Assessing Weight Bias in Nurses toward Obese Patients and Its Effect on Quality of Care

MISSING IMAGE

Material Information

Title:
Assessing Weight Bias in Nurses toward Obese Patients and Its Effect on Quality of Care
Physical Description:
1 online resource (149 p.)
Language:
english
Creator:
Garcia, Janelle Teresa
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
Publication Date:

Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Health and Human Performance, Health Education and Behavior
Committee Chair:
Stopka-Boyd, Christine E
Committee Co-Chair:
Chaney, Elizabeth H
Committee Members:
Chaney, Jerry Don
Neff, Donna F

Subjects

Subjects / Keywords:
care -- nurses -- obesity -- quality -- rural -- stigmatization -- weight-bias
Health Education and Behavior -- Dissertations, Academic -- UF
Genre:
Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
This study used a partial mixed methods approach to assess weight bias in rural registered nurses (RN), licensed practical nurses (LPN),and certified nursing assistants (CNA) working in a rural hospital setting.  The purposes of the study were to determine if weight bias existed and test its relationship with body mass index (BMI), identify causes of weight bias, and evaluate the effects bias has on quality of care.   A web-based version of the Nurses’ Attitudes Toward Obesity and Obese Patients Scale (NATOOPS) was used to assess weight bias and BMI was measured using self-report height and weight. One hundred and thirteen participants were recruited by their nurse managers via email.  Underweight/normal weight nurses were more likely to exhibit weight bias and indicated that obesity was controllable, but overweight/obese nurses were more likely to associate negative characteristics with obese patients.  CNAs were found to exhibit more bias than RNs or LPNs.  Participants were given the opportunity to participate in a semi-structured interview to discuss factors related to weight bias and quality of care; those who chose to participate were compensated with a gift card.  Thematic analysis, constant comparison analysis and code intensiveness were used to derive themes from the interviews.  Four themes emerged as causal and contributing factors to weight bias: 1) patient care tasks; 2) characteristics of the patient; 3) equipment needs; 4) nurse perception of self.  Quality of care was affected by delays in treatment.   The results indicate weight bias among nurses working in rural settings, found that multiple factors in different levels of influence cause or contribute to weight bias that affect quality of care.  Mixed methods demonstrated support between the quantitative and qualitative data. These findings provided backing for intervention strategies for bariatric sensitivity training using the ecological perspective to target specific issues at each level of influence.
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
Source of Description:
This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Janelle Teresa Garcia.
Thesis:
Thesis (Ph.D.)--University of Florida, 2012.
Local:
Adviser: Stopka-Boyd, Christine E.
Local:
Co-adviser: Chaney, Elizabeth H.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-08-31

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2012
System ID:
UFE0044616:00001


This item is only available as the following downloads:


Full Text

PAGE 1

1 ASSESSING WEIGHT BIAS IN NURSES TOWARD OBESE PATIENTS AND ITS EFFECT ON QUALITY OF CARE By JANELLE T. GARCIA A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUI REMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2012

PAGE 2

2 2012 Janelle T. Garcia

PAGE 3

3 To my family without their support, this accomplishment would not be possible To the Gator Nation

PAGE 4

4 ACKNOWLEDGMENTS The completion o f my Ph.D. program at the University of Florida (UF) and the research presented in this dissertation would not have been possible without the love and support of many. I am very fortunate to have had individuals who could provide me with the skills necess ary to become a successful researcher, educator, and intellectual human being. I thank my committee members, Drs. C hristine Stopka B eth Chaney, J. Don Chaney and D onna Neff for their patience, encouragement, and unwavering support. I appreciate each pe rson for his/her unique gifts and special talents. I am grateful for the attention shown to me, time devoted to me, and sage advice shared with me. I would like to provide a special thanks to Zeerak Haider, Angel Iverson, Adria LaCava, Holly Moses, and Dr Monica Webb who have lead me with grace and wisdom through the often arduous task of writing a dissertation. Though they may not have served on my committee they were instrumental in helping me plan, implement, and publish this research; as well as, kep t me sane. I would also like to thank my family members and friends who helped support my decision to begin and continue this degree program. T heir love, generosity and encouragement are the reasons you hold this dissertation today. Final ly, I would li ke to thank my Health Education and Behavior family, past and present, for taking me in and helping me feel like I belong. I will forever cherish the friendships made and fond memories shared.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 10 ABSTRACT ................................ ................................ ................................ ................... 12 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW ................................ ..................... 14 Introduction ................................ ................................ ................................ ............. 14 Research Problem ................................ ................................ ................................ .. 22 Significance ................................ ................................ ................................ ............ 24 Attribution Value Model of Prejudice ................................ ................................ ....... 26 Research Questions ................................ ................................ ............................... 29 Organization of the Studies ................................ ................................ ..................... 29 Analytic Techniques ................................ ................................ ................................ 31 Delimitations ................................ ................................ ................................ ........... 32 Limitations ................................ ................................ ................................ ............... 32 Ass umptions ................................ ................................ ................................ ........... 33 Definition of Terms ................................ ................................ ................................ .. 33 Summary ................................ ................................ ................................ ................ 34 2 ASSESSING WEIGHT BIAS IN NURSES TOWARD OBESE PATIENTS IN A RURAL POPULATION ................................ ................................ ............................ 35 Background ................................ ................................ ................................ ............. 35 Attribution Value Model of Prejudice ................................ ................................ ....... 39 Methodology ................................ ................................ ................................ ........... 42 Setti ng ................................ ................................ ................................ .............. 42 Sample ................................ ................................ ................................ ............. 43 Instrument Selection ................................ ................................ ......................... 44 Procedure ................................ ................................ ................................ ......... 46 Participant Recruitment ................................ ................................ .................... 47 Demographic Information ................................ ................................ ................. 48 Body Mass Index (BMI) ................................ ................................ .................... 48 Data Analysis ................................ ................................ ................................ ... 49 Ethical Considerations ................................ ................................ ...................... 49 Results ................................ ................................ ................................ .................... 5 0 Discu ssion ................................ ................................ ................................ .............. 51

PAGE 6

6 Limitations ................................ ................................ ................................ ............... 53 Conclusion ................................ ................................ ................................ .............. 54 3 QUALITATIVE ANALYSIS OF WEIGHT BIAS IN NURS ES WORKING IN RURAL HOSPITAL SETTINGS ................................ ................................ .............. 58 Background ................................ ................................ ................................ ............. 58 Methodology ................................ ................................ ................................ ........... 62 Design ................................ ................................ ................................ .............. 62 Site and Sample ................................ ................................ ............................... 63 Procedure and Data Analysis ................................ ................................ ........... 65 Results ................................ ................................ ................................ .................... 67 Theme 1: Patient Care Tasks ................................ ................................ ........... 67 Theme 2: Characteristics of Obese Patients ................................ .................... 70 Theme 3: Equipment Needs ................................ ................................ ............. 74 ................................ ................................ 76 Theme 5: Delay in Treatment ................................ ................................ ........... 78 Discussion ................................ ................................ ................................ .............. 80 Limitations ................................ ................................ ................................ ............... 86 Conclusion and Implications for Future Research ................................ ................... 87 4 THE USE OF MIXED METHODS AND PROPOSED SOLUTIONS TO WEIGHT BIAS IN NURSES WORKING IN RURAL HOSPITAL SETTINGS USING THE SOCIAL ECOLOGICAL MODEL ................................ ................................ ............. 89 Background ................................ ................................ ................................ ............. 89 RESPECT Model ................................ ................................ ................................ .... 95 Rapport ................................ ................................ ................................ ............. 95 Environment/Equipment ................................ ................................ ................... 96 Safety ................................ ................................ ................................ ............... 96 Privacy ................................ ................................ ................................ .............. 96 Encouragement ................................ ................................ ................................ 96 Caring/Compassion ................................ ................................ .......................... 97 Tact ................................ ................................ ................................ .................. 97 Methods ................................ ................................ ................................ .................. 97 Sites and Sample ................................ ................................ ............................. 98 Procedures ................................ ................................ ................................ ..... 100 Data Analysis ................................ ................................ ................................ 101 Results ................................ ................................ ................................ .................. 102 Quantitative and Qualitative Findings ................................ ............................. 102 Ecological Model ................................ ................................ ............................ 102 Intrapersonal ................................ ................................ ............................ 103 Interpersonal ................................ ................................ ............................ 105 Institutional ................................ ................................ ............................... 106 Community ................................ ................................ ............................... 107 Public Poli cy ................................ ................................ ............................. 108 Discussion ................................ ................................ ................................ ............ 109

PAGE 7

7 Limitations ................................ ................................ ................................ ............. 111 Conclusion ................................ ................................ ................................ ............ 112 5 CONCLUSIONS ................................ ................................ ................................ ... 117 Background ................................ ................................ ................................ ........... 117 Results ................................ ................................ ................................ .................. 118 Implications ................................ ................................ ................................ ........... 120 Future Research ................................ ................................ ................................ ... 121 APPENDIX A NURSES ATTITUDES TOWARD OBESITY AND OBESE PATIENTS SCALE (NATOOPS) ................................ ................................ ................................ .......... 122 B NURSES ATTITUDES TOWARD OBESITY AND OBESE PATIENTS SCALE (NATOOPS) INFORMED CONSENT ................................ ................................ ... 127 C SEMI STRUCTURED INTERVIEW INFORMED CONSENT ................................ 129 D SEMI STRUCTURED INTERVIEW DEMOGRAPHIC SHEET ............................. 136 E SEMI STRUCTURED INTERVIEW SCRIPT ................................ ........................ 138 LIST OF REFERENCES ................................ ................................ ............................. 140 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 149

PAGE 8

8 LIST OF TABLES Table page 2 1 Body mass index (BMI) table for adults ................................ .............................. 56 2 2 Comparison of me ans of total factor scores by weight category ......................... 57 2 3 Weight bias composite score and professional status ................................ ........ 57 2 4 Mean weight bias composite score and professional status ............................... 57 3 1 Themes for factors that cause or contribute to weight bias and effect on quality of care. ................................ ................................ ................................ .... 88

PAGE 9

9 LIST OF FIGURES Fi gure page 4 1 Patient Centered Care (PCC) Model ................................ ................................ 114 4 2 Breaking the Vicious Cycle of Obesity with RESPECT adapted fro m Bejciy Spring, S.M. 2008. R E S P E C T: a model for the sensitive treatment of the bariatric patient. Bariatric Nursing and Surgical Patient Care, 3, page 54, Figure 2. ................................ ................................ ................................ ........... 115 4 3 The Ecologic al Model ................................ ................................ ....................... 116

PAGE 10

10 LIST OF ABBREVIATION S ADL Activities of daily living; patient care tasks that involve mouth care, peri care, bathing, combing hair, changing gowns, changing bed sheets, setting up meal tray, feeding, and ambu lation. BMI Body mass index; screening tool that serves as an indi c ator for overweight and obesity in children and adults; measured using the height (in.) an d weight (lbs.) CNA Certified nursing assistant; individuals who have completed an accredited c ertification course; provide for the basic needs of patients under the supervision of a registered nurse (RN). CNO Chief Nursing Officer; senior nursing management position who supervises the care of all the patients at a health care facility ED Emergen cy Department ; a medical treatment facility, specializing in acute care of patients who present without prior appointment, either by their own means or by ambulance. ICU Intensive Care Unit; a specialized department in a hospital that provides intensive c are medicine. IM Intramuscular injection; certain medications require administration within the muscle for optimal absorption. IV Intravenous therapy; infusion of liquid substances directly into a vein LPN Licensed practical nurse; individuals who have completed a State approved training program in practical nursing and passed the National Council Licensure Examination, or NCLEX PN; often perform a wide range of duties, including assessing and evaluating patient care, administering medications, using medical equipment to run diagnostic tests, educating family members and patients on diseases and treatments, documenting patient information and vital signs, developing nu rsing care plans, and much more under the direction of physicians and registered nurses. MS Medical/Surgical Unit; a specialized department in a hospital that provides medical and post surgical medicine. OB Obstetrics Unit; a specialized department in a hospital that provides mate rnal and fetal medicine.

PAGE 11

11 OR Operating Room; a specialized department in a hospital that provides surgical medicine. PCC Patient centered care; framework used to direct nursing care that focuses on the individuality of patients. RN Registered nurse ; indi viduals who have completed all of the necessary educational and licensure requirements as set forth by the Board of Nursing in each state and passed the National Council Licensure Examination, or NCLEX RN ; often perform a wide range of duties, including as sessing and evaluating patient care, administering medications, using medical equipment to run diagnostic tests, educating family members and patients on diseases and treatments, documenting patient information and vital signs, developing nursing care plan s, and much more. SQ Subcutaneous injection; certain medications require administration directly under the skin for optimal absorption.

PAGE 12

12 Abstract of Dissertation Presented to the Graduate School of the University of Florida in Partial Ful fillment of the Requirements for the Degree of Doctor of Philosophy ASSESSING WEIGHT BIAS IN NURSES TOWARD OBESE PATIENTS AND ITS EFFECT ON QUALITY OF CARE By Janelle T. Garcia August 2012 Chair: Christine B. Stopka Cochair: Elizabeth H. Chaney Major: Health and Human Performance This study used a partial mixed method s approach to assess weight bias in rural registered nurses (RN) licensed practical nurses (LPN) and certified nursing assistants (CNA) working in a rural hospital setting. The purpose s of the study were to determine if weight bias existed and test its relationship with body mass index ( BMI ) identify causes of weight bias and evaluate the effects bias has on quality of care. A web based version of the y and Obese Patients Scale (NATOOPS) was used to assess weight bias and BMI was measured using self report height and weight. One hundred and thirteen p articipants were recruited by their nurse managers via email Und erweight/normal wei ght nurses were mo re likely to exhibit weight bias and indicated that obesity was controllable, but overweight/obese nurses were more likely to associate negative characteristics with obese patients. CNAs were found to exhibit more bias than RNs or LPNs. P articipants wer e given the opportunity to participate in a semi structured interview to discuss factors related to weight bias and quality of care; those who chose to participate were compensated with a gift card. Thematic analysis, c onstant comparison

PAGE 13

13 analysis and code intensiveness were us ed to derive themes from the interviews Four themes emerged as causal and contributing factors to weight bias: 1) patient care tasks; 2) characteristics of the patient; 3) equipment needs; 4) nurse perception of self. Quality of ca re was affected by delays in treatment. The results indicate weight bias among nurs es working in rural settings, found that multiple factors in different levels of influence cause or contribute to weight bias that affect quality of care Mixed methods d emonstrated support between the quantitative and qualitative data. These findings provided backing for intervention strategies for bariatric sensitivity training using the ecological perspective to target specific issues at each level of influence

PAGE 14

14 CHAP TER 1 INTRODUCTION AND LIT ERATURE REVIEW Introduction Obesity is a label that corresponds to a range of weights that are considered above a healthy standard for a given height ( Centers for Disease Control and Prevention, 201 0 ) Individuals who are considered obese are at an increased risk for heart disease, type 2 diabetes mellitus, stroke, hypertension, dyslipidemia, cancer, and respiratory, digestive and joint problems ( Centers for Disease Control and Prevention, 2010 ; Han, Truesdale, Cai, Juhaeri, & Stevens, 2009 ) There are three factors that have been rigorously rese arched to determine how obesity occurs. Researchers have determining obesity ( Center for Disease Control a nd Prevention, 2011b ) Weight gain is typically a result of a caloric imbalance; the number of calories consumed is greater than the number of calories expended. This is typically the result of consuming too many calories and not engaging in enough ph ysical activity. A calorie is a unit of energy for any given food and is the fuel that the human body requires to function ( Center for Disease Control and Prevention, 2011b ) Calories are eq uivalent regardless of their source (i.e. carbohydrates, proteins, fats). The recommended daily caloric intake for adult women should range from 1,600 to 2,400 calories per day and 2,000 to 3,000 calories per day for adult men ( U.S. Department of Agriculture, 2011 ) An individual The low end of each range is for sedentary individuals; the high end of the range is for active individuals. As adults age their daily caloric intake usually decreases due to reductions in their basal metabolic rate ( U.S. Department of Agriculture, 2011 )

PAGE 15

15 The environment that an individual lives in can be a major contributing factor to can drive their healthful decisi ons ( Center for Disease Control and Prevention, 2011b ) For example, limited access to sidewalks or bike lanes may prevent people from walking or riding their bike to school or work. Lack of affordable healthy foods, like fruits and vegetables, in grocery stores or in school cafeterias may cause people to turn to the control of the individual. Seeking en vironmental changes in the workplace, schools, or the community may require legislation or policy change. Bardet Biedl syndrome (multisystem degenerative disease) and Prad er Willis syndrome (characterized by hypotonia and insatiable appetite) ( Center for Disease Control and Prevention, 2011b ) th e more common cases of obesity. The hypothesis states that ancestral genes that were used to survive occasional famines by storing fat are now being challenged by environments in which food is plentiful year round ( Center for Disease Control and Prevention, 2011a ) The role of genetics in obesity may be more clearly seen when considering that not everyone who overeats and is physically inactive will become obese. This is displayed wi thin people in the same culture and within families. Since October 2005, the Human Obesity Gene Map has mapped several genetic mutations and chromosomal locations of potential fat genes to solve this conundrum ( Center for Disease Control and Prevention, 2011a ) The melanocortin 4 receptor gene and the fat

PAGE 16

16 mass and obesity associated gene (FTO) have been found to account for 5% and 22% of obesity cases, re spectively ( Center for Disease Control and Prevention, 2011a ) their he ight (inches) and weight (pounds) ( Centers for Disease Control and Prevention, 2010 ) BMI is a screening tool that serves as an indicator for overweight and obesity in children and adults. A BMI of 18.5 to 24.9 is consid ered healthy; whereas, a BMI of 25 to 29.9 is overweight and greater than 30 is obese ( Centers for Disease Control and Prevention, 2011 ) A common misconception about BMI is that it is a diagnostic tool. The Centers for Disease Control and Prevention (2011 ) recommends that individuals who have an abnormal BMI see their healthcare provider who can run additional assessments to determine if any health risks exist. It is important to note that a person may be considered to exceed a healthy weight for their height (overweight) which may be the cause of extra muscle mass, bone, water, or fat ( "Obesity," 2011 ) Weight bias towards obese individuals in America is prevalent. Several studies have been conducted and have found that weight bias pervades interpersonal relationships, the workplace, schools, and healthcare system leaving those who are obese with feelings of shame, guilt, and low self esteem ( Puhl & Brownell, 2003 ; Puhl, Moss Racusin, Schwartz, & Brownell, 2008 ; Schwartz, Chambliss, Brownell, Blair, & Billington, 2003 ) What is most troubling is that weight bias has become a cultural norm in the United States and other countries. A study published in 2008 estimated that weight bias and discrimination has increased 66% over the past decade ( Andreyeva, Puhl, & Brownell, 2008 ) The overwhelming negativity towards obese individuals does not come without conseq uence. Emerging research indicates that weight bias may

