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Review 

Nurses’ attitudes towards obese patients: a review of the literature

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Obesity is a public health challenge and a source of discrimination for individuals; nurses can help to tackle it by providing patient-centred, non-judgemental care. This article comes with a handout for a journal club discussion

Abstract

Obesity is a major public health issue and the number of obese people in healthcare settings is increasing. Nurses are likely to encounter obese patients, and they have a key role to play both in managing and preventing obesity. However, nurses are not immune to the prejudice against obesity that is prevalent in society in general. A literature review found several studies listing examples of negative views and attitudes among nurses towards obese patients. The literature also identified factors that increase the risk of such attitudes, and what needs to improve so nurses are better equipped to provide patient-centred, non-judgemental care. 

Citation: Pervez H, Ramonaledi S (2017) Nurses’ attitudes towards obese patients: a review of the literature. Nursing Times [online]; 113: 2, 42-45.

Authors: Hana Pervez is staff nurse, Barts Heart Centre, Barts Health Trust, London; Sinna Ramonaledi is senior lecturer in adult nursing, Middlesex University, London.

Introduction

People who are obese are often stigmatised and blamed for their weight. Nurses are not immune to obesity-related prejudice and the literature features several examples of their negative attitudes towards obese patients. These contradict the principles of patient-centred care and reduce care quality. Our literature review explores these negative views and attitudes, what can cause them, why they should be countered and how nurses can be supported to provide non-judgemental care.

A global epidemic

Obesity can be defined as malnutrition characterised by an accumulation of excess body fat that, over time, has an adverse impact on physical health and psychosocial wellbeing. The commonly accepted measure of obesity is a body mass index (BMI) of ≥30kg/m(Fig 1). Obesity predisposes people to a range of long-term conditions, including type 2 diabetes, cardiovascular disorders, cancer, arthritis and depression (World Health Organization, 2016), and is associated with premature death. 

Fig 1. What is BMI?

Currently affecting around 600 million people worldwide – that is, 13% of the world population (WHO, 2016) – obesity is a global health problem rapidly growing to epidemic levels, both in high- and low-income countries. The WHO notes that strategies currently used to prevent and manage it are either slow or ineffective. 

In the UK, the prevalence of obesity is 24.9% of the adult population (Food and Agriculture Organization of the United Nations, 2013); this is higher than in France, Germany, Ireland and other European countries, thereby raising concerns that the UK is the ‘fat man’ of Europe (Academy of Medical Royal Colleges, 2013). In 2007, extrapolating on trends at the time, Butland et al (2007) estimated that, by 2025, 47% of men and 36% of women in the UK could be obese. The Royal College of Physicians (2013) showed that bariatric or weight-loss treatments and managing comorbidities associated with obesity already cost the NHS £5bn a year – and this figure is expected to double by 2050. 

Obesity can have multiple causes (Table 1), but unhealthy eating habits and sedentary lifestyles are often perceived as the main culprits. This focus on lifestyle issues amplifies the existing prejudice towards obese people, who are often blamed for their obesity and stigmatised. The media tends to perpetuate these negative attitudes by promoting ultra-slim bodies as the ideal. These negative perceptions can lead to demeaning attitudes and discriminatory behaviour towards obese people at work and in all other areas of life, including health settings (Puhl and Brownell, 2001). 

Table 1. Possible causes of obesity

Nurses’ role

Nurses are expected to play an essential role in engaging the public in preventing and managing obesity (Royal College of Nursing, 2012). An increasing number of patients with a primary diagnosis of obesity are admitted to general wards (Health and Social Care Information Centre, 2013), so most nurses working on these wards will encounter obese patients. 

Negative attitudes towards obese patients are likely to reduce the quality of the care they receive (Poon and Tarrant, 2009), and nurses have a duty to provide compassionate, dignified and non-judgemental care (Nursing and Midwifery Council, 2015). The appropriate skills and attitudes will help them: 

  • Collaborate with patients, treating them as partners in decisions about their weight and wellbeing (Masters, 2013);
  • Advise on nutrition and lifestyle changes. 

