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Discussion

Why we need to define nurses’ role in bariatric patient care

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Bariatric surgery is becoming more common, but there is uncertainty about the bariatric care pathway and a lack of definition of the role of nurses in bariatric patient care

Abstract

Patients who undergo bariatric surgery are likely to have wide-ranging care needs, not only because obesity is a complex condition but also because of the likely presence of comorbidities and because the procedure itself can have negative repercussions. Currently, the role of nurses in supporting patients undergoing bariatric surgery, whether in secondary or primary care, is not well defined. We must establish what the nursing support of bariatric patients should include; to do this, we need to involve patients in the co-construction of knowledge about their experience and needs.

Citation: Graham Y et al (2019) Why we need to define nurses’ role in bariatric patient care. Nursing Times [online]; 115: 6, 34-35.

Authors: Yitka Graham is senior lecturer in health services and NHS engagement, University of Sunderland, and nursing, midwifery and allied health professionals strategic research lead, South Tyneside and Sunderland Foundation Trust, Sunderland Clinical Commissioning Group (CCG) and South Tyneside CCG; Lisa Wilde is specialist bariatric surgical nurse, South Tyneside and Sunderland Foundation Trust; Melanie Johnson is executive director of nursing, midwifery and allied health professions, South Tyneside and Sunderland Foundation Trust, and visiting professor, University of Sunderland; Ann Fox is executive director of nursing, quality and safety, Sunderland CCG, and visiting professor, University of Sunderland; Jeanette Scott is executive director of nursing, quality and safety, South Tyneside CCG, and visiting research fellow, University of Sunderland; Catherine Hayes is associate professor in health professions pedagogy, University of Sunderland.

Introduction

Bariatric surgery is becoming an established intervention for obesity and obesity-related metabolic disorders (such as type 2 diabetes) in adults, with 5,675 procedures performed in NHS settings in 2016-17 (Welbourn et al, 2014). Patients in UK bariatric surgical units are typically managed by a multidisciplinary team (MDT), with surgeons, nurses, physicians, dietitians, psychologists (and, in our unit at Sunderland Royal Hospital, a pharmacist) all contributing to care pre- and post-operatively. Patients are followed up in hospital for two years after surgery, then discharged to primary care for long-term care and follow-up.

In this article, we explain why we think the role of specialist nurses and practice nurses in supporting bariatric patients along the care continuum needs to be better defined, and why this involves finding out about patients’ lived experiences.

Specialist nurse’s role

The specialist bariatric nurse is an integral part of the bariatric MDT, providing support and education to patients and advocating for them, both before and after surgery. The complexity of obesity as a condition – and often the presence of at least two obesity-related comorbidities – means that bariatric patients are generally seen by all members of the MDT from initial referral to discharge. In the MDT, the specialist bariatric nurse acts as the central communication partner for the patient and is often responsible for multidisciplinary referrals, when these are necessary.

In the UK, there is no consensus on, or definition of, the role of specialist nurses in bariatric surgical settings – unlike the US, where there is a recognised certification programme (American Society for Metabolic and Bariatric Surgery, 2017). An MDT approach allows the effective use of collective expertise across a range of health professions, but practice varies between bariatric teams – some units focus on specific disciplines, such as dietetics.

Specialist bariatric nurses will be likely to come across a range of care perspectives, largely due to the various challenges faced by patients along their journey. A lack of clarity about each MDT member’s role could lead to duplication of effort and conflict between staff, both within the team and from different levels of the organisation. It could also contribute to ambiguity about the treatment care pathway, which can be confusing for patients.

Practice nurse’s role

Approximately two years after surgery, patients are discharged to general practice to receive long-term follow-up. The National Institute for Health and Care Excellence (2014) recommends annual monitoring of nutritional status and supplementation. Research suggests that, after bariatric surgery, patients undergo psychosocial adjustments (Sogg and Gorman, 2008). These are not always understood by others; judgemental attitudes towards bariatric patients for their choice of weight-loss method have been reported (Graham et al, 2017).

As with specialist nurses, the role of practice nurses in bariatric patient care is not well defined. However, practice nurses are well placed to provide follow-up using a focused biopsychosocial approach, as patients learn to negotiate the processes of living with a body changed by surgery. A framework for long-term care and follow-up underpinned by a biopsychosocial approach could be defined, with the practice nurse acting as the central source of patient support in primary care and establishing communication with the specialist bariatric nurse in secondary care.

Interprofessional working

The need for effective multidisciplinary and interprofessional working transcends medical and surgical specialties, which share perspectives in terms of the holistic management of patients (Blane et al, 2018). The increasing body of qualitative research on this field of clinical practice reveals challenges to successful collaboration between primary and secondary care (Guthrie et al, 2017). Integrative approaches to care, compassion and the co-construction of knowledge (which reveals the challenges patients face in their daily lives) are at the heart of successful collaboration.

Long-standing evidence from the literature shows that nurses are the most trusted members of any healthcare team (Cronenwett et al, 2007). Trust also lies at the heart of a successful MDT, which drives interdisciplinary practice and interprofessional relationships. When supporting patients living with altered bodies during the transition between secondary and primary care, effective leadership requires the ability to articulate the core values of patient co-construction of their lived experiences and to share information via effective communication. Nurses, both specialist and generalist, are well placed to shape and deliver such leadership.

Clarifying roles

As the number of bariatric surgical procedures increases, the need for clarity about the role of nurses across the care continuum becomes increasingly important. Trying to define nursing care for bariatric surgery patients would have implications for the education and training of nursing staff, and for the secondary and primary care infrastructures where they work.

Nursing already has a clear focus on compassionate care and the need to integrate patient and carer perspectives into values-based learning for professionals in the discipline; this provides an additional opportunity for specialist care in bariatric surgery for patients and their families and carers. We need to examine how nursing curricula might best be developed to accommodate this new field of specialist practice, both in pre- and post-registration training.

The role of the specialist nurse in the bariatric MDT needs consensus and operational clarification, perhaps using elements of the US certification programme as models but adapting them to the context of the NHS. Formal communication pathways need to be established between specialist and practice nurses, so patients can transition from hospital to community settings seamlessly and best practice can be shared.

Co-constructing knowledge

Bariatric surgery can have a negative impact on patients’ psychosocial wellbeing, as well as on their physical health status and function (Brown, 2015). To shed light on the complex, and often unmet, support needs of bariatric surgery patients (Graham et al, 2017), we need to involve patients in the co-construction of know-ledge about their lived experience. We need to give them the opportunity to influence the development of care pathways and formal educational programmes (Phoenix et al, 2018; Rowland and Kumagai, 2018; Kaplan et al, 2017). In our view, this would add much to the current system of annual monitoring of nutritional status, where there are no key mechanisms for understanding and supporting the holistic patient experience. 

Key points

  • Bariatric surgery for obesity and obesity-related metabolic disorders is increasingly common
  • The role and training of nurses in supporting bariatric patients need to be better defined
  • A biopsychosocial approach is needed in the long-term care of bariatric patients
  • We need to involve bariatric patients in the co-construction of knowledge about their experience and needs
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