PAGE 17

17 which may lead to depression, low self esteem, bad eating behaviors, poor body image, and exercise avoidance ( Puhl & Heuer, 2009 2010 ) Evidence also exists that weight bias may interfere with the suc cessful implementation of obesity prevention strategies ( Puhl & Heuer, 2010 ) Weight bias and stigma has been heavily reported among family members and friends of obese individuals ( Puhl & Brownell, 2006 ; Puhl, Moss Racusin, et al., 2008 ) Interpersonal relationship weight bias manifests as negative and inappropriate comments towards th e obese individual, typically occurring in the home ( Puhl, Moss Racusin, et al., 2008 ) Women who received negative comments from friends were more likely to experience depression and men who received negative remarks from their sons tended to have low sel f esteem ( Puhl & Brownell, 2006 ) There are several hypotheses that attempt to predict why close friends and family members are the most frequent weight bias offenders. One explanation suggests that weight bias is such a normative behavior that those engaging in it do not realize that it is offensive ( Puhl & Brownell, 2006 ; Puhl, Moss Racusin, et al., 2008 ) Another idea is that the high incidence o f weight bias from family members may be from increased and more frequent exposure or may seem more hurtful and recalled more often ( Puhl & Brownell, 2006 ; Puhl, Moss Racusin, et al., 2008 ) Other hypotheses of weight bias among close family and friends include family members intentions to motivate an obese individual to lose weight, stress from accommodating a healthier lifestyle for them, stigma that the family or friends receive for being associated with an obese individual, and fee lings of responsibility on the relatives part ( Puhl, Moss Racusin, et al., 2008 )

PAGE 18

18 Within the workplace, weight bias has been revealed in the hiring process, wages, promotions, and loss of job ( Puhl & Brownell, 2001 ; Puhl & Heuer, 2009 ) Data collected by the National Survey of Midlife Development in the United States indicated that employment discrimination had a positive correlation with increased body size, in which women were 16% more likely to re port employment discrimination than men ( Puhl & Heuer, 2009 ; Roehling, Roehling, & Pichler, 2007 ) Participants of the survey reported not being hired for a job, not receiving a promotion, or being fired as frequent types of employment discrimination ( Puhl, Andreyeva, & Brownell, 2008 ; Puhl & Heuer, 2009 ) Roehling, Pilcher, O swald, and Bruce (2008) performed a meta analysis on job related weight bias experimental studies and found that overweight applicants and employees were viewed negatively and had more negative employment outcome evaluations by their peers. Weight bias in the workplace is further validated by being less conscientious, agreeable, emotionally stable, and outgoing (R. Puhl & Heuer, 2009). Survey findings from the National Longitudinal Survey of Youth revealed that obese workers suffered wage penalties between 0.7 to 3.4% and 2.3 to 6.1% for men and women, respectively ( Baum & Ford, 2004 ; Puhl & Heuer, 2009 ) This study indicated that obese individuals may be shunned from training opportunities, thus not receiving competitive wages ( Baum & Ford, 2004 ; Puhl & Heuer, 2009 ) Another study cond ucted using the National Longitudinal Survey of Youth by Cawley (2004) found that black and white obese women experienced different wage penalties based on their level of obesity. White women who were mildly obese and severely obese saw a decrease in

PAGE 19

19 wage s of 5.8% and 24%, respectively as compared to normal weight white women; whereas, black women who were mildly to severely obese saw wage decreases from 3.3 to 14.6% less than their normal weight counterparts ( Cawley, 2004 ; Puhl & Heuer, 2009 ) Weight bias within school settings has been displayed by teachers, peers, and parents ( Puhl & Brownell, 2001 ; Puhl & Heuer, 2009 ) Studies done in Sweden and England found that obese individuals were less likely to pursue higher education opportunities than their normal weight peers ( Karnehead, Rasmussen, Hemmingsson, & Tynelius, 2 006 ; Puhl & Heuer, 2009 ; Wardle, Volz, & Jarvis, 2002 ) Additionally, a study conducted using the National Longitudinal Study of Adolescent Health rep orted that obese female students were half as likely to attend college as opposed to normal weight students ( Crosnoe, 2007 ; Puhl & Heuer, 2009 ) The study also found that in schools with a high prevalence of female obesity that obese female students were just as likely to attend college as normal weight female students ( Crosnoe, 2007 ; Puhl & Heuer, 2009 ) These findings are also supported by a study conducted by Crosnoe and Muller (2004) in which schools with lowe r average body size tended to see lower academic achievement among obese students. An explanation for this phenomena is that weight bias from educators may compromise the academic performance of obese students ( Puhl & Heuer, 2009 ) Numerous studies have been conducted over the years assessing weight bias in the health professions. Puhl and Brownell (2001) discussed how anti fat attitudes of healthcare worker s could potentially affect the care given to obese patients and that these negative attitudes could prevent obese patients from seeking care. A study

PAGE 20

20 conducted on the anti fat attitudes and perceptions of physicians found that they characterized obese pat ients as having low self esteem and being sloppy, lazy, awkward, unattractive, and noncompliant ( Foster et al., 2003 ; Puhl & Heuer, 2009 ) Participants felt that obesity was a result of physical inactivity and behavioral problems. Similar findings were found in studies conducted in England, France, and Australia in which physicians believed that obesity was a resu lt of overeating and that obese individuals lacked motivation, were physically inactive, unattractive, lazy, and self indulgent ( Bocquier et al., 2005 ; Campbell, Engel, Timperio, Cooper, & Crawford, 2000 ; Harvey & Hill, 2001 ; Puhl & Heuer, 2009 ; Thuan & Avignon, 2005 ) Medical students have also been found to exhibit weight bias towards obese patients. A study conducted by Wear, Aultman, and Varley (2006 ) surveyed 54 medical students and found that they believed severely obese patients were responsible for their condition and that they created additional work for the students. They also reported severely obese adults and overweight and obese children were the most common targets for inappropriate and derogatory remarks by attending physicians, residents, and students. Degrading comments occur red most often in the operating room and obstetrics/gynecology. Students did not feel that their derogatory comments towards obese patients were inappropriate ( Puhl & Heuer, 2009 ; Wear, Aultman, & Varley, 2006 ) A study was conducted using a video tape of actors portraying normal weight and obese patients and were r andomly viewed by medical students ( Puhl & Heuer, 2009 ; Wigton & McGaghie, 2001 ) Participants who watched the obese patient tape anticipated that the patient would be less likely to respond to counseling or make lifestyle changes and would be noncompliant as opposed to those who watched the normal weight patient

PAGE 21

21 tape. Obese patients were also desc ribed as less attractive, less compliant, and more depressed by students as compared to the normal weight patients. Fitness professionals and dieticians are also not immune to anti fat attitudes. A study on weight bias among exercise science students fou nd that students believed obese people could lose weight if they wanted to and that they were lazy, unattractive, and bought a lot of junk food ( Chambliss, Finley, & Blair, 2004 ; Puhl & Heuer, 2009 ) This study also stated that white, female exercise science students with a low BMI were more likely to demonstr ate high implicit anti fat bias. Fitness professionals also reported that lack of physical activity, poor eating choices, and psychological problems were factors that caused obesity ( Hare, Price, Flynn, & King, 2000 ; Puhl & Heuer, 2009 ) A study performed by Berryman, Dubale, Manchester, and Mittelstaedt (2006 ) corroborates these fi ndings among dietetic students (N = 76) who agreed or strongly agreed (71% to 91%) that overweight people overeat, are inactive, slow, insecure, shapeless, unattractive, have low self esteem, endurance, and no willpower. Puhl, Wharton, and Heuer (2009 ) also found that dietetics students felt that obese patients were less l ikely to comply with treatments. The study provided students with obese and non obese patient profiles with the same dietary and lifestyle information. Students describes obese patients as having poor diet quality and health status as compared to the non obese patients, despite the similarities in the profiles provided, v ictim blaming and frustration were also demonstrated among British and Australian dieticians, respectively ( Campbell & Crawford, 2000 ; Harvey, Summerbell, Kirk, & Hill, 2002 ; Puhl & Heuer, 2009 )

PAGE 22

22 r obese patients has been documented in the literature. Research indicates that nurses feel that obesity is a controllable factor and that obese patients lack self control, and are overindulgent and lazy ( Brown, 2006 ; Puhl & Brownell, 2001 ) Health professionals have reported feeling hostile, angry, and apathetic when caring for an obese patient ( Crandall et al., 2001 ) Other studies have found that student and registered nurses (RN) were unlikely to associate positive characteristics with obesity ( Poon & Tarrant, 2009 ) Undergraduate nursing stu dents and RNs associated negative words like shapeless, slow, and unattractive with obesity ( Poon & Ta rrant, 2009 ; Teachman & Brownell, 2001 ) Some studies also report nurses being repulsed by obese patients and feel a sense of dread, resentment and discomfort when having to care for them ( Bagley, Conklin, Isherwood, Pechiulis, & Waston, 1989 ; Peternelj Taylor, 1989 ; Puhl & Brownell, 2001 ) Interestingly, older nurses were found to have more negative attitudes towards obese patients than younger nurses and nurses; as were nurses with lower BMIs ( Brown, Stride, Psarou, Brewins, & Thompson, 2007 ; Puhl & Brownell, 2001 ) Research Problem es continues to be a major health problem despite the preventative actions tha t have taken place in the last 2 0 years ( Center for Disease Control and Prevention, 2012b ) In 2010, twelve states had an obesity prev alence of 30% or more which shows a marked increase from 2009 in which nine states had obesity rates of 30% or more ( Center for Disease Control and Prevention, 2012b ) The South accounts for the highest obesity p revalence (29.4%) followed by the Midwest (28.7%), Northeast (24.9%) and the West (24.1%) ( Center for Disease Control and Prevention, 2012b )

PAGE 23

23 As obesity rates continue to climb so does the provision and acquisiti on of healthcare for medical problems associated with unhealthy weight. The American healthcare system is being inundated with patients seeking treatment for obesity related health problems that include heart disease, type 2 diabetes mellitus, stroke, hyp ertension, dyslipidemia, cancer, and respiratory, digestive and joint problems ( Han et al., 2009 ) An an alysis conducted by the Behan and Cox (2010 ) from the Society of Actuaries estimated that the yearly obesity related healthcare cost is $270 billion in the United States. The analysis also demonstrated that increases in healthcare cost positively correlated with increased BMI: $72 billion for o verweight and $198 billion for obesity ( Behan & Cox, 20 10 ) Hospitalizations for obesity related chronic diseases are common and place an increased demand on nurses ( Bertakis & Azari, 2005 ) During hospitalizations, nurses deliver direct patient car e; therefore, they have the greatest amount of contacts with overweight and obese patients in inpatient settings. The threat of injury while caring for an overweight or obese patient can be stressful and has been reported as a source of negative weight bi as in nurses ( Brown, 2006 ) The medical needs of an overweight or obese patient can be physically demanding and may require lifting, turning, and mobilization which can be difficult and may threaten ( Bagley et al., 1989 ) A study conducted on occupational injuries in nurses, psych iatric and home health aides found that 54% of reported workplace injuries from 1995 2004 were musculoskeletal disorders ( Hoskins, 2006 ) Twenty seven percent of these injuries were caused by overexertion; 67% of which were caused by lifting a patient ( Hoskins, 2006 )

PAGE 24

24 Significance Overweight and obese patients have been found to be regular health consumers of primary and specialty care practices ( Brown, 2006 ) This is due t o exacerbation of symptoms of chronic conditions and prescription needs ( Han et al., 2009 ) The effects that healthcare related weight bias has on obese patients have been demonstrated in recent studies. Research indicates that providers spend less time with obese patients during scheduled appointments and do not provide the same patient education as they d o to smaller weight patients ( Bertakis & Azari, 2005 ; Hebl & Xu, 2001 ) This has not gone unnoticed by obese patients as they have described feeling disrespected when involved in such encounters. They also felt that they would not be taken seriously, believed that their health problems were blamed on their weight, and felt uncomfortable addressing thei r weight concerns with their provider ( Amy, Aalborg, Lyons, & Keranen, 2006 ; Anderson & Wadden, 2004 ; Brown, Thompson, Tod, & Jones, 2006 ) It is feared that if obese patients have negative experiences with healthcare providers they will cease treatment until their symptoms become a medical emergency ( Brown, 2006 ) A study by Amy et al. (2006 ) showed a lower percentage of preventative cancer screenings among obese women despite having insurance and high access to healthcare. The findings indicate weight is a major barrier (83%) for undergoing preventative gyne cological screenings for obese women; furthermore, women with the highest levels of obesity reported delaying preventative care because of their weight (68%). Explanations for their reluctance to seek care was past experiences with disrespectful treatment and negative attitudes by their provider, embarrassment over their weight, receiving unsought advice about losing weight, and not being provided with equipment to accommodate their size ( Amy et al., 2006 ) Another study

PAGE 25

25 found that obese women avoided seeking healthcare if they gained weight since their last visit, wou ld be weighed during an appointment, had to undress in an exam room, or would receive advice to lose weight ( Drury & Louis, 2002 ) The negative attributions towards obesity in nurses specifically, are cause for concern. Nurses are responsible for the care and treatment of overweight and obese patients and must provide quality and non judgmental care as stated in the American Nurses Association (2001 ) Code of Ethics for Nurses Therefore, from an ethical standpoint, one could say that if a nurse did display weight bias towards a patient they would have breached their code of ethics which could be grounds for termination or loss of licensure. Nurses, particularly in an inpatient hospital setting, have the most contact with obese patients; therefore, potential interventions could be targ eted at this population. It is detrimental that obese individuals are regular consumers of the healthcare system due to the number of comorbities that are associated with being obese. Neglecting to receive routine preventative screenings can result in poo r prognosis and exacerbation of symptoms. It is imperative that obese patients be treated fairly and respectfully by healthcare providers in order to reduce obesity related mortality rates and to prevent creating a larg er deficit in our strained healthcar e system ( Amy et al., 2006 ; Brown, 2006 ; Han et al., 2009 ; Puhl & Heuer, 2010 ) The studies reviewed have called for the need of further evaluation of weight bias in nurses in different settings (clinics, hospitals) using validated instrumentation. This study hopes to ac besity and

PAGE 26

26 Obese Patients Scale (NATOOPS) ( Watson, Ob erle, & Deutscher, 2008 ) to assess weight bias in a population of nurses who work in a rural inpatient hospital setting The instrument was originally used with RNs, but can be used in other areas of nursing per the authors. The lack of l iterature av ailable that assesses weight bias in licensed practical nurses (LPN) and certified nursing assistants (CNA) should not be overlooked be cause they too regularly care for overweight and obese pat ients in hospital settings, especially in rural areas; therefo re, RNs, LPNs, and CNAs were recruited for this study. Attribution V alue Model of Prejudice Attribution value model of p rejudice is an ideological model of prejudice ( Crandall et al., 2001 ) Ideology is a set of beliefs that form the psychological basi s of a political, economic, or social system ( Crandall et al., 2001 ) Attributions are causal explanations or judgments about the social world ( Heider, 1958 ) and help people understand why outcomes will elicit an emo tion. The Attribution value Model of Prejudice postulates that attitudes and prejudice towards groups are based on attributions of controllability and cultural value ( Crandall et al., 2001 ) Attributions can be situational or dispositional. Situationa l attributions are ( Weiner, Perry, & Magnusson, 1988 ) An obese chi ld may not have access to healthy foods because their parents do not buy them or they may live in an unsafe neighborhood and cannot play outside. In this situation the child cannot control their environment and will not receive the stigma that one would expect if the child chose to eat junk food over healthy food and preferred to watch TV and play video games rather than play outside.

PAGE 27

27 personality, beliefs, attitudes, or ano ther internal trait ( Weiner et al., 1988 ) The same obese child may be from a culture where fatness is reveled as a sign of prosperity and health. As nav e psychologist, humans will tend to give more credence to dispositional attributions because their need for consistency ( Crandall et al., 2001 ; Heider, 1958 ) Prejudice is described as the negative emotional feelings toward members of a social group ( Crandall et al., 2001 ) Stereotyping of groups provides attributes about the groups successes and failures. It is important to note that not all members of a group have to fit a stereotype; they can be individually excused from prejudice if the attributes do not fit ( Crandall et al., 2001 ) Prejudice towards a group only holds members responsible for the negat ive attributes and not the positive ones. The perceiver does not have to figure out if they are considered ingroup or outgroup nor do they need to have experienced any previous conflict, history, or contact with the group in question ( Crandall et al., 2001 ) Prejudice can arise from perceptual processes about causality and personal and cultural values for traits, characteristics, and stereotypic attributes about ( Crandall et al. 2001, p. 36 ) Crandall and colleagues (2001) demonstrated that prejudice can be linked to attributions of controllability. The more controllable a characteristic seems the more likely prejudice will occur towards any person or group displaying the cha racteristic. Prejudice typically occurs in cases of obesity because fatness is considered a controllable sin rather than an uncontrollable sickness ( Weiner, 1993 ) Fatness is commonly attributed to a lack of w illpower, gluttony, and laziness which are

PAGE 28

28 characteristics that can be changed at the will of the individual. When attributions about controllability are made moral judgments arise. These judgments rationalize that people get what they deserve when they act in a way that causes an outcome and should be treated accordingly ( Cahnman, 1968 ; Crandall et al., 2001 ; Crandall & Reser, 2005 ; Feather, 1996 ; Lerner, 1980 ) Therefore, a fat person has chosen to over eat and be lazy and deserves the stigmatization they receive; whereas, a thin person is a hard worker and disciplined and deserves to be treated with respect. Cultural values have also been used to understand how attributions predict prejudice. Results fr om a study conducted on cross cultural approaches to attribution ( Triandis, 1994 ) found that people belonging to individualistic co untries, like the United States, were more likely to view themselves as independent of a collective body and ego driven ( Crandall et al., 2001 ) In collectivist countries, like Mexico, individuals needs before their own because of the tight connectedness of its members ( Crandall et al., 2001 ) Individualist countries emphasized personal responsibility and viewed obese people as responsible for their weight and subsequent perils ( Crandall & Reser, 2005 ) In collectivist countries the focus was on the group so an obese person would not be considered responsible for their fatness nor would being overweight really matter ( Crandall & Reser, 2005 ) An interesting concept of the attribution value theory of p rejudice is that the self does not have special status; therefore, an individual can be prejudice towards themselves and others like them ( Crandall et al., 2001 ) Controllability and responsibility play major roles in how the self mimics the attributio ns for others ( Crandall

PAGE 29

29 & Reser, 2005 ) For instance, a person may believe that obesity is controllable and feel s that people are responsible for their own weight. A prejudice will occur from these attributions towards any obese individual. If the same person is also fat, they will view themselves as personally re sponsible for their weight and the same negative emotions will occur towards themselves. This phenomenon can be used to explain why obese people, who have negative affects towards fatness, feel depressed shame, guilt, and have low self esteem ( Crandall et al., 2001 ) Research Questions This study seeks to provide evidence that may explain the following research questions (RQ) : RQ1: Does weight bias exist towards overweight and obese patients among RNs, LPNs, and CNAs working in a rural inpatient hospit al setting? RQ2: Is there a relationship between patient related weight bias and BMI in RNs, LPNs, and CNAs working in a rural inpatient hospital setting? RQ3: Is there a difference in patient related weight bias among RNs, LPNs, and CNAs working in a rura l inpatient hospital setting? RQ4: What factors cause or contribute to weight bias in nurses? RQ5: How do the factors that cause or contribute to weight bias in nurses affect quality of care? RQ6: Do interview themes support RN, LP N, and CNA weight bias fo und in s urvey responses? Organization of the Studies A partially mixed methods sequential equal status design was used when organizing this study ( Leech & Onwuegbuzie, 2009 ) Quantitative and qualitative

PAGE 30

30 elements were c onducted during two separate phases which both utilized convenience samples. The quantitative portion took place first wherein nurses completed the previously validated NATOOPS ( Watson et al., 2008 ) and were then asked to participate in the qualitative phase of the study (interviews). After data collection and analysis for both phases was complete, the data was mixed to pro vide a broader understanding of weight bias in nurses working in a rural hospital setting through data triangulation. Both study phases held the same weight in terms of their significance to answering the proposed research questions. The aim of this stu dy is to determine if weight bias exists among nurses towards obese patients and how weight bias affects quality of nursing care. The specific purposes are to: 1) evaluate if weight bias exists among nurses in a rural inpatient hospital setting using the NATOOPS; 2) identify the factors that cause or contribute to weight bias among nurses and how care may differ for an obese patient through semi structured interviews; 3) determine if interview themes support weight bias survey measurements. The current st udy will be organized into three manuscripts which will address the aforementioned purposes. Chapter 2 will be the first manuscript. It involves the evaluation of weight bias in nurses towards obese patients in a rural inpatient hospital setting using the NATOOPS. Weight bias will be correlated with BMI through self report height and weight. The survey was administered online in order to accommodate data collection at multiple sites and the non traditional work hours of the participants. Two hundred and eighty RNs, LPNs, and CNAs were recruited via email to complete the online NATOOPS by their respective nurse managers. Refer to Appendix A for the NATOOPS.

