The increasing rates of obesity within Australia present a challenge for healthcare professionals from all disciplines working in the health system. Current statistics indicate that 63%
of adults are outside of the normal weight range, with 35% overweight and 28% obese (Australian Bureau of Statistics 2012).
Obesity is a highly complex issue influenced not only by the physiological interplay of diet and exercise but also by genetics, environmental, social, psychological, metabolic, pharmacological, economic and political factors (Budd et al. 2009; Wright and Aronne 2012; Phelan et al. 2015; Ward-Smith and Peterson 2016). Obesogenic drivers include readily available energy-dense foods that are aggressively marketed, sedentary lifestyles due to increases in technology, less access to open great spaces, busy lives, family and peer influences, stress, insomnia, anxiety, depression, past traumatic events, some prescription medication and endocrine disorders (Australian National Preventative Health Agency 2014; Leung and Fudner 2014; Wright and Aronne 2012).
People with obesity are at risk of facing daily discrimination from a weight-bias society. This bias is present amongst healthcare professionals of all disciplines. Many people who are overweight or obese report experiencing judgemental attitudes and discrimination from health professionals and subsequent feelings of fear and shame (Poon & Tarrant 2009; Bombak 2014).
Nurses represent the most prevalent workforce within the healthcare system and the challenge of obesity requires nurses to reflect on their beliefs and preconceived attitudes in order to provide optimum care.
A person-centred care approach assists nurses and other healthcare professionals to better understand, treat and support patients to gain improved control over their lives (RNAO 2015). This paper will explore through the use of a case study, the stigma and discrimination related to obesity in healthcare settings and highlight how a person-centred care approach can improve patient outcomes.
Obesity, stigma and discrimination in healthcare settings
Research by Puhl and Brownell (2006) on 2,671 overweight or obese adults found that weight-bias and discrimination occurred in 69% of interactions with doctors, 46% with nurses and 37% with dieticians/nutritionists. Given the amount of time nurses typically spend engaged in patient care, the high statistic for nurses is concerning. The bias displayed by health professionals is connected to stereotypical assumptions that people with obesity are lazy, inactive, incompetent, self-indulgent, undisciplined, lacking in willpower and have poor hygiene (Puhl and Brownell 2006; Puhl and Latner 2007; Phelan et al. 2015; Ward-Smith and Peterson 2016). For instance, a study of 398 British nurses working in primary care settings found that 69% believed personal choices related to food and exercise were the reason for patients’ obesity, and one-third believed that a lack of willpower over food choices was the main influencing factor (Brown et al. 2007). These prevalent stereotypes are often reinforced by media that ignore the broader complexity of the obesogenic environment (Pheln et al. 2015; Fruh et al. 2016).
Healthcare professionals who view people with obesity as personally responsible for their weight often perceive the patient as hindering the delivery of optimum treatment and care (Phelan et al. 2015). Studies have found that when nurses and general practitioners (GP) perceive obesity to be purely a preventable condition, this perception results in a belief that the patients’ unsuccessful weight loss is related to poor motivation and compliance with recommendations. Such a belief does not consider the profound impact that the healthcare professionals approach or attitude can have on the patients change process (Hoppe and Odgen 1997; Campbell et al. 2000).
Weight-bias is so pervasive that nurses who work specifically with patients who have obesity and who wish to be unbiased can still struggle against the dominant societal message that individuals are solely responsible for their weight (Teachman and Brownell 2001; Bessenoff and Sherman 2000; Reto 2003). In a study of implicit and explicit weight-bias amongst 4,732 medical students, Phelan et al. (2014) found that overt negative attitudes directed towards people with obesity were more socially acceptable than overtly racist attitudes.
Impact of stigma and discrimination on the patient
Several studies have shown that individuals with obesity learn to become vigilant for signs of stigma in order to protect themselves psychologically (Phelan et al. 2015; Drury and Louis 2002; Puhl and Heuer 2009; Fruh et al 2016). Experiences of weight bias can result in the fight and flight response, thereby increasing levels of anxiety and impairing cognitive functioning, resulting in ineffective communication causing the person to retreat or display defensive reactions (Phelan et al. 2015). As is clearly demonstrated in the case study below, these psychological effects of discrimination can have an immediate and enduring impact on self-esteem, depression and an increase in body image dissatisfaction. Behaviours resulting from these psychological impacts include binge eating, social isolation and the delay or avoidance of seeking much-needed future healthcare (Drury and Louis 2002; Puhl and Heuer 2009; Phelan et al. 2015; Fruh et al. 2016).