Literature review

We conducted a literature review to explore nurses’ attitudes towards obese patients and how their effect on care. MEDLINE, CINAHL and British Nursing Index were searched using the keywords ‘obesity’, ‘bariatric’, ‘acute nursing settings’ ‘hospitals’ ‘nurses’ attitudes’, and ‘negative perceptions or stereotype’. The UK literature revealed limited research so the search was expanded beyond the UK. Abstracts of identified articles were read and 10 qualitative, quantitative and mixed-research studies from the US, Hong Kong and Sweden were selected due to the similarities with UK nursing practice and the initiatives to tackle obesity in adults. The principles of Caldwell et al’s  (2005) research critique framework  were used to analyse the studies’ essential elements as well as the objective interpretation of data and findings. 

We found a consensus among studies from all four nations that some nurses hold negative views of obesity and display negative attitudes towards obese patients. We also identified a number of factors that may contribute to these negative views and attitudes, including: 

  • Perceptions of, and interactions with, obese patients;
  • A lack of comprehensive knowledge on obesity; 
  • Challenging workloads in care settings with a high number of obese patients. 

Perceptions and interactions

A few studies explored nurses’ perceptions of, and interactions with, obese patients using qualitative research methods. One, carried out as a survey in four neighbouring NHS primary care trusts in the north of England (Brown et al, 2007). They sent a questionnaire to 564 nurses and health visitors in primary care settings, of whom 72.3% responded. Although outright negative stereotypes were rare, negative attitudes and beliefs were expressed, with 68.9% viewing obesity as a result of poor personal food choices and level of physical activity, while perceiving obese patients as, “greedy”, “indulging” and “lazy”; 54.7% thought these patients had no willpower, motivation or strong personality to change their lifestyles. These views and the expressed awkwardness in discussing weight loss hindered nurses’ ability to support and empower patients effectively. 

Despite initiatives to implement national clinical guidance on obesity prevention (National Institute for Health and Care Excellence, 2006), there was poor understanding of how to apply this to practice. The researchers concluded that there was a need to improve nursing education regarding obesity, awareness of obese patients’ needs, and how to work in partnership with them.

Keyworth et al (2013) used semi-structured interviews to explore the perceptions and beliefs of a purposive sample of 20 undergraduate nursing students with placement experiences in adult, child or mental health services in the north-west of England. Almost half reported having witnessed negative attitudes from qualified nurses who “mocked, ridiculed, judged and discriminated against” obese patients in some wards. This would set a bad example for students, potentially encouraging them to be demeaning and judgmental, instead of showing respect and working in partnership with patients (NMC, 2015). 

Some students said nurses who were themselves overweight were poor role models, as their weight undermined their credibility to give advice on weight control. The students said they were being taught how to communicate with patients about reducing alcohol intake and smoking, but approaches designed to help patients tackle obesity were lacking. Despite the small sample size, the authors highlighted two important barriers to good professional practice: 

  • Lack of knowledge;
  • Poor role modelling (Keyworth et al, 2013).

In the US, Buxton and Snethen (2013) interviewed 26 English-speaking obese women about their experiences of interacting with primary care providers (GPs and practice nurses) and use of healthcare services. The women had BMIs of 30 and above and had regular contact with a nurse or doctor about managing their weight and/or long-term conditions, such as diabetes. They recognised themselves as obese but reported feeling healthy and able to accomplish daily activities, and did not relate their long-term conditions to obesity. The women experienced negative attitudes from some nurses and doctors, such as insensitive comments and gestures, and felt they were being treated as “charts” or “obese women”, rather than individuals. Some felt nurses showed disrespect by not listening to, believing or acknowledging their stress about weight loss. 

Nurses and doctors were perceived as focusing mainly on obesity and being indifferent to other personal concerns. They were also seen as not spending enough time with patients or showing any interest in getting to know them as individuals, while underestimating their capacity to understand their own bodies. The women in the study perceived this as ineffective communication and poor client-professional relationships compromising the quality of care, trust and respect (Buxton and Snethen, 2013). These findings underline the importance of viewing patients in a positive light, using sensitive, respectful communication and providing holistic care. 