PAGE 31

31 Chapter 3 will be the second manuscript. Prompts were posed to determine what factors cause or co quality of care through semi structured interviews. Those who completed the NATOOPS had the opportunity to volunteer to participate in a 30 minute interview. Interview probes were written to elicit co nversation and participants were encouraged to speak freely. Of the 113 participants, 16 completed interviews. The themes of the interviews were derived using thematic analysis, constant comparison analysis and code intensiveness Chapter 4 will be th e third manuscript. The quantitative (NATOOPS) and qualitative (interview) data were compared to determine if they support one another. The Ecological Model of Health Behavior ( K. McLeroy, D. Bibeau, A. Steckler, & K. Glanz, 1988 ) was used to illustrate the multiple effects and interrelatedness of social elements in the environment. Rural areas are markedly different than their suburb an and urban counterparts. They typically lack resources and are economically inferior. Research does not exist looking at weight bias among this population; therefore, little is known about the environment and its influences. By understanding these fac tors implications regarding weight bias can be made. Lastly, Chapter 5 provides an overall summary of the manuscripts and a thorough discussion of the results, limitations, and implications for nurses, and recommendations for future research and practice Analytic Techniques To better understand if weight bias exists among nurses in a rural inpatient hospital setting, the following statistical analyses were conducted. First, descriptive statistics determined frequencies, measures of central tendency (mea n, median), and spread (standard deviation) of the surveyed population. Second, independent t tests

PAGE 32

32 assessed weight bias differences across BMI categories (underweight/normal weight, overweight/obese). Third, an ANOVA assessed differences in weight bias across professional status (RN/LPN/CNA) and demographic data. Fourth, Spearman correlations were performed to assess associations between weight bias and nurse BMI. Sixth, thematic and constant comparison analysis w ere performed to derive themes from the qualitative interviews and code intensiveness was done to illustrate quantitative saturation of com mon data across the interviews. Finally, the themes found during this analysis were compared to the survey data to determine if the qualitative data suppor ted the quantitative data. Delimitations The following delimitations should be considered when interpreting results of this investigation: Participants of this study include RNs, LPNs, and CNAs, aged 18 and older, working in a rural inpatient hospital s etting. Only nurses with at least one year nursing experience were selected. A list of all eligible RNs, LPNs, and CNAs was provided by the Human Resources Department at each hospital. Managers for each nursing unit were responsible for disseminating rec ruitment emails to their eligible staff. Respondents in this study agreed to voluntarily participate and may not be representative of those who chose not to participate. Limitations The following limitations should be considered when interpreting results o f this investigation: Data collected from this cross sectional study reflects responses from participants at a specific point in time. It will not follow respondents longitudinally to view personally normative behaviors and therefore direct causation cann ot be established.

PAGE 33

33 A convenience sample was chosen because the study site did not have a large number of employees. Convenience sampling limits the generalizability of the study findings to other populations including the area used in this study. Volunt eer bias is of concern, but every effort was made to engage all nurses to participate. Perceptions of obesity are cultural (Crandall et al., 2001) and rural populations tend to have higher rates of obesity. Correlating weight bias in overweight or obese nurses will allow us to understand what the cultural norms are for the area. The lack of patient care resources and limited staffing may also affect the study. If weight bias is significant in the pilot study, there will be grounds for qualitative d ata collection to determine the external causes of weight bias Assumptions For the purposes of this investigation, the following assumptions were made: Every participant had access to the Internet The hospitals provide Internet access to nursing staff on al l computers located on each nursing unit. The Human Resources Department provided an accurate list of eligible participants to contact. Names included on the lists may not have been removed if the participant was terminated or resigned in the last six mon ths; therefore, the response rate may be influenced by non receipt of survey materials. The nurses who participate in the study answered the survey questions honestly. The recruitment email, consent form, and email reminders assured participants of their anonymity and encouraged them to answer truthfully. Every participant had experience caring for an obese patient. Rural communities have higher rates of obesity; therefore, it is to be expected that participants have cared for an obese patient at some poi nt before or during data collection. Definition of Terms A REA OF N URSING Area of nursing the participant is employed. (Ex. E mergency Department, Intensive Care Unit, Medical/Surgical Unit ). BMI Discrimination or stereotyping based on one's weight D EMO GRAPHICS Gender age, race, income, and education level. P ROFESSIONAL Full time, part time, per diem, seasonal. S TATUS

PAGE 34

34 Q UALITY OF C ARE needs are met (Williams, 1998). S HIFT Time regul arly scheduled to work. (Ex. 7:00am 7:00pm). W EIGHT B IAS Indicator of overweight or obesity. Y EARS OF N URSING Number of years spent working in the nursing field. E XPERIENCE Summary The purpose of this study is to determine if weight bias exist s towar ds obese patients among RNs, LPNs and CNAs in a rural hospital setting an d to identify the factors that a ffect quality of patient care in order to create empathy training for caring for the obese patient. This chapter describes the overall focus of this res earch and includes a description of the research problem, purpose of the study, significance, applicable theories, research questions, statistical analyses, delimitations, limitations, assumptions, and definition of terms. Weight bias in the healthcare set ting has major public health consequences. The present study provided a comprehensive description of weight bias among nurses and the factors that cause or contribute to their weight bias The results help to provide a clearer understanding of the relatio nship between weight bias and BMI and will aid in the development of effective public health interventions and policies.

PAGE 35

35 CHAPTER 2 ASSESSING WEIGHT BIA S IN NURSES TOWARD O BESE PATIENTS IN A R URAL POPULATION Background The prevalen ce of obesity in the Unit ed States continues to be a major health problem despite the preventative actions tha t have taken place in the last 2 0 years ( Center for Disease Control and Prevention, 2012b ) The highest rates of obesity in the U.S. exist in the South (29.4%) and are above the national average in rural communities where resources are sparse ( Center for Disease Control and Prevention, 2011c ) Incidentally, w e ight bias and di scrimination in the United States has also increased over the past decade to a staggering 66% ( Andreyeva et al., 2008 ) The overwhelm ing negativity towards obese individuals does not come without consequence. Emerging psychological and physical health which may lead to depression, low self esteem, bad eating behaviors, poor body image, and exercise avoidance ( Puhl & Heuer, 2009 2010 ) Furthermore, evidence exists that weight bias may interfere with the successful implementation of obesity prevention strategies and treatment which is a major cause for concern ( Puhl & Heuer, 2010 ) As obesity rates continue to climb so does the provision and acquisition of healthcare for medical problems associated with unhealthy weight. The inflatio n in obesity related hospitalizations have placed an increased demand on nurses working in the inpatient hospital setting ( Bertakis & Azari, 2005 ) towards obese pat ients indicates feelings of repulsion, resentment, dread, and discomfort when having to care for them ( Bagley et al., 1989 ; Brown, 2006 ; Peternelj Taylor, 1989 ; Puhl & Brownell, 2001 ) controllable and

PAGE 36

36 that obese patients l ack self control, and are overindulgent and lazy are not only false, but raise issues concerning patient care ( Brown, 2006 ; Puhl & Brownell, 2001 ) Misconceptions are common in relation to the causes of obesity. Over the last decade, numer ous studies have shown that healthcare professionals believe that obesity is a controllable factor that is a result of overeating and physical inactivity ( Berryman et al., 2006 ; Bocquier et al., 2005 ; Brown, 2006 ; Campbell et al., 2000 ; Chambliss et al., 2004 ; Foster et al., 2003 ; Hare et al., 2000 ; Harvey & Hill, 2001 ; Puhl & Brownell, 2001 2006 ; Puhl & Heuer, 2009 ; Puhl, Moss Racusin, et al., 2008 ; Thuan & Avignon, 2005 ; Wear, Aultman, & Varley, 2006 ) The irony of these findings is that obesity research ha s demonstrated that obesity is actually a multifactorial disease that is a result of genetics, environment, diet, and insufficient physical activity ( Center for Disease Control and Prevention, 2011b ; National Institutes of Health, 2012 ) It is concerning that health professionals with these negative attitudes may not be providing adequate or fair care ( Bertakis & Azari, 2005 ; Hebl & Xu, 2001 ) Research indicates that providers spend less time with obese patients during scheduled appointments and do not provide the same patient edu cation as they do to thinner patients ( Bertakis & Azari, 2005 ; Hebl & Xu, 2001 ) Obese patients have reported feeling disrespected by their their health problems were blamed on their weight, and felt uncomfortable addressing their weight concerns with their provide r ( Amy et al., 2006 ; Anderson & Wadden, 2004 ; Brown et al., 2006 ) It is feared that if obese patients have negative experiences with healthcare providers they will cease treatment until their symptoms become a medical emergency

PAGE 37

37 ( Brown, 2006 ) A study conduct ed by Amy et al. (2006 ) showed a lower percentage o f preventative cancer screenings among obese women despite having insurance and high access to healthcare. Weight was found to be a major barrier (83%) for undergoing preventative gynecological screenings for obese women; furthermore, women with the highe st levels of obesity reported delaying preventative care because of their weight (68%). Explanations for their reluctance to seek care was past experiences with disrespectful treatment and negative attitudes by their provider, embarrassment over their wei ght, receiving unsought advice about losing weight, and not being provided with equipment to accommodate their size ( Amy et al., 2006 ) Another study found that obese women avoided seeking healthcare if they gained weight since their last visit, would be weighed during an appointment, had to undress in an exam room, or would receive advice to lose weight ( Drury & Louis, 2002 ) The negative attribut ions towards obesity in nurses specifically, are cause for concern. Nurses are responsible for the care and treatment of overweight and obese patients and must provide quality and non judgmental care as stated in the American Nurses Association (2001 ) Code of Ethics for Nurses Nurses, particularly in an inpatient hospital setting, have the most contact with obese patients; therefore, potential interventions could be targeted at this population Health p rofessionals have reported feeling hostile, angry, and apathetic when caring for an obese patient ( Crandall et al., 2001 ) Other studies have found that student and registered nurses (RN) were unlikely to associate positive characteristics with obesity ( Poon & Tarrant, 2009 ) Undergra duate nursing students and RNs associated negative words like shapeless, slow, and unattractive with obesity ( Poon & Tarrant, 200 9 ; Teachman & Brownell,

PAGE 38

38 2001 ) Interestingly, older nurses were found to have more negative attitudes towards obese patients than younger nurses and nurses; as were nurses with lower BMIs ( Brown et al., 2007 ; Puhl & Brownell, 2001 ) It is detrimental that obese individuals are regular consumers of the healthcare system due to the number of comorbities that are associated with being obese. Neglecting to receive routine preventative screenings can result in poor prognosis and exacerbation of symptoms. It is imperative that obese patients be treated fairly and respectfully by healthcare providers in order to reduce obesity related mortality rates and to prevent creating a larg er deficit in our strained healthcare system ( Amy et al., 2006 ; Brown, 2006 ; Han et al., 2009 ; Puhl & Heuer, 2010 ) Further evaluation of weight bias in nurses in differe nt settings (clinics, hospitals) using validated instrumentation is necessary ( Crandall et al., 2001 ; Watson et al., 2008 ) This study hopes to accomplish itudes Toward Overweight and Obese Patients Scale (NATOOPS) ( Watson et al., 2008 ) to assess weight bias in a population of nurses who work in a rural, inpatient hospital setting. The instrument was originally used with RNs, but can be used in other areas of nursing per the authors. The lack of literature available that assesses weight bias in licensed practical nurses (LPN) and certified nursing assistants (CNA) should not be overlooked because they too regularly care for overweight and obese patients in hospital settings, especially in rural areas; therefore, RNs, LPNs, and CNAs were recruited This study seeks to answer t he following research questions (RQ) : RQ1: Does weight bias exist towards overweight and obese patients among RNs, LPNs, and CNAs working in a rural inpatient hospital setting?

PAGE 39

39 RQ2: Is there a relationship between patient related weight bias and BMI in RNs LPNs, and CNAs working in a rural inpatient hospital setting? RQ3: Is there a difference in patient related weight bias among RNs, LPNs, and CNAs working in a rural inpatient hospital setting? Attribution Value Model of Prejudice Attribution V alue M odel of P rejudice is an ideological model of prejudice ( Crandall et al., 2001 ) Ideology is a set of beliefs that form the psychological basis of a political, economic, or social system ( Crandall et al., 2001 ) Attributions are causal explanations or judgme nts about the social world ( Heider, 1958 ) a nd help people understand why explanations for why actions cause a certain outcome elicit specific emotion s The A ttribution V alue M odel of P rejudice postulates that attitudes and prejudice towards groups are based on attributions of controllability and cultural value ( Crandall et al., 2001 ) Attributions can be situational or dispositional. Situational attributions are ( Weiner et al., 1988 ) An obese child may not have access to healthy foods because their parents do not buy them or they may live in an unsafe neighborhood and cannot play ou tside. In this situation the child cannot control their environment and will not receive the stigma that one would expect if the child chose to eat junk food over healthy food and preferred to watch TV and play video games rather than play outside. Disp ositional attributions another internal trait ( Weiner et al., 1988 ) The same obese child may be from a culture where fatness is seen as a sign of prosperity and health. As nave psychologist, humans will tend to give more credence to dispositional attributions because of their

PAGE 40

40 need for consistency and belief that peo ple create their own destiny ( Crandall et al., 2001 ; Heider, 1958 ) Prejudice is described as negative emo tional feelings toward members of a social group ( Crandall et al., 2001 ) Stereotyping of groups provides attributes about the groups successes and failures. It is important to note that not all members of a group have to fit a stereotype; they can be i ndividually excused from prejudice if the attributes do not fit ( Crandall et al., 2001 ) Prejudice towards a group only holds members responsible for the negative attributes and not the positive ones. The perceiver does not have to figure out if they ar e considered ingroup or outgroup nor do they need to have experienced any previous conflict, history, or contact with the group in question ( Crandall et al., 2001 ) Prejudice can arise from perceptual processes based on the about cau sality and personal and cultural values for traits, characteristics, and stereotypic attributes about ( Crandall et al., 2001, p. 36 ) Crandall and colleagues (2001) demonstrated that prejudice can be linked to a ttributions of controllability. The more controllable a characteristic seems the more likely prejudice will occur towards an y person or group displaying that characteristic. Prejudice typically occurs in cases of obesity because fatness is considered a c ontrollable sin rather than an uncontrollable sickness ( Weiner, 1993 ) Fatness is commonly attributed to a lack of willpower, gluttony, and laziness which are characteristics that can be changed at the will of the individual. When attributions about controllability are made moral judgments arise. These judgments rationalize that people get what they deserve when they act in a way that causes an outcome and should be

PAGE 41

41 treated accordingly ( Cahnman, 1968 ; Feather, 1996 ; Lerner, 1980 ) Therefore, a fat person has chosen to overeat and be lazy and deserve s the stigmatization they receive; whereas, a thin person is a hard worker and disciplined and deserves to be treated with respect. Cultural values have also been used to understand how attributions predict prejudice. Results from a study conducted on cro ss cultural approaches to attribution ( Triandis, 1994 ) found that people belonging to individualistic countries, like the United St ates, were more likely to view themselves as independent of a collective body and be ego driven ( Crandall et al., 2001 ) In collectivist countries, like Mexico, individuals needs before their own because of the tight connectedness of its members ( Crandall et al., 2001 ) Individualist countries emphasized personal responsibility and viewed obese people as responsible for their weight and subsequent perils ( Crandall & Reser, 2005 ) In collectivist countries the focus was on the group so an obese person would not be considered responsible for their fatness nor would being overweight really matter ( Crandall & Reser, 2005 ) An interesting concept of the attribution value model of prejudice is that the sel f does not have special status; therefore, an individual can be prejudice towards themselves and others like them ( Crandall et al., 2001 ) Controllability and responsibility play major roles in how the self mimics the attributions for others ( Crandall & Reser, 2005 ) For instance, a person may believe that obesity is controllable and feel that people are responsible for their own weight. A prejudice will occur from these attributions towards any obese individual. If the same person is also fat, they will view

PAGE 42

42 themselves as personally responsible for their weight and the same negative emotions will occur towards themselves. This phenomenon can be used to explain why obese people, who have negative affects towards fatness, feel depressed shame, guilt, and have low self esteem ( Crandall et al., 2001 ) The Attribu tion Value Model of Prejudice served as the conceptual framework for the NATOOPS ( Crandall et al., 2001 ; Watson et al., 2008 ) Scaled items were based on the attribution instrument dev eloped by Bagley et al. (1989 ) and other items were added in accordance with the theory and knowledge about obesity ( Watson et al., 2008 ) Questions were created to represent attributions and values about obe sity and experiences associated with working with obese patients ( Watson et al., 2008 ) Methodology Setting A cross sectional pilot study design took place at a three rural hospital s in Southwest Florida. A rural site was chosen because higher levels of obesity are associated with rural li ving ( Center for Disease Control and Prevention, 2011c ) ; therefore, the researcher can be sure that the nurses surveyed will have had experience caring for obese patients. According to the American Hospital Association (2012 ) a hospital is considered rural if it meets at least one of the following criteria: ha s 100 or fewer beds, 4000 or fewer admissions, or located outside a Metropolitan Statistical Area. All of the hospitals used in this study met at least one of the criteria. Hospital #1 houses 48 inpatient beds and 109 potential participants. The population of the surrounding municipality was 7,637, which consisted of 51% male and 49% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 )

PAGE 43

43 reported that the population consisted of 53% whites, 25% African Americans, and 33% Hispanic or Latino. Hospital #2 has 50 inpatient beds and 63 potential participants. The population of the surrounding area was 2,223, which consisted of 51% male and 49% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 70% whites, 7% African Americans, and 46% Hispanic or Latino. Hospital #3 has 159 inpatient beds and 171 potential participants. The population of the surrounding area was 10,491, which consisted of 48% male and 52% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 76% whites, 15% African American, and 18% Hispanic or Latino. Hospitals 1 and 2 have little to no specialty medical services and require that patients be transferred to nearby facilities (~20 miles) if they require care outside the scope of the hospital services. Hospital #3 is the largest of the three sites and can provide specialty care, but is still considered rural. Nursing demographics were not provided by the participating hospital s Sample A response rate of 42.9% nurses (N=113) was obtained from all participating hospitals Respon dents were predominantly female (83.2%, n=94) and ranged in age included white (72.6%, n=84), Hispanic/Latino (8.9%, n=10), black (4.4%, n=5), Asian/Pacific Islander (3.5%, n=4 ), other (3.5%, n=4), and Native American (0.9%, n=1). Areas of nursing included medical/surgical care (23.9%, n=27), emergency care (21.2%,