*Sara’s story: A case study
Sara’s case study, as detailed below through extracts from an interview, highlights both the devastating impact that weight bias from healthcare professionals can have on patients, as well as the positive impacts of a person-centred care approach, including improved motivation and self-efficacy.
After many years of struggling with her weight and now in her early fifties, Sara’s GP suggested she consider bariatric surgery. She attended an initial appointment with a bariatric surgeon in the hope of discussing her options. During this appointment, Sara was told she was ‘too fat’ and could not be helped. Sara described how the surgeon did not give her eye contact during the consultation and concluded the appointment by saying ‘meeting’s over’. A month later, Sara presented to the same hospital’s emergency department (ED) with abdominal pain. She was told by several ED nursing staff that she would not be in pain if she lost weight. However, Sara had a large incisional hernia that was exaggerating her size and causing pain, and which would go undiagnosed for a further two years.
Sara described her encounter with the surgeon and ED nursing staff as having a devastating effect on her psychological health, which in turn impacted her physical, social and spiritual wellbeing. She recalled her thoughts and feelings at the time:
“…oh my God I’m nothing to anybody. No-one can help me, I’m beyond help. I’m a waste of oxygen.”
“I think I went into a complete depression. I didn’t talk to people, I just shut right off. I just didn’t care about myself, about my house, about my relationship, about anything. I just, I just went into withdrawal. I just closed in and just had to deal, had to deal with that in my own way, in which my way is just shutting my doors and windows and just sitting in
my lounge room and just saying well that’s it I’m just going to die like this.”
Sara speaks here of losing self-respect and self-worth. She also reflected that the impact of her interactions with the medical and nursing staff might have led her to ‘punish’ herself on some level, feeling that others did not care about her. As such, she learnt to internalise her low self esteem. Puhl, Moss-Racusin and Schwartz (2007) suggest that people with obesity have a greater tendency than other stigmatised groups to internalise the stereotypes made against them because such stereotypes constitute pervasive and socially accepted ideas.
Shaming individuals with obesity in the belief that it will motivate them to lose weight has been found to have the opposite effect (Phelan et al. 2015). This was the case with Sara in the two years following her initial bariatric surgical consultation:
“I gained weight, I gained a lot more weight, I probably gained about 30 kilos because I just didn’t care…I felt like I didn’t matter.”
A person-centred care approach
A person-centred care approach is described as a deflection from the biomedical model to an emphasis on creating partnership with patients to understand the whole person and their experiences of health (The Nursing and Midwifery Office 2014; RNAO 2015). The aim is to improve both the psychological and physiological wellbeing of a person through seeking to understand their personal circumstances, competing life priorities and how these impact health outcomes. A best practice approach is the 5A’s framework of behaviour change which uses a brief intervention model to explore motivation and promote self management (RNAO 2015; NHMRC 2013; ACSQHC 2011). The underlying principles of a person-centred care approach include treating people with dignity, respect, active participation in informed decision making and collaboration in the delivery of care that is acceptable to the patient.
A person-centred care approach can have a significant impact for patients who are overweight or obese. Motivational interviewing, a key tenet of a person-centred care approach aims to explore and resolve ambivalence to change and can aid in the significant reduction of weight (Armstrong et al. 2011). Sara’s story clearly highlights the absence of a person-centred care approach and its consequences. Non-verbal cues, such as the lack of eye contact Sara experienced, communicates an absence of empathy and respect, which can affect a patient’s commitment to treatment (Perskey and Eccleston 2010).
As in the case of Sara she isolated herself for two years and gained additional weight before being diagnosed with a hernia. At this time she sought a second opinion from a different surgeon on her options for bariatric surgery so that she could have the hernia repaired. Sara described the consultation with this surgeon differently, highlighting that he took an interest in attempting to understand her journey, while being attentive and giving her a sense
“It was like chalk and cheese. Completely different attitudes. The doctor met me in the waiting room, shook my hand as he met me, walked me in, had a nice conversation on the way to the room, asked me my life story’ (and said following the consultation)
‘I can and I will help you’.”
