action has been taken to listen to the ‘patient’s opinion’ through the Patient Opinion website where relevant information can be found and shared. Patients can read about others’ experiences, what they think of local hospitals, hospices and mental health services and share ideas on how services can improve. The Patient Opinion website was founded by a general practitioner (GP), Paul Hodgkin, who wanted to establish a way of making the wisdom of patients available to the NHS (Patient Opinion, 2010).
Therefore a review of the literature was conducted with the aim of examining nurses’ attitudes towards obesity and the obese patient and to analyse the available evidence base on nursing attitudes to obesity to improve the understanding of patients’ experience
Nurses are obliged to follow the Nursing and Midwifery Council (NMC) Code which states that they must keep their skills and knowledge up to date and deliver care on the best available evidence or best practice (NMC, 2008).
A literature review was performed to identify and review published material relating to the patients’ experience and perception of nurses’ attitudes towards them after bariatric surgery as an area of interest to develop and research. Various databases including CINAHL plus with full text, Cochrane library, MEDLINE, Interscience and the Ibis library catalogue were searched. Even though there are many resources available for a literature review these resources were chosen for their suitability and ease of access.
The search was restricted to published resources in relation to health and social care and the selected literature restricted to nursing. The following key words and Boolean operators were used in the initial search; obesity, bariatric surgery, nursing, attitudes and post operative care. Relevant studies were selected, reviewed, analysed and summarised.
Critical analysis of literature found.
Brown (2006) conducted a literature review on nurses’ attitudes towards adult obese patients with the aim of gaining an understanding of the attitudes of nurses towards this client group and the methods by which they have been studied. The review highlighted eleven studies relevant to the aims of the study, the earliest being published in 1985. Eight of the studies used quantitative designs and three of the studies qualitative. The most common method used in the qualitative studies was semi-structured interviews with sample sizes of ten nurses, using purposive sampling technique which were analysed using thematic analysis. The main findings on attitudes were that nurses’ felt ambivalent and uneasy when working with obese patients.
The most common method in the quantitative studies was self-administered questionnaires using convenience sampling with a sample size of seventy people and above. The main findings on attitudes included obese patients were evaluated more negatively and that is was physically exhausting when caring for an obese patient.
The review concluded that there is relatively little research about the subject and further research is needed. Brown found that most of the studies reported weaknesses of sampling and measurement. For the qualitative studies, the theoretical basis, rather then simply convenience for the sampling was not clear and the lack of analytical or exploratory depth restricts the transferability of these studies. Also the quantitative studies had relatively small samples drawing on convenience samples making it difficult to generalise the findings.
An important and consistent finding was that a proportion of nurses have negative attitudes and beliefs reflecting stereotyping according to variables such as age, gender, experience and the weight of the nurse which influences their attitudes.
Brown, Stride, Psarou, Brewins and Thompson (2007) conducted a correlation study on the management of obesity in primary care in which nurses’ practices, beliefs and attitudes were analysed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organisations in England. All nurses and health visitors working within the four primary care trusts in the North of England which were selected for their typicality with respect to initiatives to tackle obesity and levels of obesity were included in the study.
Of the 564 questionnaires posted, 544 were actually delivered and 398 completed and returned, resulting in a response rate of 72.3%. Data analysis was conducted by categorising the questions for example demographic and occupational characteristics, practice activity and beliefs and attitudes and then the means scores were calculated.
The selection of data collection tool successfully generated a high response rate however two of the attitudinal scales had low internal reliability. The findings highlighted the need for training and organisational support for obesity management by primary care nurses and, although outright stereotypes were rare, there was a range of potentially negative beliefs and attitudes relating to obesity and obese patients.
Wright (1997) investigated female nurses’ perceptions of acceptable female body size in a qualitative study using semi-structured interviews with a sample size of ten nurses recruited through convenience sampling. Convenience sampling was used because of time and financial restriction however this method decreases the representativeness of the sample and size of the sample being small means the findings cannot be generalised to the whole profession. The nurses were of a variety of ages with hospital-based nursing backgrounds however, none were directly involved in work with weight management.