PAGE 44

44 n=24), intensive care (17.7%, n=20), surgery (12.4%, n=14), obstetrics (8%, n=9), and IV therapy/other (2.7%, n=3 ). The majority of respondents held an associates (ASN) (43.4%, n=51) or bachelors (18.6%, n=21) degree in nursing (BSN) and the remaining (MSN) (5.8%, n=6), a license in practical nursing (8.8%, n=10), or a certification in n ursing assistance (3.5%, n=4). Over 86.8% (n=102) of the respondents reported caring for 1 or more obese patients on a daily basis and 68.1% (n=77) had never attended an educational program focusing on obesity. Nursing experience ranged from 5 years or l ess (20.4%, n=23) to more than 25 years (18.5%, n=21). However, most nurses reported having worked between 10 to 25 years (54.9%, n=62). Instrumen t S election The NATOOPS (Appendix A ) was used to determine if weight bias existed among nurses The NATOOP S was developed and validated in 2008 by Dr. Lorraine Watson, Dr. Kathleen Oberle, and Danielle Deutscher of the University of Calgary. The study was conducted using a large cohort of RNs in Calgary (n=626). It was developed using the A ttribution V alue T heory ( Weiner et al., 1988 ) and motivation arise from their judgment about the causes of outcomes ( Crandall & Reser, 2005 ) Validity was determined via exploratory factor analysis. Items were included if they loaded .4 or higher allowing for stronger correlations between the item and the factor ( Watson e t al., 2008 ) The researchers chose items they felt displayed multidimensional concepts of bia s toward obesity and obese patients ( Watson et al., 2008 ) The NATOOPS has 36 items from the following identified five factors: (1) Response to obese patients (14 items; eigenvalue 5.41; variance explained 20.82%; reliability estimate .78); (2) Characteristics

PAGE 45

45 of obese individuals (9 items; eigenvalue 2.45; variance explained 9.43%; reliability estimate .45); (3) Controllable factors contributing to obesity (8 items; eigenvalue 2.20; variance explained 8.47%; reliability estimate .62); (4) Stereotypic characteristics of obese patie nts (2 items; eigenvalue 1.56; variance explained 6.01%; reliability estimate .79); (5) Supportive roles in caring for obese patients (3 items; eigenvalue 1.17; variance explained 4.50%; reliability estimate .58) ( Watson et al., 2008 ) Overall i (.81). The instrument uses a 100 mm visual analogu e scale (VAS) to measure responses using the anchors seldom to often or agree to disagree depending on the question. VAS was used instead of a Likert scale in order to decrease response bias and provide continuous data ( Devellis, 2003 ) The respondent makes a mark between the response anchors on the 100 mm line that indicates how strongly they feel. Scores are dete rmined by measuring the distance in millimeters from the left anchor to the mark. Higher scores (>50) indicate more negative attitudes. Questions were also asked in the opposite direction and scored in reverse in order to decrease response bias. The NA TOOPS was adapted into a web based survey using Qualtrics ( Qualtrics Labs Inc., 2011 ) The purpose of using a web based survey was to provide convenience to the participants who work varying shifts and may not have been available during normal working hours. The survey was adapted using a sliding scale from 0 100 to mimic the VAS used in the original tool.

PAGE 46

46 Procedure The hospital Chief Executive Officer (CEO) and Chief Nursing Officer (CNO) were engaged in March 2011 and gave permission for the study to take place at Hospital #1 (n=1 09) The nurse managers in each hospital unit were notified of the study during a Nursing Leadership meeting in June 2011 in which the researcher attended. During that time, the researcher explained the study to the nurse managers and questions were ans wered. After approval from the nurse managers, the researcher obtained Institutional Review Board (IRB) approval and attended another Nursing Leadership meeting in August 2011 to inform the CNO and nurse managers that the study was approved and to discuss survey dissemination tactics and needed support. The nurse managers suggested that they send recruitment emails to their staff and that the survey link be placed on the hospital intranet for easy access. The online survey was disseminated in September 2 011 and closed in January 2012. Reminder emails were sent at two week increments from the time of the initial email until data collection ended. The director of Human Resources provided a list of the number of RNs, LPNs, and CNAs working in each unit in J uly 2011. The CNO of Hospitals 2 and 3 (n=63 and n=171, respectively) was contacted in July 2011. Consent forms and supporting documents explaining the study were forwarded to the CNO in August 2011 and the study was approved. The researcher met with t he CNO in September 2011 to further discuss survey dissemination tactics and needed support in which they recommended that the Director of Clinical Education be contacted to further discuss these matters. A phone meeting between the researcher and the Dir ector of Clinical Education took place in September 2011 during which the director decided to reach out to the nurse managers of Hospital #2 and #3

PAGE 47

47 during a Nursing Leadership meeting which took place the following day. During the Nursing Leadership meet ing the D irector received approval from the nurse managers and permission to email their staff the study information. The survey was also nated in September 2011 and closed in January 201 2. Reminder emails were sent at two week increments from the time of the initial email until the end of data collection. The D irector of Human Resources provided a list of the number of RNs, LPNs, and CNAs working in each unit in July 2011. Participant Recruitment A power analysis was conducted using G*Power ( Faul, Erdf elder, Lang, & Buchner, 2007 ) software to establish effect size. An effect size of 0.2, alpha of 0.5, and power of 0.80 with five predictors indicated that a convenience sample of 113 RNs, LPNs, and CNAs needed to be surveyed. Three, demographically si milar rural hospital s located in Southwest Florida were chosen to provide an adequate sample size. Participants had to be 18 years of age and employed full time part time, or per diem (as needed) at the study site s The study was explained to the nursi ng staff in a recruitment email sent by their respective nurse manager. The email included the risks and benefits associated with participation, privacy methods, compensation, and autonomy A secure link was provided in the email for those who were inter ested in participating in the study. The home page of the survey included the informed consent ( Appendix B ) and a check box for the participant to choose if they wished to participate. If consent was provided, participants were able to complete the NATOO PS and provide their demographic data.

PAGE 48

48 Self report height and weight were taken to measure obesity at the end of the questionnaire Demographic Information Gender, age, race, employment status, education /professional level, socioeconomic status, area of nursing currently employed, years of nursing experience, work shift, attendance of an obesity related educational program and the prevalence of caring for an ove rweight or obese patient were collected for each participant. Body Mass Index (BMI) BMI is a screening tool that serves as an indi c ator for overweight and obesity in children and adults BMI is measured using the height (in.) and weight (lbs.) of an individual. The formula for calculating BMI and BMI table can be found in Table 2 1 A BMI of 18 .5 to 24.9 is considered healthy; whereas, a BMI of 25 to 29.9 is overweight and greater than 30 is obese ( Centers for Disease Control and Prevention, 2010 ) A common misconception about BMI is that it is a diagnostic too l. The Center for Disease Control and Prevention (2011b ) recommends that individuals who have an abnormal BMI see their healthcare provider who can run additional assessments to determine if any health risks exist. Self report height and weight was used in this study because it is more feasible within the chosen population. With the varying shifts of nurses it would be extremely difficult to obtain direct measure heights and we ights of the survey respondents. Also, direct measure heights and weights would require the participants to reveal their identity to the researcher which they may not be comfortable doing. Free text fields at the end of the demographic data secti on of t he survey were used to obtain height (inches) and

PAGE 49

49 weight (pounds) of each participant. BMI was calculated using the Center for Disease Control and Prevention (2012a ) BMI calculator. Data Analysis To better understand if weight bias existed among nurses in a rural inpatient hospital setting, the following statistical analyses were conducted. First, descriptive statistics deter mined frequencies, measures of central tendency (mean, median), and spread (standard deviation) of the surveyed population. Second, independent t tests assessed weight bias differences across BMI categories (underweight/normal weight, overweight/obese). Third, an A nalysis of Variance (ANOVA) assessed differences in weight bias across professional status (RN/LPN/CNA) and demographic data. Fourth, Spearman correlations were performed to assess associations between weight bias and nurse BMI. Case wise del etion was used to manage missing data. SPSS 18.0 statistical software ( SPSS Inc., 2009 ) was used to complete all analyses. Data were norma lized using the square root transformation function in SPSS. Upon normalizing the data, weight bias composite scores over 7.07 were considered to be weight bias; whereas, weight bias composite scores below 7.07 were considered not weight bias. Ethical C onsiderations The study received ethics approval from IRB 02 in July 2011. Revisions were made and accepted in September of 2011. Data collection began in September 2011 at both study sites Participant IP addresses were not logged track ed or attach ed to study data to ensure anonymity

PAGE 50

50 Results BMI calculations using the standard formula (weight (kg)/height (m2)) resulted in an underweight/normal weight group of 35 participants (31%), and an overweight/obese group of 63 par ticipants (55.8%), with 15 missing values. Weight bias among nurses grouped by BMI was compared by independent t test. Between BMI group comparisons on the five factors identified in the NATOOPS yielded statistically significant differences between the m eans of the underweight/normal weight (t=8.556, df=70.680, p<.003) and overweight/obese groups for Factor 3 (controllable factors contributing to obesity); wherein underweight/normal weight nurses exhibited weight bias. Overweight/obese nurses had a highe r level of weight bias (t=8.083, df=44.049, p=.286) as compared to underweight/normal weight nurses (t=7.8653) for Factor 2 (characteristics of obese individuals); however, this was not stat istically significant. See Table 2 2 for independent t test resul ts. An ANOVA was run to determine weight bias differences between professional status (CNA, LPN, ASN, BSN, MSN). Results showed that CNAs had weight bias (M =8.375, p=.13 8); indicating w eight bias decreased with increasing levels o f education. These resul ts, however, were not statistically significant. Refer to Table 2 3 and Table 2 4 fo r ANOVA results. Effect size ( partial eta 2 ) was also determined using ANOVA in order to estimate the variability of weight bias that could be attributed to nursing profes sional status ( Trusty, Thompson, & Petrocelli, 2004 ) Professional status explained 14% ( 2 = .143, p = .138) of variabi lity in weight bias scores, but was insignificant. Spearman correlation was used to determine if a relationship existed between weight bias and nurse BMI. The findings indicate a weak negative correlation

PAGE 51

51 b 0.121, p =.335) such that nurses with lower BMIs had greater weight bias. Descriptive statistics were run on a diagrammatic evaluation of body size (Appendix A). Respondents could choose more than one diagram to classify bo dy size. Ninety two percent of respondents correctly identified the normal weight diagram, 19% correctly identified the overweight diagram, and 96% percent correctly identified the obese diagram. The obese diagrams were commonly misinterpreted as the ove rweight diagram (77%). These perceptions indicate that nurses view individuals who are larger than normal weight to be obese. Overall internal consistency reliability of the Discussion The nurses in this study exhibited weight bias. These findings are consistent with other published studies that have sought to assess weight bias among healthcare professionals specifically nurses ( Bagley et al., 1989 ; Brown, 2006 ; Crandall et al., 2001 ; Peternelj Taylor, 1989 ; Poon & Tarrant, 2009 ; Puhl & Brownell, 2001 ; Schwartz et al., 2003 ; Teachman & Brownell, 2001 ; Watson et al., 2008 ) The findings in this study replicate and expand this prior research by using a rural sample of nurses, including LPNs and CN As, as well as measuring the associations between weight bias and BMI. Results indicate that underweight/normal weight nurses were more likely to exhibit weight bias towards obese patients particularly in regards to obesity being controllable. These find obesity are often misunderstood and a frequent cause of weight bias making increasing knowledge a key intervention strategy ( Berryman et al., 2006 ; Bocquier et al., 2005 ; Brown, 2006 ; Campbell et al., 2000 ; Chambliss et al., 2004 ; Foster et al., 2003 ; Hare et al., 2000 ;

PAGE 52

52 Harvey & Hill, 2001 ; Puhl & Brownell, 2001 2006 ; Puhl & Heuer, 2009 ; Puhl, Moss Racusin, et al., 2008 ; Thuan & Avignon, 2005 ; Wear, Aultman, & Varley, 2006 ) Strangely, n urses with higher levels of education (BSN and MSN) were more likely to identify obesity as a multifactorial disease, but still exhibited negative attitudes and beliefs. This is concerning because it illustrates that even those with knowledge about the conditi on infer behavioral blame on patients ( Schwartz et al., 2003 ) CNAs appeared t o be more weight bias than RNs and LPNs. Not having true activities of daily living (ADL) needs which was shown to be a source of bias. Also, CNA certification requires the least amount of educational preparation calling for a high school diploma or general education development (GED) certificate as well clinical hours and successful completion of the state certification exam. CNA programs may benefit from incorporating bariatric sensitivity training into their curriculum and educating their students on safe and effective ways of assisting with ADL tasks for obese patients. Overweight and obese nurses may be more likely than normal weight nurses to associate negative characteristi cs with obese patients. Characteristics of obese individuals identified within the NATOOPS factor analysis were low self este em, depression, guilt, ridicule, angry, fatigue self conscious, socially unaccepted, and low self confidence ( Watson et al., 2008 ) These findings demonstrate the phenomena that overweight and obese nurses have negative attitudes and feelings towards similarly shaped patients. The attribution value model of prejudice suggests tha t this group of nurses may self reflect biases towards themse lves because they also identify with these negative attributes ( Crandall et al., 2001 )

PAGE 53

53 Correspondingly, nurse s were likely to view patients as being obese when, in fact, they were overweight, which may indicate that weight bias extends beyond obesity and effects overweight individuals, as well. Nurses may also be over reporting the number of obese patients they care for on a daily basis if they are incorrectly classifying overweight patients as obese. The majority of participants indicated they never had attended an obesity related education al program while in school or while working in the clinical setting. Bas ed on these findings, a multi effort approach should target nurses knowledge and attitudes about obesity. A bariatric sensitivity e ducational program that explains the role of the environment and genetics in obesity and increases awareness about the nega tive effects staff attitudes have on patient outcomes and quality of care may help to reduce bias. Limitations Several limitations of the proposed study limit interpret ation of the possible findings, such as the study relies solely on self selected nurse s at one point in time. T he cross sectional study design that was used prevents conclusions about the causal relationships among the variables and does not follow participants longitudinally to view personally normative behaviors. The use of c onvenience sampling limits the generalizability of the study findings to other populations and decreases external validity ; however, it was chosen because the study site s did not hav e large number s of employees. Volunteer bias is of concern, b ut every effort was made to engage all nurses to participate The results also lack generalizability because participants were predominantly white women who worked as

PAGE 54

54 populat ions in different geographic locations, races, to LPNs and CNAs, and to male nurses. Self report height and weight for BMI measurements are subject to bias. Future studies should seek to directly collect height and weight data to provide more accurate re sults. Cultural norms of obesity are also a limitation. Perceptions of obesity are cultural (Crandall et al., 2001) and rural populations tend to have higher rates of obesity. The results indicate that weight bias existed among nurses of all sizes but t hat smaller nurses may be mo re likely to display bias. A larger sample is needed to make these claims Conclusion of the negative effects biases can have on patient outcomes and th e quality of care delivered. Conducting weight bias research in rural hospital setting s provide a unique perspective of the attitudes that nurses have who work in areas where obesity is prevalent. Even when obesity is a societal norm it does not serve as protective factor against biases in rural communities; thus, nurses working in these communities require as much attention as their urban counterparts. The current study determined that weight bias exist ed towards overweight and obese patients among RNs, LPNs, and CNAs working in a rural inpatient hospital setting through independent t test analysis; established that there was a weak negative correlation between weight bias and nurses BMI v ia Spearman correlation; and found that CNAs were more likely to b e weight biased than RNs or LPNs through ANOVA analysis. The limited resources allocated to rural hospitals and dependence on the use of LPNs and CNAs for staffing may breed higher weight bias rates making further research

PAGE 55

55 among this population a necessity Utilizing an instrument, like the NATOOPS, that was and provides evidence for the need of qualitative research to clearly understand the internal and external fac tors that cause bias. Understanding the etiology of weight bias in nurses will make planning intervention strategies easier and more effective in the future.

PAGE 56

56 Table 2 1. Body mass index (BMI) table for adults BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 Height (inches) Body Weight (pounds) 58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167 59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173 60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179 61 100 106 111 116 122 127 132 137 143 148 15 3 158 164 169 174 180 185 62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 186 191 63 107 113 118 124 130 135 141 146 152 158 163 169 175 180 186 191 197 64 110 116 122 128 134 140 145 151 157 163 169 174 180 186 192 197 204 65 114 120 12 6 132 138 144 150 156 162 168 174 180 186 192 198 204 210 66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216 67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223 68 125 131 138 144 151 158 164 171 177 184 190 197 20 3 210 216 223 230 69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236 70 132 139 146 153 160 167 174 181 188 195 202 209 216 222 229 236 243 71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250 72 140 147 154 162 16 9 177 184 191 199 206 213 221 228 235 242 250 258 73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265 74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272 75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 26 4 272 279 76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287

PAGE 57

57 Table 2 2 Comparison of means of total factor scores by weight category Factor scores Factor 1 (MSD) Factor 2 (MSD) Factor 3 (MSD) Factor 4 (MSD) Factor 5 (MSD) Underweight/ Normal (N = 35) 5.542 ( 1.91) 7.865 ( 1.02) 8.556 ( 0.616)* 6.378 ( 2.21) 6.253 ( 1.50) Overweight/ Obese (N = 63) 4.997 ( 1.86) 8.083 ( 0.781) 8.056(0.753) 6.212 ( 2.01) 6.414( 1.49) A mean s core of 7.07 or g reater on the weight bias composite s core represents weight bias. *p< .05 Table 2 3 Weight bias c omposite score and p rofessional s tatus Sum of Squares d f Mean Square F Sig. Between Groups 7.755 6 1.293 1.693 .138 Within Groups 46.559 61 .763 To tal 54.314 67 A mean score of 7.07 or greater on the w eight bias composite s core represents weight bias. *p< .05 Table 2 4 Mean w eight bias c omposite score and p rofessional s tatus Professional Status Mean Weight Bias Composite Score (SD) Certifie d nursing assistant 8.375 (.40) L icensed practical nurse 7.010 (.706) A ssociate degree in nursing 6.622 (.909) Bachelor of Science in nursing 6.610 (.847) M aster of Science in nursing 6.221(1.32) A mean score of 7.07 or greater on the w eight bias composit e s core represents weight bias. *p< .05

PAGE 58

58 CHAPTER 3 QUALITATIVE ANALYSIS OF WEIGHT BIAS IN N URSES WORKING IN RUR AL HOSPITAL SETTINGS Background Quality patient care has become a major concern in the last two decades and nursing is an integral component. R epresenting the largest, single group of healthcare professionals, nurses have significant influence over the experiences and outcomes of their patients ( National Quality Forum, 2004 ) The meaning of quality n ursing care has been vague ( Gunther & Alligood, 2002 ; Lynn, McMillen, & Sidani, 2007 ) Researchers identified this issue, and numerous studies have sought to define quality of care. A study conducted by Burhans and Alli good (2010 ) found the lived meaning of quality nursing care from practicing nurses was within w hich responsibility, intentionality and advocacy form an essential, integral foundatio n ( Burhans & Alligood, 2010, p. 1694 ) Great efforts have been made to identify quality nursing standards and measure them through nursing and patient inv olvement. Redfern and Norman (1999a 1999b ) attempted this task by interviewing 96 patients and 80 nurses from three hospitals to determine what the patients and nurses identified as indicators of quality nursing care. Nurses and patients both ranked therapeutic ward atmosphere, and t horough and sensitive individualized care as important quality of nursing care indicators. Patients felt of care, and social control were significant were factors cont ributing to high quality ; whereas, nurses believed that effective leadership and teaching and clinical supervision of student nurses and staff was essential for high quality. Findings were similar in a