This narrative indicates the key components to a person-centred care approach, including showing respect and the building of a rapport through effective communication, such as making eye contact, active listening and attempting to understand the person’s health journey from their perspective. Sara made it clear how such an approach provided a human connection that promoted emotional and spiritual wellbeing and gave her a sense of hope. Sara was asked how she felt following this interaction:
“…I just walked out of there on like a pillow of air, I just felt 10 foot tall and proud and everything else in between, I just can’t explain it, the feeling that I walked out of there with. And I think that made a big change. I just felt at last somebody can see that I’m not a waste of space. That I am a human being who has an issue that needs serious help. And I just felt like ‘Thank God’. I think I went home and for the first time in a long time I was happy. I hadn’t been happy in a very, very long time. About myself, about my situation, about how my life was.”
As Sara journeyed towards bariatric surgery she worked with a multi-disciplinary team, including several nursing staff, to optimise her fitness for surgery. She spoke of how the team of healthcare professionals involved her in the planning of her care and the positive impact this had:
“A very planned approach and the approach is personal. Every time I seen them it was a personal ‘Hello how are you going’ and I felt like I’m the only one that mattered. And that to me made a big difference. Because I felt then very important and that’s a big step, big step.”
Sara also highlighted how her ability to self manage improved:
”Well whatever they require of me, I’m going to do 110%, because they’re putting themselves out, I need to prove to them that I am now worthy of them doing that. And that turned everything around, it just made me feel more positive about the whole situation.”
“…something clicked in my head that said you have to do this. If you want people to help you, then you have to help yourself. So every day I got up with that in my head…you have to keep going, you have to keep working at it. It’s not going to be an overnight process. You’re not going to wake up tomorrow and have no weight problems. Tomorrow you’re going to get up and it’s still going to be there so you better just deal with it. And that was the difference, I just had that in my head that…and I think that it was because everyone around me was so positive that I could do it, then I became positive as well.”
The outcome from this person-centred care approach was an increase in Sara’s self-efficacy resulting in a reduced BMI from 87kg/m2 to 61kg/m2 or a 30% reduction in body weight over a seven month period prior to surgery.
Lessons for improving clinical practice
Reflective practice is at the foundation of good clinical nursing care (Nursing and Midwifery Board of Australia 2006). Having an awareness of one’s own belief systems to identify and overcome bias is an important step to ensuring these beliefs do not adversely impact patient care (Fruh et al 2016; Ward-Smith and Peterson 2016). Gujral, Tea and Sheridan (2011) in their evaluation of nurses’ attitudes towards adult patients with obesity, found that while bariatric sensitivity training did improve care it did not change the nurses’ belief systems. This suggests that nurses need to find a way to challenge or accept their fears of weight while providing care with compassion and attempting to understand the individual patient’s unique experiences (Reto 2003). Since nurses are trained to provide holistic care and are the most prevalent discipline in our healthcare system, it is important for nurses to be a positive influence as leaders for themselves, their peers, students and the public, through raising awareness of the complexity of obesity and role-modelling unbiased attitudes (Fruh et al. 2016).
There are several best practice evidence based guidelines and public view online resources that provide recommendations to improve a person-centred care approach as well as helping healthcare providers to explore and combat their own weight bias (see table).
Obesity is complex in its aetiology and there is conclusive evidence of the pervasive and damaging effects of weight bias in Western society. In the case of Sara, the discrimination she experienced through weight bias resulted in lowering her self-esteem, social isolation, a sense of worthlessness and substantial weight gain. Conversely, a patient-centred care approach gave her hope, increased her self-efficacy and improved her motivation for positive behaviour change resulting in clinically significant weight loss.
This demonstrates the importance of nurses and other healthcare professionals monitoring and challenging their own preconceptions so that they can better understand, treat and assist their patients to gain improved control over their lives. Key organisations have tools and best practice guidelines to assist healthcare providers to increase their self-awareness and examine their thinking. It is nurses who are well-placed to provide leadership in this area and in doing so can help to dismantle some of the barriers to the provision of expert care and the injustice that accompanies prejudice.
*Sara is a pseudonym in the interest of confidentiality.
Kerry Wakefield, BNg, Grad Dip MHN, is the Pre-hab/Bariatric Clinical Practice Consultant, Central Adelaide Local Health Network, Adelaide. Kerry.firstname.lastname@example.org
Rebecca Feo, BPsych(Hons), PhD, is a Postdoctoral Research Fellow in the Adelaide Nursing School at The University of Adelaide
To read more articles from ANMJ, view the full journal online at https://issuu.com/australiannursingfederation/docs/anmj_july_2017_issuu