Lack of comprehensive knowledge

Most participants in Brown et al’s (2007) study associated obesity mainly with poor diet and inactivity, and lacked knowledge of the environmental risk factors for obesity and associated diseases. 

Nolan et al (2012) conducted semi-structured interviews with 22 practice nurses in the UK on their beliefs regarding their skills and responsibilities in supporting obese patients. Most recognised that empowering patients in weight control is an integral part of their role in health promotion and long-term care. However, participants who had not received obesity-specific training felt they lacked knowledge to provide effective advice, despite having good communication skills. They felt confident in supporting patients with obesity-related long-term conditions, but inadequately skilled to motivate them to lose weight or offer specialist nutritional advice. They were aware of NICE’s (2006) national clinical guidance on obesity prevention, but had not read it or had not fully understood how to apply it to practice. They explained they would often assess patients’ motivation to change by using their ‘gut feeling’. 

Participants knew they could refer patients to dietitians, but were unaware of other community-based lifestyle-changing programmes. They also displayed a lack of cultural sensitivity, as they did not believe their culture, gender or age could influence how they advised obese patients. They had however, noticed the lack of adequate health promotion materials for people with English as their second language. 

Participants blamed patients for their poor motivation and low success rates in achieving good weight control. Some felt obesity was a low priority in their work setting: it was not discussed among colleagues, therefore preventing them from sharing challenges and improving practice. Finally, they expressed a lack of confidence in encouraging obese teenagers to lose weight, due to fear of triggering an eating disorder (Nolan et al, 2012). 

Swift et al (2013) used a survey to assess attitudes towards obese patients and weight bias among 1,409 trainee dietitians, doctors, nurses and nutritionists from a UK university; 1,130 (80.2%) participants responded. Most had encountered obese patients in placements, especially those studying nursing and dietetics. A questionnaire on Fat Phobia (F-scale) was used; respondents had to choose from 14 pairs of adjectives (for example, lazy vs industrious) to indicate their perceptions of obese patients. The F-scale score ranged between 1 and 5, with 2.5 or less showing neutral and/or positive attitudes and >2.5 showing negative attitudes. The average score was 3.8, showing high levels of negative attitudes, although 10.4% of all students scored 4.4. The researchers concluded that there is need for balanced healthcare education programmes to prepare future professionals to be fit to meet obese patients’ care needs. 

Nurse education programmes have often been found to lack content on obesity and related health issues. In a study of undergraduate student nurses and nurses on post-registration courses in Hong Kong, Poon and Tarrant (2009) found that education programmes were not providing in-depth knowledge of obesity, its prevalence, what it is like to live with it, and biases and/or attitudes towards it. In both study groups some participants viewed obese people as “shapeless”, “lazy”, “ugly” and liking food. Patients were blamed for overeating, lacking self-control and having “to be put on a diet” when hospitalised. Some nurses said caring for obese patients was “physically exhausting”, “disgusting” and “repulsive”. Patient empowerment, patient-centred goal setting and motivating individuals to control their weight were not being considered. The authors suggested this lack of knowledge should be tackled by better education programmes teaching empathy towards obese patients (Poon and Tarrant, 2009).

Challenging workloads

Keyworth et al (2013) found that, in some bariatric care settings, nurses had heavy workloads that left them feeling overworked and exhausted to the point that they were unable to practise efficiently and with empathy; nurses were inclined to resent patients for their heavy workloads, which resulted in negative attitudes. 

Keyworth et al’s findings echoed those of Zuzelo and Seminara (2006), who recruited 119 nurses from a medical centre, acute medical rehabilitation institution and nursing home in the US. Overall, nurses showed positive attitudes and provided dignified, empathetic and holistic care to all patients, irrespective of body shape and size, but there were concerns about the physical care of obese patients, such as toileting, handling and moving. Nurses dreaded these aspects of care and found them laborious, exhausting, time-consuming and emotionally challenging. Fears for personal safety were compounded by a lack of adequate equipment for safe practice. Poor staffing levels and a lack of support from managers in resolving these issues were demoralising and frustrating. The authors acknowledged that the demands of caring for obese patients and the shortages of staff, equipment and support created a risk of negative feelings towards patients (Zuzelo and Seminara, 2006).