PAGE 59

59 study conducted by Larrabee and Bolden (2001 ) needs met, and nursing competence. Lee and Yom (2007 ) found that when nurses perceptions of their performance and expectations were higher than what their patients perceived nursing care quality was considered low to the patient. A study con ducted by Williams (1998 ) determined that inconsistent quality of nursing care is a result of insufficient time and dissatisfaction and stress among nurses. Current nursing quality of care research provides vital information about the similarities and differences between nursing and patient standards, but literature related to the quality of nursing care towards obese patients would be valuable in light of our tion. Obesity has become a major health proble m in America in the last two decade s leading to an increase in hospitalizations due to obesity related conditions ( Han et al., 2009 ) The American healthcare system is being inundated with patients seeking treatment for obesity related health problems that include heart disease, type 2 diabetes mellitus, stroke hypertension, dyslipidemia, cancer, and respiratory, digestive and joint problems ( Han et al., 2009 ) An analysis conducted by the Behan and Cox (2010 ) from the Society of Actuaries estimated that the yearly obesity related healthcare cost is $270 billion in the United States. The analysis also demonstrated that increases in healthcare cost positively correlated with increased BMI: $72 billion f or overweight and $198 billion for obesity ( Behan & Cox 2010 ) Hospitalizations for obesity related chronic diseases place an increased demand on nurses ( Bertakis & Azari, 2005 ) During hospitalizations, nurses deliver direct patient

PAGE 60

60 care; therefor e, they have the greatest amount of contact with overweight and obese patients in inpatient settings and have tremendous influence over their health outcomes ( Gallagher, 2010 ; National Quality Forum, 2004 ) The medical needs of an overweight or obese patient can be physically demanding and may require lifting turning, and mobilization which can be difficult an ( Bagley et al., 19 89 ) A study conducted on occupational injuries in nurses, psychiatric and home health aides found that 54% of reported workplace injuries from 1995 2004 were musculoskeletal disorders ( Hoskins, 2006 ) Twenty seven percent of these injuries were caused by overexertion; 67% of which we re caused by lifting a patient ( Hoskins, 2006 ) The threat of injury while caring for an overweight or obese patient can be stressful and has been reported as a source of negative weight bias in nur ses ( Brown, 2006 ) Weight bias among nurses towards obese patients often results in feelings of repulsion, resentment, dread, and discomfort when having to care for them ( Bagley et al., 1989 ; Brown, 2006 ; Peternelj Taylor, 1989 ; Puhl & Brownell, 2001 ) to provide empathetic care can be linked to insufficient training and equipment, inappropriate nursing care models, and misunderstanding the etiology of obesity ( Camden, Brannan, & Davis, 2008 ) other healthcare professionals is that obesity is controllable and is the result of no self control, overindulgen ce, and laziness ( Berryman et al., 2006 ; Bocquier et al., 2005 ; Brown, 2006 ; Campbell et al., 2000 ; Chambliss et al., 2004 ; Foster et al., 2003 ; Hare et al., 2000 ; Harvey & Hill, 2001 ; Puhl & Brownell, 2001 2006 ; Puhl & Heuer, 2009 ; Puhl, Moss Racusin, et al., 2008 ; Thuan & Avignon, 2005 ; Wear, Aultman, & Varley, 2006 )

PAGE 61

61 The irony of these findings is that obesity research has demonstrated that obesity is actually a multifactorial disease that is a result of genet ics, environment, diet, and insufficient physical activity ( Center for Disease Control and Prevention, 2011b ; National Institutes of Health, 2012 ) Other studies have found that s tudent and registered nurses (RN) were unlikely to associate positive characteristics with obesity ( Poon & Tarrant, 2009 ) Undergraduate nursing students and RNs associated negative words like shapeless, slow, and unattractive with obesity ( Poon & Tarrant, 2009 ; Teachman & Brownell, 2001 ) Interestingly, older nurses were found to have more negative attitud es towards obese patients than younger nurses and nurses; as were nurses with lower body mass indices (BMI) ( Brown et al., 2007 ; Puhl & Brownell, 2001 ) .. It is concerning that healthcare professionals with negative attitudes may not be providing quality care to obese patients, which can subsequently lead to healthcare avoidance ( Bertakis & Azari, 2005 ; Brown, 2006 ; Hebl & Xu, 2001 ) Providers spend less time with obese patients during s cheduled appointments and do not provide the same patient education as they do to thinner patients ( Bertakis & Azari, 2005 ; Hebl & Xu, 2001 ) A study by Amy et al. (2006 ) revealed a lower percentage of preventative cancer screenings among obese women despite having insurance and high access to healthcare. Weight was found to be a major barrier (83%) for undergoing preventative gynecological screenings f or obese women; furthermore, women with the highest levels of obesity reported delaying preventative care because of their weight (68%). Explanations for their reluctance to seek care was past experiences with disrespectful treatment and negative attitude s by their provider, embarrassment over their weight, receiving unsought advice about losing weight, and not being provided with equipment

PAGE 62

62 to accommodate their size ( Amy et al., 2006 ) Obese women also avoided seeking healthcare if they gained weight since their last visit, would be weighed during an appointment, had t o undress in an exam room, or would receive advice to lose weight ( Drury & Louis, 2002 ) Obese individuals should feel comfortable being regular healthcare consum ers and be encouraged to properly mange their comorbities by healthcare professionals. Neglecting to receive routine preventative screenings can result in poor prognosis and exacerbation of symptoms. It is imperative that obese patients be treated fairly and respectfully by healthcare providers in order to reduce obesity related mortality rates and to prevent creating a larg er deficit in our strained healthcare system Furth er evaluation of weight bias in nurses from rural hospitals using qualitative methods is needed to understand why weight bias occurs and the effects it may have on quality of patient care The purpose of this study was to explore and understand the factor s that cause or contribute to weight bias in nurses and how they affect quality of nursing care. This study hopes to accomplish this through one on one interviews with RNs, licensed practical nurses (LPN), and certified nursing assistants (CNA) working in a rural inpatient hospital setting by answering the following research questions (RQ) : RQ1: What factors cause or contribute to weight bias in nurses? RQ2: How do the factors that cause or contribute to weight bias in nurses affect quality of care? Meth odology Design The current qualitative study was a component of a partial mixed methods equal status study. A partially mixed sequential equal status design involves conducting a

PAGE 63

63 study with two phases that occur in succession, with the quantitative and qu alitative phases having equal weight ( Leech & Onwuegbuzie, 2009 ) The first component, a quantitative nursing weight bias study conducted by Garcia, Stopka, Chaney, Chaney, and Neff (2012a ) sought to assess whether weight bias existed among RNs, LPNs, and CNAs in a rural inpatien t hospital setting using an online version of the previously val O besity and Obese Patients Scale (NATOOPS) ( Watson et al., 2008 ) Interested participants were then interviewed for their thoughts on the factors that cause or contribute to weight bias and if weight bias affected the quality of care they provided to obese patients. These intervi ews occurred in private conference rooms within each participating hospital at a mutually convenient time. Site and Sample The quantitative and qualitative phases took place at a three rural hospital s in Southwest Florida. A rural site was chosen becaus e higher levels of obesity are associated with rural living ( Center for Disease Control and Prevention, 2011c ) ; therefore, we can be sure that the nurses surveyed and interviewed had experience caring for obese patients. According to the American Hospital Association (2012 ) a hospital is considered rural if it meets at least one of the following criteria: have 100 or fewer beds, 4000 or fewer admissions, or be loc ated outside a Metropolitan Statistical Area. All of the hospitals used in this study meet at least one of the criteria. Hospital #1 houses 48 inpatient beds and 109 potential participants. The population of the surrounding municipality was 7,637, whic h consisted of 51% male and 49% female residents ( U.S. Cen sus Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 53% whites, 25% African Americans, and 33% Hispanic or Latino.

PAGE 64

64 Hospital #2 has 50 inpatient beds and 63 potential participants. The population of the surrounding area was 2,223, which consisted of 51% male and 49% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 70% whites, 7% African Americans, and 46% Hispanic or Latino. Hospital #3 has 159 inpatient beds and 171 potential participants. The population of the surrounding area was 10,491, which consisted of 48% male and 52% fema le residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the populat ion consisted of 76% whites, 15% African American, and 18% Hispanic or Latino. Nursing demographics were not provided by the participating hospitals. Hospitals 1 and 2 have little to no specialty medical services and require that patients be transferred to nearby facilities (~20 miles) if they require care outside the scope of the hospital services. Hospital #3 is the largest of the three sites and can provide specialty care, but is still considered rural. Using a convenience sample, 16 nurses agreed t o participate in the study. Respondents were predominantly female (93.8%, n=15) and ranged in age from 23 to (93.8%, n=15) and Native American (6.3%, n=1). African Americ an and Hispanic/Latino nurses were not represented in the sample. Areas of nursing included medical/surgical care (18.8%, n=3), emergency care (25%, n=4), intensive care (25%, n=4), surgery (12.5%, n=2), obstetrics (6.3%, n=1), and IV therapy/other (6.3%, n=1) with one missing value. The m ajority of respondents held an A ssociates (50%, n=8) degree in nursing

PAGE 65

65 (ASN) and the remaining had either a B (BSN) degree (MSN) (12.5%, n=2), a license in practical nursing (12.5%, n=2), or a certification in nursing assistance (12.5%, n=2). Nursing experience ranged from 5 years or less (12.5%, n=2) to more than 25 years (18.8%, n=3). However, most nurses reported having worked between 10 to 25 years (68.7%, n=11). Over 81.3% (n =13) of the respondents reported never attending an educational program focusing on obesity. According to BMI measurements from the previous study, 50% (n=8) of the participants were obese, 12.5% (n=2) were overweight, and 25% (n=4) were normal weight wit h two missing values. Procedure and Data Analysis After Institutional Review Board (IRB) and hospital approvals were obtained from their respective Chief Nursing Officers (CNO) participants were sent emails from their respective nurse managers to particip ate in the main quantitative study. Participants who completed the NATOOPS were given an option at the end of the survey to provide the researcher with their email address via a free text box if they were interested in completing an interview. The messag e included that interviewees would receive a $10 Wal Mart gift card as an incentive for participating. Interviews were scheduled within 48 hours of contact information receipt and completed between September 2011 and February 2012. Interviews were conduc ted on a volunteer basis and continued until saturation of themes occurred. A semi structured interview design was used to elicit honest responses and to allow the participants to discuss topics of importance that may be unknown to the researcher ( Wengraf, 2001 ) Prior to the start of each interview the researche r provided the participant with a

PAGE 66

66 professional status. For example, if a female CNA participated in the third interview their identifier would be F3CNA. The participant was asked to read the informed consent (Appendix C) and to ask any questions if they arise and to fill out the demographic survey (Appendix D). The signed informed consent and the demographic survey were placed in a manila envelope and given back to the r esearcher. Upon receiving the sign informed consent and demographic survey, the researcher began tape recording the question portion of the interview by reading the interview script listed in Appendix E. After all interview prompts were asked, the resear cher read aloud their notes to confirm the opinions and idea s of the participant to ensure validity. T he participant was also given the option to add or remove any information that was provided At the completion of the interview the researcher provided the participant with their incentive and reminded them to contact them with any questions or concerns. Interviews were transcribed and all transcript s w ere re read and compared to the valid ity Qualitative analysis using ATLAS.ti Scientific Software Development (2010 ) was conducted on the transcribed interviews. Transcriptions were uploaded individually into ATLAS.ti and analyzed using constant comparison analysis ( Glaser & Strauss, 1967 ) Each transcript was read and broken into smaller, more manageable chunks. Each chunk was then inductively coded. Once all data were coded, they were reevaluated to ensure that similar codes were placed together and general themes were made. The frequency of themes within the data was evaluated using thematic and consta nt comparison analyse s. Code intensiveness was used to examine quantitative saturation of common data across the interviews. This was done to understand which

PAGE 67

67 codes were used most, eliciting a greater understanding of the most important concepts reported by the participant s. The more information (e.g., data units) contained in a category, the greater relevance of the category. Certain categories were allowed to possess fewer data units, as long as they still possessed enough units to merit exclusive dis tinction. Results From the nursing data, the following themes emerged as factors that cause or contribute to weight bias: patient care tasks, characteristics of obese patients, attempt to give all of their patients the same level of care, but admitted that quality of care has suffered due to delays in treatment. Explanations for delays in treatment will be addressed in the Discussion section. See Table 3 1 for thematic frequen cies. witnessed through their peers. Theme 1: Patient Care Tasks The theme patient care tasks was supported by 1 66 comments by 16 (100%) respondents. Patient care t asks in cluded the following 4 concepts: 1) Ambulation/moving 2) Procedural 3) Education 4) Activities of Daily Living (ADL) The task of ambulation/moving includes assisting a patient to a chair, bedside commode, bathroom, positioning or transferring them in a stretcher or b ed, and walking the patient. Comments made by nurses regarding assisting obese patients with ambulation/moving included the following responses:

PAGE 68

68 repositioning or lifting higher up in the bed or getting them up in a chair, They almost seem unwilling or they are willing to just lay there. Ya know? And they allow you to just move them completely. I mean move your legs! Do something for me! the first thing, is like we hope they can move themselves because many they need to move as much as possible on their own. satisfaction stuff we have to do now and we have to do whatever we can to make them happy, Procedural tasks include inser ting an intravenous catheter (IVs) inserting foley catheters surgery prep, surgery, and examinations. C omments made by nurses regarding assisting obese patients with ambulation/moving included the following responses: I think that, ya know, is that, that IM (intramuscular injection ) needs to be tandard inch and half needle. Is it really an IM injection or is it a SQ (subcutaneous) injection? an IV Starting foleys on obese female patients well, even on men, because it can be very difficult, because with a woman just assisting her in spreading includ ing myself to hold back the pannis, you know a large abdomen, to hold back their legs, a person on each leg and then actually have to hold up catheter into it, that was very diffi cult.

PAGE 69

69 When prepping them for surgery we have to wash the area, so you know if tal monitor The task of patient education includes providing the patient with information regarding their diagnosis, treatment, nutrition, disc harge care, and preventive care. Comments made by nurses regarding assisting obese patients with patient education included the following responses: person to stop eating or get them diet information when I can have it down myself. banging your head against the wall. I hear the physician addres ses it with them and say it at the bedside and I dietician in here to talk to them. televisions to the patients and one patient that was overweight, we tried to do education on high blood pressure with him on the television have to eat a lot a d ay to get to, ya know, weigh 400 or 500 pounds. And then I will always say hat did ya do at the home how do you do this at home? How did you get into the hospital, did you crawl over on all fours? Did you walk i n ? How did ya get in here? ADLs include mouth care, peri care, bathing, combing hair, changing gowns, changing bed sheets, setting up meal tray, feeding, and am bulation (which will

PAGE 70

70 addressed separately). Comments made by nurses regarding assisting obese patients with ADLs included the following responses: bigger person in the bed because th be pushing up. Yes, unfortunately you cop an attitude because 98% of the time the obese patient has a difficult time taking care of themselves which getting up to the bedside commode, wiping themselves, sometimes even as far as feeding themselves is your responsibility. hope that they can at least stand up so you can pr ovide some hygienic care. You wish you had a room with a showering bed because sometimes them. absolut It drives me crazy, and you may have heard this before, if they have to use the bedsid Theme 2: Characteristics of Obese Patients The theme characteristics of obese patients was supported by 146 comments made by 16 (100%) respondents. Characteristics of obese patients were both internal and external and included these 3 concepts: 1) Patient personality Lazy/helpless Attitude Demanding Stupid Depressed 2) Physical characteristics App earance/size Personal hygiene

PAGE 71

71 3) Family involvement The patient personality characteristic of obese patients being lazy/helpless relates comments regarding obese patients being lazy/helpless included the following: themselves. If they come up here with the expectation that we are going to do everything for them to get them up, bare most of their weight as we are get ting them You do have those patients who are fully able to care for themselves and a blood pressure cuff, you have t o do all the heavy lifting, so I know that, The patient personality characteristic of attitude e included the following: across that they have a non Sometimes they come off to the nurse as being hostile or what we might consider hateful or just anti social. than life. ell me

PAGE 72

72 was intensified because of my size, if another nurse who was fighting weight loss were to come in there, they would be more open or receptive. The patient personality charac teristic of demanding examples of demanding obese patients included the following: call bell. th they are the way they are. They tend to be more needy than the average patient for whatever reason. The patient personality characteristic of stupid obese patients may be less intelligent than patients seeming stupid included the following: I worked in a Newborn Intensive Care where we did get a lot of people that were on the lower end of the socioeconomic had attitude because of that or because they were heavy, but it was, there person is not as inte lligent, that they do not take care of themselves as well. Are we talking down to them or are we just thinking they are not intelligent enough to understand because an individual could have a higher education you just think well because move or know how to control your diet. s of self themselves and the resulting view I know that a lot of times how the patient sees herself would maybe affect how we see and view her.

PAGE 73

73 because they are overweight a I think that there are patients who get, the patients pick up on a better word, disparaged maybe better, they know that, they pick up on it. The patient personality characteristic of depressed about obese patients seeming unhappy. Examples of this included the following: because they have no self esteem. We feel that they can take better care of themselves that they have let themselves go and I suppose some that is due to depression. The patient physical characteristic of appearance You know they say tha t within the first few seconds that you see a person you draw an opinion about them, so maybe they see them and draw a negative opinion. I mean I say, my common term is they look like a Volkswagen in bed. I think anyone who is overweight is going to catch a lot of grief. kept, just, stink. Just dirty, nasty, long toe nails, just look like a homeless kinda person. How the hell can somebody get that big?