A semi-structured format was used for the interviews so that it included clarification and discussion while ensuring that all areas were addressed. Interviews took place at a time and place convenient to participants and had no time restrictions. Analysis was carried out by examination of themes that emerged from interviews.
After reviewing this study many interesting aspects were highlighted; for example, nurses feel uneasy about assessing and talking about weight management with patients, there was a view that overweight patients are seen in a negative light because of potential health risks and that strong evidence suggests that there is discriminatory practice towards overweight female patients by doctors.
A study by Drake et al. (2008) identified challenges in caring for the morbidly obese. A quantitative, descriptive, questionnaire survey design using a purposive sample of approximately four hundred nurses was used. Even though the sample was large there were only 109 usable surveys (27%) because all the questions had not been answered. Nurse’s names and e-mail addresses were generated from the membership list of the National Association of Bariatric Nurses. Statistical analyses were performed using the SPSS 13.0 software package.
The nurse’s attitude to obese patients was identified by the nurses themselves as a significant barrier to care. However, the study concluded that more research needs to be carried out to first understand what constitutes the ‘nurse’s attitude’ and then to understand how it relates to the proceeding variable. Several other factors were identified which included staffing adequacy, lack of specialised equipment, a belief that behavioural issues are a major contributor to morbid obesity and finally, a belief that it is the patient’s personality which is a major barrier in preventing the nurse from providing optimal care (Drake et al., 2008).
Research conducted by Zuzelo and Seminara (2006) rejects all the preceding assumptions of nurses holding negative attitude towards the client group. This study was non-experimental and designed to elicit a description of registered nurses (RN) attitudes toward obese adult patients using survey instrumentation. Full time RNs employed by a single health care network and practicing across three types of care settings within a medical centre, acute rehabilitation institution and skilled facility were encouraged to participate. RNs received the survey in their mailboxes, they replied during an eight week period with an overall response rate of 16.2%
The instrumentation scale consisted of twenty eight items developed to measure attitudes of RNs towards obese patients across three dimensions; nursing management, lifestyle and personality characteristics. Statements were rated along a 5-point Likert scale, 1 being strongly agree and 5 being strongly disagree.
Data analysis was conducted using the statistical package for social sciences (SPSS), version 11.5. The results revealed the RNs have positive attitudes towards obese adults and were keenly concerned with providing respectful patient care. However, the RNs did voice concerns about safety when mobilising patients and they were aware of increased amount of time required of nurses when providing care for this client group. Limitations of this study included a low response rate (16.2%) and a low alpha score of 56 which determines the internal consistency suggests the instrument was less consistent than anticipated for the sample.
Finally, Watson, Oberle and Deutscher (2008) conducted research on the development and psychometric testing of nurses’ attitudes towards obesity and obese patients (NATOOPS) scale. This study was designed to develop and test an instrument to measure nurses’ attitudes towards obese adult patients and obesity as a whole.
Attribution-value theory served as the conceptual framework for the study. Item development began with a careful review of the scale developed by Bagley et al (1989) which formed the basis for most of the item scales. Further scales were added in accordance with the theory and current understandings of obesity. Most items were phrased such that a higher score would indicate more negative attitude but to avoid response bias some items were phrased in the opposite direction. To ensure content validity, the questionnaire was submitted to a panel of experts consisting of 3 memebrs with expertise in questionnaire design and 2 nurses who work with obese patients. There was 100% agreement that the development items were appropriate.
The instrument was sent to 1,400 randomly selected Alberta registered nurses and achieved a response rate of 46.1%. Respondents were predominantly female (95.5%) and the average age of respondents was 42 years. A total of 71 scale items which reflected what the researchers believed to be a multidimensional concept of attitude toward obesity and obese patients were included. All scale items were framed as 100mm visual analogue scale (VAS) which allows seldom too often or agree to disagree on each end, depending on the item stem.
The sample size was sufficient to conduct factor analysis, as there were nearly 9 cases per item for the 71-item scale. This study had a relatively high response rate for a random sample and the sample was considered to be reasonably representative of Alberta nurses. The scale demonstrated very good internal consistency reliability. A limitation of this study is that a detailed analysis of relationships among those variables and scale responses was not performed.