Discussion 

The literature shows that nurses in a variety of settings display negative attitudes towards obese patients and that this affects the quality of care. Williams (2009) stressed that, to challenge and prevent negative views, assumptions and attitudes, it is essential to recognise that they exist. Buxton and Snethen (2013) found that obese patients felt disrespected and blamed for their weight by nurses, who displayed poor listening skills and disregarded their personal concerns. Keyworth et al (2013) found that nurses lacked confidence in their skills to give bariatric patients the appropriate nutritional education.

Nurse education at all levels must tackle obesity (Poon and Tarrant, 2009) and provide a broad understanding of its challenges. Pre-registration curricula should promote awareness of bariatric studies, evidence-based health promotion/prevention and weight control. Culturally sensitive communication skills must be taught so nurses can apply the principles of person-centred care, encouraging obese patients to: 

  • Express their thoughts and feelings;
  • Participate in decisions regarding their weight control;
  • Make lifestyle changes. 

Nurses in Zuzelo and Seminara’s (2006) study found caring for obese patients physically demanding and emotionally exhausting. Meeting patients’ physical needs was time-consuming, which could lead nurses to neglect their psychological concerns. A lack of appropriate equipment, staff levels and managerial support were commonly experienced, making nurses feel frustrated and at risk of injury. Pokorny et al (2009) proposed that such feelings could contribute to negative attitudes towards patients. Heavy workloads were a key reason why nurses would be reluctant to accept obese patients referred or transferred to their wards (Nolan et al, 2012). Employers need to ensure managers support nursing staff by listening and responding with the appropriate resources. 

If obesity is to be tackled with prevention strategies and weight-loss treatments, the UK needs more specialist bariatric wards or units, such as the East-Midlands Bariatric and Metabolic Institute at Derby Teaching Hospitals Foundation Trust (Bit.ly/EMBMI). These units are designed to promote patient and staff safety, and employ health professionals who have the knowledge and skills that are needed to provide preventive and compassionate care. The institute offers learning environments where students can observe and emulate non-judgemental, positive attitudes and respectful partnership working – which could nurture ambitions of careers in bariatric care, and provide good role modelling for staff and positive experiences for patients (Reddy, 2006).

Conclusion 

Obesity is a serious public health challenge and source of discrimination for obese people in most aspects of their lives, including healthcare. Health professionals and healthcare providers share a responsibility to address the current obesity epidemic; updating workplace policies and procedures for the care of obese people is required, while nurses need to be better trained and equipped to offer patient-centred, non-judgemental care in order to treat and prevent obesity. Patients need to have positive care experiences, with their preferences acknowledged, and to feel empowered to make decisions about their weight control and lifestyle changes. 

The small number of studies appraised is a limitation of this article but we hope to highlight issues of unintentional discrimination towards obese patients and the need to prepare  future nurses in this area of nursing practice.

Key points 

  • Obesity is multifactorial, but lifestyle is often seen as the main culprit and obese people are often blamed for their weight 
  • Nurses have a key role in managing and preventing obesity, and a duty to provide non-judgemental care 
  • Some nurses hold negative views on obesity and display negative attitudes towards obese patients 
  • Nursing curricula lack specific content on obesity and how to empower patients to control their weight
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Readers' comments (2)

  • Surely obesity should come under the umbrella of 'Eating Disorders', as the causes are often similar to those who starve or are bulimic. With the risks associated it makes sense to offer all obese counselling as well as dietary advice, after all you would not offer a patient who was dangerously underweight just dietary advice without some behavioural interventions. Once we all accept that people do not eat themselves into morbidly obese states because they want to then we are well on the way to changing our perception of these unfortunate souls. One other thought; over time our world changes and so do we, perhaps now is the time to revise what is considered 'obese'. When so many of the population are considered outside the 'norm', is it not time to reconsider what is 'normal'?

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  • I totally agree with Nanny 1 i have witnessed much prejudice towards obese patients pre-operatively. Within my own practice the only thing I can offer is referral to a dietician without any behavioural interventions. Having discussed this on many an occasion we still do not seem any closer to finding a solution to help these patients

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