PAGE 74

74 The patient physical character istic of personal hygiene I know a lot of nurses will comment about not wanting to care fo r a patient little bit of extra care for yourself when you are large, but I do feel somewhat of an aversion. I think that if there is an o You can be clean and big. understand how they can get to that or let themself get to th at point. We had an obese patient come in with lots of, for lack of better way to say stink, you smell horri b family involvement refers Yeah, sometimes the family also, they play into it. Like they, i f they have You get that intro to where you can actually start some education about proper diet, because chances are the patient is pr obably diabetic, so you really want to touch on that big time and the family brings in Burger King and McDonalds for the patient to eat. Like seriously? Theme 3: Equipment Needs The theme equipment needs was supported by 13 6 comments made by all 16 (100 %) respondents. E quipment needs included these 2 concepts: 1) Limited number of bariatric supplies 2)

PAGE 75

75 Having a limited number of bariatric supplies was cited as a common barrier and occasional issue fo r nurses when caring for an obese patient. Common bariatric supplies in need were stretchers, hospital beds, wheelchairs, bedside commodes, gowns, scales, blood pressure cuffs, lift devices, wireless fetal monitors, and speculums. The following are examp related to needing bariatric supplies: I think not having the proper equipment is an issue. One of the patients that speculum to do it. We only have, in the ER (emergency room) one bed that is like a bariatric bed and we only have one wheelchair, when they come in the front lobby ur hospital and there are a chair and some can weigh the patient. We have one bedside commode and I am not sure it would hold an extremely large patient, it might, but I have my doubts. truly for the handicap, and that gives you lots of room to manipulate around and a larger wheelchair just barely squeaks by through the door. size fits everyone gowns or one size fits most. So we have to find big gowns. The barrier with fetal monitors, we have two that will monitor, as they call it the last couple of weeks. We have a Hoyer lift, but we need more mobility devices and sometimes We have to put them in the equipm ent we have, like the bed, um, they are now affects their psycho

PAGE 76

76 You have to make sure you have the right size blood pressure cuffs, arm or wrist because their arm is even too big for the large cuff. How together and lock them and put a stretcher that accommodated their size. Needing larger equipment/environment to accommodate patient size results in an inadequate size of equipment a nd/or amount of space for clinicians to work with or diagnose the patient safely and comfortably The following are examples of barriers that nurses have faced when dealing with a standard size equipment/environment: The OR (operating room) table is not d esigned for obese people, I think it only holds up to 250 or 300 pounds. Again, CAT (computed axial topography) scan, x ray, MRI (magnetic resonance imaging) old up to 350 pounds. We may have to just take a plain film. The doctor works with what he has in his bag of tricks. Well the other rooms are just spaces with curtains between them. You have just enough space to pull the bed in and then, um, and enough room to stand on each side and may be a chair on a side, but you have to move We have one of five rooms that are like this, and their primary purpose is reserved for patients that are gettin g blood transfusions. If a room is available we will use it so the patient has more privacy or more room to manipulate. The theme was supported by 23 comments made by 6 (37.5 %) respondents. N 3 concepts: 1) Personal struggle with weight 2) Low self esteem 3) See self in patient

PAGE 77

77 may af fect the way that they treat obese patients. The own weight problems included the following: I used to be a thinner person and I myself have been the object of quite a bit of ridicule, I was a lot bigger than this, and weight is a constant battle for everybody. I feel for th em. If the nurse has issues with her own weight and is disgusted by what she sees, it triggers feelings of negativity towards herself and her patient. low self esteem thoughts about their own bo dies and appearances and how that affects the way they esteem included the following: If my self that it can be done and everyone can do it. No one likes to look in the mirror for too long and certainly, out of that, an attitude can manif est. seeing themselves in their patient related e following:

PAGE 78

78 Theme 5: Delay in Treatment The theme del ay in treatment was supported by 96 comments made by 12 (75 %) respondents. Participants were asked if they felt that the quality of care they provided was the same for obese patients. Del ay in treatment included these 4 concepts: 1) Staffing issues/assista nce 2) Equipment availability 3) Avoidance/procrastination 4) Difficult to perform patient care tasks and assessments Staffing issues/assistance refers to issues that occurred because there was not enough staff scheduled or available to help perform a patient care task for an obese patient resulting in a delay of treatment. The following are comments related to this concept: nothing concrete. Do I think there is going to have to be one in the future? Yes. Quality of care can be different because of the obese person and the amount of care that it requires to help them. Are you gonna turn them work. Sometimes the oth We may need more help than what we have as far as nursing care. We We normally only have 2 of us. us. Equipment availability c an be an issue in rural hospitals because they may not have the room or money to fully purchase high priced items like bariatric beds and specialty mattresses. Nurses voiced that waiting for equipment may be quick, but often

PAGE 79

79 it requires waiting for items to be delivered from an external company. The following ar e comments made referring to equipment availability: We had a 650 pounder here that, um, it took us a, a couple of weeks, but we finally got them on a bariatric bed. We did everything from a care standpoint that we could with 2 staff. We order specialty m attresses from purchasing. In the Intensive Care Unit they already have their specialty mattresses purchased. Then in the Med/Surg area, which is the majority of the patients, they have to actually order something and they probably have to wait between12 and 24 hours. Participants expressed that treatment was delayed to obese patients because of would take to assist them would be significant and could take away from the ir other patients. Another common explanation was a fear of injury. The following are comments that were made regarding procrastination/avoidance: Yeah, they may have to wait a little bit because, you hate to say it, but you may procrastinate a little bi Yes we do have, um, a big issue with obesity, as far as nurses caring for them. If they are too large we jus need it. leave the patient waiting and/or not do it. Nurses often commented that care was delayed because of it was difficult to perform p atient care tasks or assessments on obese patients. Many questioned the quality of vital signs and diagnoses because of alternative approache s that had to be taken. The following are comments related to delays in patient care tasks and assessments: I thi nk we try to provide the same quality of care, but I think obesity can be an issue. You might have a delay in care when you have to put a foley in

PAGE 80

80 on an obese patient and you need 4 people, you have to have all 4 people available to participate so you hav o easy things become more difficult. quality of care because the point is to have everything exposed so you can needed. If an obese person is vomiting and they need some medication to make them stop vomiting, some Zofran IV, it takes longer to get an IV on them. well? Do I need to clean under that fold before I can put a monitor lead on it so it can pick it up accurately? Discussion The research findings illuminate factors that cause or contribute to weight bias in nurses and the effect they have on quality of care. The four factor rela ted themes that feelings, and beliefs about themselves, their patients, and the work environment cause or contribute to weight bias in a rural inpatient hospital setting. The corresponding sub themes provide an in depth analysis of the unique experiences of participants and provide valuable information about where interventions may be appropriate. Patient care tasks were commonly discussed in participant interviews. Perf orming providing patient education were common topics. Recurring emotions emerged when discussing particular tasks. Dread, frustration, resentment, avoidance, anger, annoy ance, additional work, fear of injury (self and patient), anxiety, and pity were all used to describe feelings that the participants experienced when caring for an obese

PAGE 81

81 patient. The feelings discussed are corroborated in past research among nurses from s uburban and urban hospitals ( Bagley et al., 1989 ; Brown, 2006 ; Peternelj Taylor, 1989 ; Puhl & Brownell, 2001 ) moving themselves. Nurses questioned their own physical abilit y to perform ambulation tasks that would require them to use physical force to assist an obese patient. They expressed fear, anxiety, and resentment that they or their patient would be injured which is a common concern in nursing ( Brown, 2006 ; Hoskins, 2006 ) Feelings of dread, frustration, anger, avoidance were stated during interviews size and the extra amount of work they generated ( Bagley et al., 1989 ; Crandall et al., 2001 ; Peternelj Taylor, 1989 ; Puhl & Brownell, 2001 ) Nurses mentioned that they felt the quality of care given to their other patients suffered when they also had to care for an obese patient because they would get held up in their room assist ing them. The catheter. Educating obese patients about the dangers of being overw eight were seldom brought up by clinicians. Many felt it was too touchy a subject to discuss and that they ( Bertakis & Azari, 2005 ; Hebl & Xu, 2001 ) Typically, healthy eating and exercise were only discussed when patients were diabetic or if the physician, patient or family wa nted to discuss it.

PAGE 82

82 Nurses described obese patients using negative attributes like lazy, demanding, stupid, depressed, unkempt, dirty which is similar to findings made by Brown (2006 ) a nd Puhl and Brownell (2001 ) Nurses reported having these negative perceptions towards after assessing the patient did they remo ve any preconceived biases that did not fit the patient. This phenomenon can be explained by the Attribution Value Model of Prejudice ( Crandall et al., 2001 ; Heider, 1958 ; Weiner et al., 1988 ) Prejudice towards a group is generalized to all of its members until an occasion occurs where the stereotype does no t fit. Simply, all obese patients do not have to fit the stereotype of helpless, lazy, and dirty; they can be individually excused from prejudice if the attributes do not fit, but the general prejudice will still exist toward the group ( Crandall et al., 20 01 ) Patient hygiene elicited strong feelings of dread and frustration from nurses. They admitted that foul odors immediately caused negative feelings and a desire to avoid the patient. They also felt frustrated that patients could not tell that they smelled or did not seem to care that they did. Medically, nurses explained that obese patients that were unclean typically had skin infections within their skin folds that, if not cared for, could create serious health problems. They did concede that it was probably more difficult for obese patients to clean themselves, but they still held them responsible. Family involvement was described as a nuisance, frustration, and barrier to providing adequate care to an obese patient. Nurses felt that family mem bers typically enable the patient making them demanding and needy towards the nurse. They also felt that family members undermined their authority and the health of the patient by bringing in fast food for the patient to eat. While many nurses addressed this issue for

PAGE 83

83 the patient would continue eating poorly once discharged so there was no point bringing it up. Equipment needs was a major issue for nurses ( Frank, 1993 ) They reported needing more bariatric supplies to provide competent and efficient care to the patient. The participating rural hospitals did have a limited supply of bariatric supplies on hand, but had the ability to order special supplies when needed. Wait times for supplies were reported to take anywhere from five minutes to two weeks to obtain. Nurses explained that they would have to make do with the supplies and equipment they had u ntil the ordered supplies arrived or the patient was discharged or transferred. They also explained that diagnostic and surgical equipment could not accommodate a morbidly obese patient. Standard radiological equipment cannot hold more than 350 pounds so obese patients needing certain x rays or scans would have to transferred to another facility or not receive the exam. Doctors would be forced to find alternative methods to come to a diagnosis. Nurses admit that they have withdrawn themselves from their patients when they have put themselves in their situation. They explained that the way in which they perceive themselves has an effect on how they view and treat obese patients. It was found that nurses who had previous struggles with weight felt sympath y and pity for obese patients. They were also more likely to view obesity as a disease process. Nurses who admitted to having low self esteem or body image issues tended to procrastinate or avoid interacting with obese patients and had more negative feel ings towards them. Crandall et al. (2001 ) explains that when an individual perceives an

PAGE 84

84 attribute as negative in another person they will have a prejudice towards them. If they, too, possess the same attribute they will also have negative feelings towards themselves which can manifest as depression. Quality of care was reported to be affected by and beliefs about themselves, their patients, and the work environment cause or contribute to weight bias. Nur ses reported that though they attempted to provide the same care, assistance, and treatment it was often delayed Delays were a result of increased complexity of performin g patient tasks on obese patients. Staffing issues played a major role in treatment delays. Nurses reported having to wait for other staff members, who may have to come from other units, to become available to assist with helping with an obese patient. Q uality of patient care has been directly linked to nurse staffing by Aiken, Clarke, and Sloane (2002 ) who found t hat has also been found to increase job dissatisfaction and burnout in nurses which may heighten negative a ttitudes towards patients. As mentioned in Theme 3, bar iatric equipment is limited in the participating hospitals. When equipment is not readily available patients and nurses are forced to make due with what resources are available. An obese patient with bed sores will have to be cared for in a standard hosp ital bed making turning and cleaning the patient difficult for nurses. Unfortunately, the rural hospitals used in this study are in financial distress and purchasing needed bariatric items is not a possibility. Further from reality are the hospitals purc hasing diagnostic equipment that can accommodate morbidly

PAGE 85

85 obese patients. As mentioned before, morbidly obese patients will often times not receive a radiological scan or surgery unless they are sent to another facility. In non life threatening cases, ph ysicians have to find alternative methods to diagnose and treat. In many on the themes, nurse procrastination and avoidance was noted. Patient care tasks that require a significant amount of time, are physically taxing, or odorous cause nurses to postpone or avoid the patient. Many explain that procrastination occurs they are not kept waiting; the irony is that the obese patient is then forced to wait. Other nurse s admit to avoiding obese patients because they believe they are needy and demanding and do not want to be stuck in their room. Nurses also avoid obese patients when they see themselves in the patient. They explain that it is scary to think that they cou Understanding the factors that cause or contribute to weight bias and how they affect quality of care are important. Obese patients typically have multisystem health problems and need are frequent healthcare consumers. They deserve to be given compassionate care and attention despite how time consuming or unpleasant the task may b e. In an effort to measure quality of nursing care the Amer ican Nurses Association (1994 ) launched the Safety and Quality Initiative to explore and identify the relationship between nursing care and patient outcomes. By 1997, the National Database of Nursing Quality Indicators was created to define quality indic ators and test data collection methodology and instruments ( National Database of Nursing Quality Indicators, 2012 ) The National Database of Nursing Quality Indicators (2012 ) identified

PAGE 86

86 the following three indicators: nursing sensitive indicators reflect the structure (supply of nursing staff, skill, education/certification) process (nursing assessment, interventi on, and RN job satisfaction), and outcomes ( improve if there is a greater quantity or quality of nursing care related to institutional care) of nursing care These quality indicators are enforced and regularly evaluated in the hospital system not only to ensure that patient safety and care are adequate, but they are also major components for Medicare reimbursement ( Centers for Medicare and Medicaid Services, 2012 ; Welton, 2008 ) Limitations Several limitations of the proposed study limit interpret ation of the possible findings, such as the study relies solely o n self at one point in time. Volunteer bias is of concern, but every effort was made to engage all nurses to participate Recall bias may also pose a problem in participants. The use of c onvenience sampling limit s the generalizability of the study findings to other populations including the area used in this study; however, it was chosen because the study site s did not hav e large numbers of employees. The results also lack generalizability because participants we re predominantly white women who worked as populations in different geographic locations, races, to LPNs and CNAs, and to male nurses. African Americans, Hispanics, and Latin os were not represented in this study but make up close to half of the population of the rural communities studied Future research should focus on recruitment strategies within these underrepresented populations in order to provide a true understanding of the weight bias phenomenon in the researched rural communities.

PAGE 87

87 Conclusion and Implications for Future Research Weight bias in nurses is an issue in rural inpatient hospital settings that has quality taken seriously and dealt with appropriately to prevent them from avoiding healthcare. Nurses must be able to overcome their initial biases towards obese patients in effort to prevent negative attitudes and actions from interfering with the quality of ca re they provide. Hospital administrators should focus on creating a weight based staffing matrix to ensure that patient care occurs in a timely and safe manner. Though the cost of increased staffing may be an issue, administrators need to remember that M edicare reimbursement is partially dependent on patient satisfaction scores. Hospitals need to also consider seeking grant funding to purchase commonly rented bariatric supplies, such as stretchers and mattresses, in order to provide comfort to obese pati ents in a timely manner Nurses may benefit from educational or training opportunities that provide evidence based knowledge of the impact that nursing care has on patient outcomes with an emphasis on nursing sensitive measures. Annual nursing competenci es can serve as the evaluative measure. Future qualitative research should be done on a larger random sample of rural RNs, LPNs, and CNAs in different areas of the United States to offer generalizability of findings.

PAGE 88

88 Table 3 1. Themes for factors that c ause or contribute to weight bias and effect on quality of care. Factors by Theme Comments Theme 1: Patient are Tasks Ambulation/moving Procedural Education Activities of Daily Living (ADL) 166 79 30 30 27 Theme 2: Characteristics of Obese Patients Patie nt personality Lazy/helpless Attitude Demanding Depressed Stupid Physical characteristics Personal hygiene Appearance/size Family involvement 146 79 30 29 7 6 4 3 46 42 4 21 Theme 3: Equipment Needs Limited number of bariatric supplies Larger equipment/environment to 136 80 56 Personal struggle with weight Low self esteem See self in patient 23 13 5 5 Theme 5: Delay in Treatment Equipment availability Staffing issues/assistance Difficult to perform patient care tasks and assessments Avoidance/procrastination 96 41 25 20 10

PAGE 89

89 CHAPTER 4 THE USE OF MIXED METHODS AND PROPOSED SOLUTIO NS TO WEI GHT BIAS IN NURSES WORKING IN RURAL HOSPITAL SETTI NG S USING THE SOCIAL EC OLOGICAL MODEL Background Obesity has become a major health problem. Obese patients typically suffer from multiple comorbities and, therefore, are frequent healthcare consumers ( Bertakis & Azari, 2005 ; Centers for Disease Control and Prevention, 2010 ; Han et al., 2009 ) Nurses r e present the largest, single group of healthcare professionals and have the greatest exposure to obese patients ( National Quality Forum, 2004 ) Having significant influence over the experiences and outcomes of their patients, nurses must be aware of the special needs and characteristics o f this special population Weight bias is a common social issue that obese individuals face in all aspects of their lives Numerous studies indicate that weight bias pervades i nterpersonal relationships, the workplace, schools, and the healthcare system leaving those who are obese with feelings of shame, guilt, and low self esteem ( Puhl & B rownell, 2003 ; Puhl, Moss Racusin, et al., 2008 ; Schwartz et al., 2003 ) What is most troubling about weight bias is it has become a cultural norm in established countries including the United States increasing 66% over the past decade ( Andreyeva et al., 2008 ) The overwhelming neg ativity towards obese individuals does not come without psychological and physical health ( Puhl & Heuer, 2009 2010 ) Evidence exists that weight bias may interfere with the successful implementation of obesity prevention strategies; as well as healthcare access and quality of care ( Puhl & Heuer, 2010 )

PAGE 90

90 Providing compassionate and quality care is essential in ensu ring o bese patients remain regular health care consumers. A lower percentage of obese women are seeking preventative cancer screenings despite having insurance and high access to healthcare; weight was found to be a major barrier ( Amy et al., 2006 ) Reluctance stemmed from past experiences with disrespectful treatment and negative attitudes by their provider, embarrassment over their weight, receiving unsought advice about losing weight, and not being provided with equipment to accommodate their size ( Amy et al., 2006 ) Other reported reasons for avoiding healthcare include d weight gain since the last visit, being weighed during an appointment, undressing in an exam room, or receiving weight loss advice ( Drury & Loui s, 2002 ) equipment, inappropriate nursing care models, and misunderstanding the etiology of obesity ( Camden et al., 2008 ) Healthcare professionals need to abort the mindset that obesity is controllable and, instead, recognize that it is a multifactorial disease in which genetics and the environ ment play a vital role ( Berryman et al., 2006 ; Bocquier et al., 2005 ; Brown, 2006 ; Campbell et al., 2000 ; Center for Disease Control and Prevention, 2011b ; Chambliss et al., 2004 ; Foster et al., 2003 ; Hare et al., 2000 ; H arvey & Hill, 2001 ; National Institutes of Health, 2012 ; Puhl & Brownell, 2001 2 006 ; Puhl & Heuer, 2009 ; Puhl, Moss Racusin, et al., 2008 ; Thuan & Avignon, 2005 ; Wear, Aultman, & Varley, 2006 ) Some studies suggest that educating nurses about the etiology of obesity would be effective in reducing bias, but this has been found to be incorrect. Schwartz et al. (2003 ) found that physicians and nurses who specialized in bariatric care still had weight bias, illustrating that even those with knowledge about the condition

PAGE 91

91 infer behavioral blame on patients ( Schwartz et al., 2003 ) Sadly, nursing curricula and competencies do not address problems or solutions for caring for an obese patient and there are scarce resources available in rural hospitals. Recent research into nurse weig ht bias and quality of care has supplied valuable information regarding its effects on patient attitudes and outcomes ( Larrabee & Bolden, 2001 ; Lee & Yom, 2007 ; Mold & Forbes, 2011 ; National Quality Forum, 2004 ) However, many studies of weight b ias and quality of care do not provide detailed information on rural nurses or sufficient information on what causes weight bias and how it affects quality of care. Rural communities tend to have a higher incidence of obesity than urban areas and face lim ited staffing and equipment ( Center for Disease Control and Prevention, 2011c ) ; thus, nurses working in rural areas are more likely to have regularly cared for obese patients and may be more likely to experience weight bias. Rural hospitals may benefit from bariatric sensitivity programming to educate their nursing staff to reduce or prevent weight bias. Moreover, previous nursing weight bias studies limited participation to nurse practitioners, regis tered nurses (RN) and nursing students excluding licensed practical nurses (LPN) and certified nursing assistants (CNA) who are an integral part of the healthcare team in rural hospitals. A study conducted by Garcia, Stopka, Chaney, Chaney, and Neff (2012 a; 2012b) attempted to fill these gaps by surveying nurses (RNs, LPNs, and CNAs) in three rural hospitals using the previously validated Nurses Attitudes Toward O besity and Obese Patients Scale ( NATOOPS ) ( Watson et al., 2008 ) and by conducting interviews with participants to determine the reasons for their bias and the effects it had on quality of care. A partially mixed met hods sequential equal status design was used in which

PAGE 92

92 quantitative and qualitative elements were conducted during two separate phases using the same convenience samples ( Leech & Onwuegbuzie, 2009 ) The findings were com parable to those from similar studies conducted in different regions in which nurses reported to having negative feelings and attitudes towards obese patients ( Brown, 2006 ; Brown et al., 2007 ; Poon & Tarrant, 2009 ; Puhl & Brownell, 2001 ; Schwartz et al., 2003 ; Teachman & Brownell, 2001 ; Watson et al., 2008 ) Common feelings expressed were frustration, stress, av oidance, victim blaming, anger, fear of injury, dread, and the belief that obesity was controllable. Common characteristics used to describe obese patients by normal weight and overweight and obese nurses were lazy, unkempt, depressed, difficult attitude, and stupid. Quality of care was found to be effected by the combination of the stated feelings and perceptions along with having limited bariatric equipment and staffing, which resulted in delays in treatment. There seems to be a lack of overall guidan ce from a practice standpoint to provide nurses with the necessary knowledge and support they need to reduce their bias. Commonly employed nursing care models, which provide the guidelines for nursing practices, do not even address bariatric sensitivity. The hospitals used in the previous studies conducted by Garcia et al. (2012a; 2012b) all employed the patient centered care (PCC) model to guide nursing practice. PCC is widely popular and is endorsed by majoring governing bodies in healthcare which emph asize the importance of quality care and patient satisfaction ( Centers for Medicare and Medicaid Services, 2005 ; Institute of Medicine, 2001b ) The Institute of Medicine (IOM) defines PCC practitioners, patients, an d their families (when appropriate) to ensure that decisions

PAGE 93

93 ( Institute of Medicine, 2001b p. 7 ) their health status ( Lauver, Ward, Hedrick, & et al., 2002 ; Wolf, Lehman, Quinlin, Zullo, & Hoffman 2008 ) Patients are not viewed as their disease and can negotiate their care in a respectful and dignified environment ( McCormack, 2004 ) PCC ultimately seeks to improve communication, promote patient involvement, and create a positive relationship between the nurse and patient ( Robinson, Callister, Berry, & Dearing, 2008 ) individual needs ( Wolf, Lehman, Quinlin, Zullo, et al., 2008 ) expectations may not be appropriate for their diagnosis and may affect their prognosis. During these instances, nurses have to negotiate and find a level of treatment that is appropriate and amendable for the patient ( Lyon, 1989 ) Patient care plans are unique for each patient and are created through the interactions of the nurse patient relationship ( Lauver et al., 2002 ) PCC has been listed as a national quality aim for healthcare system improvement by the IOM ( Institute of Medicine, 2001a ) It has also been recommended by the Centers of Medic are and Medicaid Services (CMS) ( 2005 ) as one of twelve actions for quality improvement. It is not a criterion for insurance reimbursement, but rather a model that impacts policies related to credentialing, licensure, medical education, and quality of care assessment ( Epstein et al., 2005 ; Robinson et al., 2008 )

PAGE 94

94 Though the use of PCC is w idely supported, there have been issues in its implementation. A report by the Agency of Health Research and Quality (AHRQ) ( 2005 ) found that patients reported never experiencing patient centered care despite the institutions use of it. Th e effectiveness of PCC was also pilot tested and retested in a bariatric setting with no significant improvement in length of stay, infection, falls, post operative complications, quality of care, satisfaction level, or perceptions of nursing care between the two studies ( Wolf, Lehman, Quinlin, Rosenzweig, et al., 2008 ) ; however, operative preparation. Figure 4 1 depicts the cyclic nature of a PCC model used by the participating hospitals. Th e figure implies that the patient is centrally located in the framework of the hospitals with nurses playing a key role. Currently, each hospital employs annual competencies for their staff to complete to ensure that nurses are up to date on current, evid ence based policies and procedures. Competency training modules cover patient confidentiality, fire safety, back safety, natural disasters, radiation safety, medication error prevention and patient safety, corporate compliance, elder care, child abuse, do mestic violence, workplace safety, blood borne pathogens, restraints education, transmission precautions of infectious diseases, AccuCheck meter education, blood bank banding review, blood transfusion and reaction review, organ donation education, catheter acquired UTI, patient education improvement, end of life training, growth and development in infants and children, injury prevention, diversity in healthcare, occurrence reporting, advanced directives, patient rights, and electrical safety. Bariatric sen sitivity training is entirely absent and has direct implications for nursing care and patient outcomes as previously stated. The RESPECT model is a simple, cost effective

PAGE 95

95 way to fill the bariatric patient care gap in PCC by providing empathetic care train ing strategies ( Bejciy Spring, 2008 ) The purpose s of this study were: 1) to summarize the quantitative and qualitative data pr esented by Garcia, Stopka, Chaney, Chaney, and Neff ( 2012a ; 2012b ) and 2) to propose potential points of inervention within the context of the ecological perspective The following research question (RQ) will be answered by this study: RQ1 : Do interview themes support RN, LP N, and CNA weight bias found in s ur vey responses? RESPECT Model The RESPECT model was developed in response to the National Association of Bariatric Nurses (NABN) position paper ( 2007 ) that called for the nursing profession to provide safe and equal care to obese patients. The model emphasizes the following seven concepts of cultural sensitivity: 1) rapport; 2 ) environment/equipment; 3) safety; 4) privacy; 5) encouragement; 6) caring/compassion; and, 7) tact ( Bejciy Spring, 2008 ) Thes within the obese patient population ( Bejciy Spring, 2008 ; National Association of Bariatric Nurses Position Statement, 2007 ) Figure 4 2 repr esents the vicious cycle of weight bias that obese patients endure and the resulting positive impacts from implementing the RESPECT model. Each concept will be discussed briefly. Rapport empathy, and ( Be jciy Spring, 2008, p. 50 ) Building rapport with patients is key in developing the

PAGE 96

96 nurse patient relationship that is vital to PCC and is the foundation of creating a culturally sensitive relationship and environment ( Bejciy Spring, 2008 ) Be jciy Spring (2008 ) recommends the following actions to build nurse bariatric patient rapport: Environment/Equipment The environment provided to obese patients has a significant effect on their comfort and safety. Bejciy Spring (2008 ) considers providing a bariatric friendly environment and equipment to be fundamental elements of sensitive care because they promote i ndependence, mobility, participation, and improve quality of care and life. The following are recommendations made by Bejciy Spring (2008 ) to promote mobilization and independence for obese patients: Safety As discussed in the qualitative study, movement and mobilization of obese patients elicited fear and dread in nurses. The fear not only existed for themselves, bu t also their patients. Identifying critical safety concerns of nurses and patients and addressing them properly can help promote the development of trust in the nurse patient relationship ( Bejciy Spring, 2008 ) Privacy Patient privacy and dignity are key quality of care indicators and are important to obese patients. Trust can be developed and maintained by ensuring patient privac y, confidentiality, and by preserving their dignity ( Bejciy Spring, 2008 ) Encouragement Motivation and attitude can have a profo und effect on the health outcomes of an obese patient, but can be challenging. Many obese patients healthcare journeys have been long and arduous which can lead to discouragement, disappointment, and

PAGE 97

97 frustration ( Bejciy Spring, 2008 ) Motivation from nurses may just give patients enough hope to actively participate in their treatment, further fostering the trust between nurse and patient. Caring/Compassion ( Bejciy Spring, 2008, p. 53 ) Caring requires a reciprocal relationship of connectedness and respect between the nurse and patient ( Carter et al., 2008 ) A major component of caring is compassion combined w ( Bejciy Spring, 2008, p. 53 ; von Dietz & Orb, 2000 ) The qualities of caring a nd compassion allow nurses to be present for their patients and help to establish sensitive, respectful care. Tact Obese patients are commonly the victims of jokes, crude comments, ridicule, stereotyping, and teasing ( Puhl & Brownell, 2003 ; Puhl, Moss Racusin, et al., 2008 ; Schwartz et al., 2003 ; Wear, Aultman, Varley, & Zarconi, 2006 ) Tact can be effectively used to establish trust, rapport, and a productive nurse patient partnership ( Bejciy Spring, 2008 ) Nurses must be able to speak and interact with patients without offending them keeping in mind the situational circumstances, feelings, viewpoints, values ( Bejciy Spring, 2008 ) Methods A partially mixed sequential equal status design was used to organize both components of the Garcia et al. (2012a; 2012b) nursing weight bias studies. The parent

PAGE 98

98 study had two phases that occur red in succession using both quantitative and qualitative phases that carried equal weight ( Leech & Onwuegbuzie, 2009 ) Sites and Sample A convenience sam ple was used for t he quantitative and qualitative phases which took place at a three rural hospital s in Southwest Florida. According to the American Hospital Association (2012 ) a hospital is considered rural if it mee ts at least one of the following criteria: h as 100 or fewer beds, 4000 or fewer admissions, or located outside a Metropolitan Statistical Area. All of the hospitals used in this study meet at least one of the criteria. Hospital #1 houses 48 inpatient be ds and 109 potential participants. The population of the surrounding municipality was 7,637, which consisted of 51% male and 49% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 53% whites, 25% African Americans, and 33% Hispanic or Latino. Hospital #2 has 50 inpatient beds and 63 potential participants. The population of the surrounding area was 2,223, which consisted of 51% male and 49% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 70% whites, 7% African Americans, and 46% Hispanic or Latino. Hospital #3 has 159 inpatient beds and 171 potential particip ants. The population of the surrounding area was 10,491, which consisted of 48% male and 52% female residents ( U.S. Census Bureau, 2010 ) The U.S. Census Bureau (2010 ) reported that the population consisted of 76% whites, 15% African American, and 18% Hispanic or Latino.

PAGE 99

99 Nursing demographics were not provided by the participating hospitals. Hospit als 1 and 2 have little to no specialty medical services and require that patients be transferred to nearby facilities (~20 miles) if they require care outside the scope of the hospital services. Hospital #3 is the largest of the three sites and can provi de specialty care, but is still considered rural. The quantitative study had a nurse response rate of 42.9% (N=113). Respondents were predominantly female (83.2%, n=94) and ranged in age from 20 to 79 years, with an average of 47 years (SD=12.4). Respo ( 72 .6%, n=84), Hispanic/Latino (8.9%, n=10), black (4.4%, n=5), Asian/Pacific Islander (3.5%, n=4), other (3.5%, n=4), and Native American (0.9%, n=1). Areas of nursing included medical/surgical care (23.9%, n=27), emergency care (21.2%, n=24), intensive care (17.7%, n=20), surgery (12.4%, n=14), obstetrics (8%, n=9), and IV therapy/other (2.7%, n=3). The majority of respondents held an associates (ASN) (43.4%, n=51) or bachelors (18.6%, n=21) degree in nursing (BSN) and the remaining had either a (MSN) (5.8%, n=6), a license in practical nursing (LPN) (8.8%, n=10), or a certification in nursing assistance (CNA) (3.5%, n=4). Over 86.8% (n=102) of the respondents reported caring for 1 or more obese patients on a daily basis and 68.1% (n=77) had never attended an educational program focusing on obesity. Nursing experience ranged from 5 years or less (20.4%, n=23) to more than 25 years (18.5%, n=21). However, most nurses reported having worked between 10 to 25 y ears (54.9%, n=62). In the qualitative study 16 nurses ag reed to participate in interviews Respondents were predominantly female (93.8%, n=15) and ranged in age from 23 to

PAGE 100

100 hite (93.8%, n=15) and Native American (6.3%, n=1). African American and Hispanic/Latino nurses were not represented in the sample. Areas of nursing included medical/surgical care (18.8%, n=3), emergency care (25%, n=4), intensive care (25%, n=4), surger y (12.5%, n=2), obstetrics (6.3%, n=1), and IV therapy/other (6.3%, n=1) with one missing value. The majority of respondents held an A SN (50%, n=8) and the remaining had either a BSN (12.5%, n=2), MSN (12.5%, n=2), a LPN (12.5%, n=2), or a CNA (12.5%, n=2 ). Nursing experience ranged from 5 years or less (12.5%, n=2) to more than 25 years (18.8%, n=3). However, most nurses reported having worked between 10 to 25 years (68.7%, n=11). Over 81.3% (n=13) of the respondents reported never attending an educati onal program focusing on obesity. According to body mass index (BMI) measurements from the previous study, 50% (n=8) of the participants were obese, 12.5% (n=2) were overweight, and 25% (n=4) were normal weight with two missing values. Procedures After In stitutional Review Board (IRB) and hospital approvals were obt ained from their respective Chief Nursing Officers (CNO) participants were sent emails from their respective nurse managers to participate in the main quantitative study during the Fall of 2011 The NATOOPS was adapted to a web based version and imbedded in each RNs, LPNs, and CNAs that completed the survey also provided their height and weight which was used to calculate BMI using the standard formula (weight (kg)/height (m 2 )). Participants who completed the NATOOPS were given an option at the end of the survey to provide the researcher with their email address via a free text box if they were

PAGE 101

101 interested in completing a 30 minute interview. The message included that in terviewees would receive a $10 Wal Mart gift card as an incentive for participating A phenomenological approach was used to determine the factors that cause or contribute structure d interviews. Interview probes were written to elicit conversation and participants were encouraged to speak freely. Interviews were scheduled within 48 hours of contact in formation receipt Interviews were conducted on a volunteer basis and continued u ntil saturation of themes occurred. Data Analysis Within the quantitative study, descriptive statistics determined frequencies, measures of central tendency (mean, median), and spread (standard deviation) of the surveyed population. Second, independent t tests assessed weight bias differences across BMI categories (underweight/normal weight, overweight/obese). Third, an analysis of variance ( ANOVA ) assessed differences in weight bias across professional status (RN/LPN/CN A) and demographic data. Finally Spearman correlations were performed to assess associations between weight bias and nurse BMI. SPSS ( 2009 ) was used in all of the af orementioned analyses. Qualitative analysis consisted of constant comparison analysis which was used to derive themes from the qualitative interviews and code intensiveness was done to illustrate quantitative saturation of common data ac ross the interview s. ATLAS.ti ( 2010 ) qualitative analysis software was used to organize transcripts and perform analyses.

PAGE 102

102 Results Quantitative and Qualitative Findings The quantitative study sample consisted of an underweight/normal weigh t group of 35 participants (31% ), and an overweight/ob ese group of 63 participants (55. 8%). Independent t test b etween BMI group comparisons indicated that underweight/normal weight nurses believed obesity is controllable (t=8.556, df=70.680, p< .003) Overweight/obese nurses displayed negative feelings rega rding characteristics of obese individuals (t=8.083, df=44.049, p=.286) ; however, this was not statistically significant. ANOVA results indicate d weight bias de creased with professional status and that CNAs had weight bias ( M =8.375 p=.138 ) ; however, CNA weight bias w as not statistically significance. Professional status explained 14% ( 2 = .143, p= .138) of variability in weight bias scores, but was insignificant. There was a weak negative correlation between BMI and weight bias ( = 0.121, p= .335) such that nurses with lower BMIs had greater weight bias. Using a phenomenological approach, the qualitative study sought to determine the factors that caused or contributed to weight bias and how weight bias affected quality of care. F ive themes emerged through constant comparison analysis and code intensiveness: 1) patient care tasks (166 comments) ; 2) characteristics of obese p atients (146 comments) ; 3) equipment needs (136) ; (23 comments) ; and 5) delay in treatment (96 comments) Themes will be organized in the Ecological Model and also identify intervention points. Ecological Model The nature of weight bias is a complicated, multifacted public health issue. Though knowledge is key in overcoming weigh t bias, behavior change requires multiple

PAGE 103

103 efforts. An ecological perspective emphasizes the interaction between and interdependence of factors within and across all levels of problem behaviors ( Glanz, Rimer Barbara, & Institute, 2005 ) By applying an ecological perspective we are able to io cultural environments and can formualte tailored intervention strategies at each level. Two key concepts of the ecological perspective identify intervention points: the interactive behavioral effects of multiple layers of influence and reciprocal causa tion where the individual both shapes and is shaped by the social environment ( Glanz, Lewis, & Rimer, 2002 ; Glanz et al., 2005 ) McLeory et al. identified the concept of multiple layers of influence which helps to systematically guide interventions ( K. R. McLeroy, D. Bibeau, A. Steckler, & K. Glanz, 1988 ) The five levels of influence of the Ecological Model are intrapersonal, interpersonal, organization, community and public policy (Figure 4 3). The upcoming sections identify intervention points within the ecological model using the RESPECT model and results presented in this study. Intrapersonal Intrapersonal factors are those items relating to the individual, such as attitudes, beliefs, knowledge, demographics, and psychological characteristics ( Glanz et al., 2002 ) Health education is very effective at changing behavior at the intrapersonal level, but requires more than increasing knowledge for the behavior change to last. Behavior change requires acquiring the necessary skills that h elp to facilitate and maintain changes. The results of this study provided a glimpse into the attitude, perceptions, and beliefs of nurses regarding obesity. Future interventions addressing intrapersonal factors of weight bias should provide information tailored to the individual. The

PAGE 104

104 RESPECT model suggests nurses focus on demonstrating care and compassion towards their patient during times of insecurity or judgment ( Bejciy Spring, 2008 ) For example, nurses who find themselves withdrawn or avoiding their patient because of their own body issues should focus on accepting themselves and their patient while recognizing that their patient also has feelings and insecurities, as well as unique qualities and capabilities ( Bejciy Spring, 2008 ) Conversely, nurse s who successfully lost weight were more likely to blame their patient for being obese. Using themselves as the ultimate example, nurses who lost weight felt like there was no excuse why anyone could not succeed in losing weight if enough effort was put f orth. These nurses should recognize that obesity is a disease process that is often times uncontrollable. Instead of blaming obese patients, these nurses should be encouraging and educating interested patients on the benefits of adopting healthy behavior s and self acceptance to gain independence in a tactful manner. Victim blaming was also common among respondents. Much of the blame was confusion when trying to un derstand how people become obese and why they do not lose weight. Ways in which nurses may be able to learn methods for conveying care, compassion, and tact could be during a mandatory workshop or annual bariatric competencies Workshops or competencies can increase knowledge by discussing the causes of obesity focusing on the role that genetics and the environment play; as well as, educating nurses how their attitudes negatively impact patient care.

PAGE 105

105 Understanding how to safely use bariatric assistive eq uipment may decrease the level of fear nurses experience when ambulating or moving obese patients. Nurses need to become familiar with commonly used handling aids (lifts, gait belts, stand assist aids, friction reducing aids) and be able to teach patients how to effectively assist in their movement. Annual assistive device competencies should be developed to assess body mechanics and assistive device operation. Interpersonal The interpersonal level of the model relates to the physical environment and soci al network of the individual ( Glanz et al., 2002 ) Weight bias behaviors are interpersonal by nature, where relationships, social networks, and culture aid in the development of will help shape their intention and participation in those behaviors. Since social norm plays a role in the acceptability of the weight bias, peer education programs should b e considered. The mandatory workshops could include storytelling by an obese patient who can speak about their experiences with weight bias and discuss its effects. Obese nurses could also serve as guest speakers, because they can talk about their feelin environment. Rapport building exercises can help nurses learn how to approach obese patients in a tactful manner and increase care and compassion by teaching nurses how size. Family involvement was a theme that emerged from interviews. p and enable the patient. Nurses explained they seldom addressed any family issues

PAGE 106

106 be cause it could cause them trouble and they did not feel like reprimanding them would have any long term effects. The RESPECT model suggests nurses focus on demonstrating care, compassion, and tact towards their patient and their family members while promo ting patient safety ( Bejciy Spring, 2008 ) Family members should be educated upon visitation that the patient is on a prescribed diet by their physician from bringing in any outside food or drink into the units. Institutional The institutional level is characterized by commercial organizations social institutions, associations, and clubs with rules, regulations, policies, and informal structures ( Glanz et al., 2002 ) Weight bias prevention interventions should occur first at the nursing school level where the curriculum can highlight obesity as a disease and the consequences of weight bias from an emotional and financial standpoint. At the clinical level, a bariatric training module can be incorporated into the current annual competency training schedule to assess knowledge retention from workshops. Moving be yond knowledge, we acknowledge resources in the institutional environment can help or hinder quality of patient care. The limited availability of bariatric equipment cause delays in treatment and great frustration among staff which was reported to decrea se quality of care Appropriately sized equipment, such as beds, wheelchairs, bedside commodes, toilets, chairs, exam tables, and lifting devices should be used consistently. Correct size instruments and supplies, like blood pressure cuffs, and IV and sy ringe needles, should also be available and easily accessible. Patient rooms should be clean and accessible for obese patients and bariatric equipment; therefore, doorways, hallways, patient and exam rooms, and showers and bathrooms

PAGE 107

107 should be able to safe ly accommodate the size and weight of obese patients. New equipment technology should be researched and evaluated for bariatric patient usage ( Bejciy Spring, 2008 ) Nurse staffing matrices should account for patient acuity. Currently, nurse staffing is only dependent on the number of patients in each unit and does not take into account acuity. The level of acuity is the complexit care required to provide safe and competent care. Therefore, a nursing unit with three patients may only be given a RN and CNA during a shift, but two of the patients are obese and need ambulation and moving assistance every two hours. Conversely, a nursing unit with eight patients may be given two RNs, a LPN, and a C NA even though their patients are fully independent. Staffing matrices that disregard patient acuity breed an environment of preventable accide ntal injury nurse burnout and can severely alter the quality of care that can be given Community The community is a broader level of the hospital environment as it also includes surrounding areas. The community is both physical as well as functional an d includes standards among groups and social network norms ( Glanz et al., 2002 ) All three of the communities involved in the study have weekly farmers markets for their residents, but they are located in the epicenter of each town. Providing satellite markets in other popul ated areas of the community may help to serve a greater number of residents. Also, providing transportation by county owned school buses could bus residents into the epicenter and provide access to those without transportation. Each hospital could also pr ovide the community with monthly health education courses at the hospital, churches, or in a community owned building. Monthly programs

PAGE 108

108 can focus on topics that are chosen by the community and can provide nurses with opportunities in building rapport with commun ity members. County wide health fairs within the schools, churches, and/or community activit i es (i.e. county fairs, rodeos, parades, etc.) may also provide opportunities to nurses to interact with the community and in turn, reduce victim blaming b y showing nurses that obesity extends beyond the individual and is a community problem that requires attention. Engaging in community based activities may provide the hospital with opportunities for funding through state or federal agencies. Public Policy Local, state, and federal policies and laws outline the public policy level in the ecological model ( Glanz et al., 2002 ) This level can provide greater influence and accessibility to resources or establish policy against weight bias. At the hospital level, policy can be ma de that requires mandatory workshops and annual competencies for bariatric sensitivity training. Incident reports can also be tailored to identify witnessed weight bias infractions by peers or patients in order to identify those who may need further inter vention. At the national level, nursing credentialing and certifying bodies can test bariatric care knowledge and sensitivity skills by including them in national exams. The inclusion of evidence based bariatric sensitivity would lead nursing schools to a dopt such training into their curricula. A major step that must be taken for either of these two suggestions to happen is the healthcare community has to view obesity as a clinical diagnosis. Additionally, mandating that nursing student clinical rotation s include bariatric facilities will allow early exposure to sensitivity practices.

PAGE 109

109 Discussion The quantitative and qualitative methods used in this study indicate that nurses working in a rural hospital setting have weight bias again st obese patients. Th e survey significantly demonstrated that normal weight nurses believed obesity was controllable (Factor 3) which was also expressed by interview participants. Nurses commonly argued that obese patients could lose weight is they would eat properly and exer cise. Similarly, nurses who identified obesity as a multifactorial disease still expressed that they did not understand why obese patients did not take control of their lifestyle s These nurses tended to be RNs whom were taught in school the etiology of blaming patients for their behaviors. According to the survey, nurses with lower BMIs were more likely to be weight biased than nurses with higher BMIs. Interestingly, more than half of the participants in both studies were either overweight or obese which was similar to the original NATOOPS study ; however, weight bias was still prevalent. The current quantitative study did not have many under weight nurses participate which may indicate that the surveyed areas were heavier. Testing more under weight and normal weight nurses may help to clarify this statistical claim. Both data sets indicate d nurses have negative attitudes related to characteristics of obese patients (F actor 2) Characteristics identified in the interviews that supported survey measures included obese patients being angry and depressed. Interestingly, nurses from both BMI categories did not identify obese patients with the stereotypical characteristics found in Factor 4 of the survey, but the interviewed nurses did. Interviewed nurses common ly perceived obese patients as being lazy, helpless, and

PAGE 110

110 unkempt. In fact, when patients were identified as lazy or helpless the nurses were more likely to experie nce feelings of dread, anger, frus tration, resentment, avoidance, and victim blame Patient hygiene also elicited strong feelings of avoidance, dread, disgust, frustration, and repulsion. The feelings expressed about obese patient characteristics in inte rviews aligned with the nurse responses to obese patients tested in the NATOOPS and in the literature This validates that these feelings are also prevalent in rural populations. Survey results indicate that nurses did not have negative attitudes about the supportive roles they have in caring for obese patients (monitoring food intake, weight management programs, and emotional support) described in Factor 5 but this was not supported by interview findings. Family member involvement tended to interfere with monitoring food intake and emotional support Family members commonly enabled the patient by doing everything for the patient, repeatedly ringing the call light for the patient, and bringing in fast food. Many nurses e xpressed they did not bother ed ucating the patient and family members on the importance of independence and healthy eating because they would not have the patient long enough to change their behavior. The nurses who did bring up these issues were often angered when the patient and fami ly because they did not want to offend them. They were only comfortable moving forward with healthy lifestyle education if the patient or physician wanted to discuss it. Int erview findings also indicate that nurses felt obese patients were depressed and had low self esteem. Some nurses explained that if they felt a patient was sad they would try to be kind and supportive towards them without directly addressing what was both ering them.

PAGE 111

111 Conversely, other nurses chose to avoid engaging themselves with the patient so they did not have to deal with their problem. Though significance was not found a mong this factor in the quantitative study, it was brought up regularly among interviewed nurses. Feelings of irritation, impatience, frustration, stress, and discomfort were often associated with bariatric equipment needs. Nurses explained that not havi ng the appropriately sized equipment made caring for obese patients difficult, more time consuming, and stressful. They also noted that poor staffing created additional problems because if assistive equipment was not available they needed extra hands to a ssist them. Nurses explained that since dealing with a shortage of bariatric supplies was so common they associated caring for obese patients are being extremely difficult. Limitations Using multiple methods to explain one phenomena can lead to more err or ( Fielding & Fielding, 1986 ) Much thought and research went into choosing the methods used for each study. The selected methods were supported in the literature and with any research may be difficult to replicate Replication of the methods would allow the researcher to determine the accuracy of their research. The quantitative and qualitative stu dies rely solely on self individual experiences at one point in time. T he cross sectional study design that was used prevents conclusions about the causal relationships among the variables and does not follow participants longitudinally t o view personally normative behaviors. The use of c onvenience sampling limits t findings to other populations including the area used in this study; however, it was chosen

PAGE 112

112 because the study site s did not hav e large number s of employees. Volunteer bias is of concern, but every effort was made to engage all nurses to participate Recall bias is also of concern. The results also lack generalizability because participants were predominantly white women who worked as RNs wit findings cannot be applied to nursing populations in different geographic locations, races, to LPNs and CNAs, and to male nurses. African Americans, Hispanics, and Latinos were not represented in this study, but make up close to half of the population of the rural communities studied. Future research should focus on recruitment strategies within these underrepresented populations in order to provide a true understanding of the weight bias phenomenon in the researched ru ral comm unities. Cultural norms of obesity are also a limitation. Perceptions of obesity are cultural (Crandall et al., 2001) and rural populations tend to have higher rates of obesity. The results indicate that weight bias existed among nurses of all si zes, but that smaller nurses may be more likely to display bias. A larger sample is needed to make these claims The results may not be transferred to hospitals without a similar environment and culture The sampled hospitals have scarce resources and st affing and are situated in areas of low socio economic means with high rates of obesity. In addition the data collection was conducted during a specific amount of time and thus does not follow respondents longitudinally to view personally normative behavi ors. Conclusion Method triangulation was an effective way of reinforcing weight bias findings. Qualitative analyses helped to support and provide a deeper understanding of quantitative significance. The findings also further validate nursing weight bia s research currently in the literature, but among an underserved population. Gaining a broader

PAGE 113

113 understanding of weight bias among rural nurses will help researchers to target point of change and develop useful tailored interventions. The ecological model can be difficult to operationalize and apply to behavior changes; however, the current study aids to specifically define the interacting behaviors of weight bias and intervention strategies appropriate at each level. Further research should focus on conti nued assessment of weight bias in nurses working in different populations. Additional efforts should be made to include LPNs and CNAs in research in order to better inform educational strategies during their training. Qualitative measures should be used to further understand the causes of weight bias among nurses. Multiple method approaches should also be considered to gain a broader understanding and deeper appreciation of weight bias. The researcher also suggests testing the proposed interventions for feasibility and cost effectiveness. Though caution must be applied in generalizing the results, the proposed study would provide a comprehensive description of weight bias in nurses working in a rural population and aid in addressing the gap o f the knowle dge base.

PAGE 114

114 Figure 4 1. Patient Centered Care (PCC) Model Research Education Competence

PAGE 115

115 Figure 4 2 Breaking the Vicious Cycle of Obesity with RESPECT a dapted from Bejciy Spring, S.M. 2008 R E S P E C T: a model fo r the sensitive treatment of the bariatric patient. Bariatric Nursing and Surgical Patient Care 3, page 54, Figure 2 Obese Condition Health Problems/ Comorbities Need for Health Care/ Interventions Exposure to RESPECT Positive Feelings/ Emotional Responses Accessing of Healthcare Services Healthy Behaviors/ Self Care/Esteem

PAGE 116

116 Figure 4 3. The Ecological Model

PAGE 117

117 CHAPTER 5 CONCLUSIONS Background The prevalence of obesity in the United States continues to be a major health problem and has triggered an increase in w e ight bias and discrimination in t he United States and its healthcare system ( An dreyeva et al., 2008 ) Obese patients typically suffer from multiple comorbities and, therefore, are frequent healthcare consumers and victims of nursing weight bias ( Bertakis & Azari, 2005 ; Centers for Disease Control and Prevention, 2010 ; Han et al., 2009 ) Nurses r epresent t he largest, single group of healthcare professionals and have the greatest exposure and significant influence over the experiences and outcomes of their patients ( National Quality Forum, 2004 ) The negativity displayed by nurses towards obese individuals may have significant effects and may interfere with the successful implementation of obesity prevention strategies and treatment ( Puhl & Heuer, 2009 2010 ) Sadly, nursing curricula and competencies do not address problems or solutions f or caring for an obese patient. Nurses and nursing assistants working in r ural hospital s were of great interest in the current study because of the ir increased exposure to an obese population scarce resources, and a lack of representation in weight bias l iterature ( Center for Disease Control and Prevention, 2011c ) The aim of this study was to determine if weight bias existed among nurses working in a rural hospital setting towards obese patients and assess how weight bias affected quality of nursing care. This was accomplished through a partially mixed methods sequential equal status approach that was presented in Chapters 2, 3, and 4 of this manuscript. The specific purposes were to: 1) evaluate if

PAGE 118

118 weight bias exists among nurses in a rural inpatient hospital setting using the Nurses Attitudes Toward O besity and Obese Patients Scale ( NATOOPS ) ; 2) identify the factors that cause or contribute to weight bias among nurses and how care may differ for an obese patient through semi structured interviews; 3) determine if interview themes support weight bias survey measurements. The triangulated findings provided insightful evidence for intervention strategies using each level of influence of the Ecological Model of Health Behavior ( K. McLeroy et al., 1988 ) Results Body mass index ( BMI ) calculations from the quantitative study resulted in an underweight/normal weight gr oup of 35 participants (31% ), and an overweight/obese group of 63 participants (55. 8%), with 15 missing values. Between BMI group comparisons on the five factors yielded statistically significant differences between the means of the tw o weight categories for Factor 3 (t = 3.069, p < .003) ; wherein underweight/normal weight nurses described obesity as controllable. Overweight/obese nurses identified negative characteristics to obese patients as compared to underweight/normal weight nurses for Factor 2; how ever, this was not statistically significant. Analysis of variance ( ANOVA ) was conducted to assess differences in weight bias between registered nurses (RN) licensed practical nurses (LPN) and certified nursing assistants (CNA) The results indicate th at CNAs had weight bias (M=8.375, SD=.40, p=1.38) ; however, CNA weight bias was not statistically significant. A s pearman correlation was conducted to determine if a relationship existed between weight bias means and nurse BMI. The findings indicate a ne gative correlation between BMI and weight bias ( = 0.121, p = 0.335) such that nurses with lower BMIs had greater weight bias.

PAGE 119

119 T he qualitative study sought to determine the factors that caused or contributed to weight bias and how weight bias affected quality of care. F ive themes emerged through them atic and constant compar ison analyse s and code intensiveness: 1) patient care tasks (166 comments) ; 2) characteristics of obese p atients (146 comments); 3) equipment needs (136); (23 comments); and 5) delay in treatment (96 co mments) The ecological perspective was used to identify points of intervention in each level of influence to which the RESPECT model was employed to fill the gaps of the Patient Centered Care (PCC) model used by the hospitals. Intrapersonal attitudes, perceptions, and beliefs of nurses regarding obesity included believing obesity is controllable, low self esteem of the nurse, and victim blaming ( Glanz et al., 2002 ) The RESPECT model suggest ed nurses focus on demonstrating care and compassion towards their patient during times of insecurity or judgment ( Bejciy Spring, 2008 ) Interpersonal relationships and the physical environment included social norms such as the acceptability of the weight bias among peers ( Glanz et al., 2002 ) The RESPECT model recommended rapport building exercises that can help nurses learn how to approach obese patients in a tactful manner and increase care and compassion by teaching nurses how ( Bejciy Spring, 2008 ) Institutional levels of influence included commercial organization s, social institutions, associations, and clubs with rules, regulations, policies, and informal structures ( Glanz et al., 2002 ) Major institutional issues included no standardized bariatric educational modules, limited bariatric equipment, and inappropriate staffing

PAGE 120

120 matrices The RESPECT model suggested making mandatory annual bariatric sensitivity competencies, providing appropriately sized bariatric equipment and supplies accessible and using an acuity based staffing matrix that will provide a safer environment for the pa tient and nurse ( Bejciy Spring, 2008 ) Community policies and programs were non existent in terms of providing the rural commun ities with knowledge about obesity or access to healthy affordable foods. The RESPECT model recommended using community based interventions, like health fairs, to build rapport within the community using caring, compassionate, and tactful communication. Public policy involves all local, state, and federal policies and laws ( Glanz et al., 2002 ) No policy exists in national licensure or certification agencies that require nursing students or working nurses to engage in bariatric sensitivity training. Placing RESPECT model strategies into nursing school curricula will allow student nurses to be exposed to respectful practices early on in their career. Implications Public health promotion initiatives are successful when they move beyond knowledge of protective factors and inc orporate multiple strategies outside of personal behavior and knowledge. This is especially true among complex behaviors like weight bias. Having a broader understanding of the factors that cause or contribute to weight bias in a rural hospital setting e mphasize the need for engaging in a multi level intervention approach. An ecological perspective helps to highlight the interaction between and interdependence of factors within and across all levels of problem behaviors ( Glanz et al., 2005 ) By applying an ecological perspective we are able to and their interactions with the physical and socio cultura l

PAGE 121

121 environments. In the case of this study, the researcher was able to identify that rural hospitals tend to have limited bariatric resources and staff which had an effect on nurse biases and quality of care By understanding the multiple levels of influ ence, researchers are able to provide viable and realistic recommendations to elicit behavior changes. Future Research Further research should focus on continued assessment of weight bias in nurses working in different populations. Additional efforts should be made to include LPNs and CNAs in research in order to better inform educational strategies during their training. Qualitative measures should be us ed to further understand the causes of weight bias among nurses. Multiple method approaches should also be considered to gain a broader understanding and deeper appreciation of weight bias. African Americans, Hispanics, and Latinos were not well represented in this study, but make up close to half of the population of the rural communities studied. Future res earch should focus on recruitment strategies within these underrepresented populations in order to provide a true understanding of the weight bias phenomenon in the researched rural communities. The researcher also suggests testing the proposed interventio ns for feasibility and cost effectiveness. Though caution must be applied in generalizing the results, the proposed study would provide a comprehensive description of weight bias in nurses working in a rural population and aid in addressing the gap o f the knowledge base.

PAGE 122

122 APPENDIX A NURSES ATTITUDES TOW ARD OBESITY AND OBESE PATIENTS S CALE (NATOOPS) Instructions : Please read each statement carefully before responding. Mark a straight line across the given line at the point which indicates how you feel about obesity. Your line can occur any place on the given line. For example: I like to eat ice cream. Seldom____________________________________________________Often 1. Obese adults overeat. Seldom____________________________________________________Often 2. Obese adults exercise. Seldom____________________________________________________Often 3. Seldom____________________________________________________Often 4. Nurses feel uncomfortable when caring for obese adult patients. Seldom____________________________________________________Often 5. If given the choice, nurses would prefer not to care for obese adult patients. Seldom____________________________________________________Often 6. Obese adult patients would pr efer to be put on a weight management program while in hospital. Seldom____________________________________________________Often 7. Obesity is treatable. Disagree___________________________________________________Agree 8. Obese adult patients need more emotion al support than other patients. Seldom____________________________________________________Often 9. Nurses should monitor the food intake of obese adult patients more carefully than that of non obese patients. Disagree____________________________________ _______________Agree 10. Obese adult patients are more self conscious than normal weight patients. Seldom____________________________________________________Often

PAGE 123

123 11. Obesity can be prevented by self control. Disagree______________________________________ _____________Agree 12. Obese adults can lose weight if they change their eating habits. Disagree___________________________________________________Agree 13. Obesity is a matter of lifestyle. Seldom____________________________________________________Often 14. I feel the same about caring for an obese patient as a normal weight patient. Seldom_ __________________________________________________Often 15. Caring for an obese adult patient is more frustrating than caring for a normal weight patient. Seldom_________ ___________________________________________Often 16. I feel more irritated when I care for an obese adult patient than a normal weight patient. Seldom____________________________________________________Often 17. I feel more impatient when caring for an obese ad ult patient than a normal weight patient. Seldom____________________________________________________Often 18. I feel disgust when I am caring for an obese adult patient. Seldom____________________________________________________Often 19. I feel indifferent to th e obesity when I am assigned to an obese patient. Seldom____________________________________________________Often 20. It is difficult to feel empathy for an obese adult patient. Seldom____________________________________________________Often 21. not touch an obese adult patient. Disagree___________________________________________________Agree 22. Caring for an obese adult patient is more emotionally draining than caring for a normal weight patient. Seldom_____________________________________________ _______Often 23. Caring for an obese adult patient is more stressful than caring for a normal weight patient. Seldom____________________________________________________Often 24. Caring for an obese adult patient repulses me. Seldom_______________________________ _____________________Often

PAGE 124

124 25. Obese adults are self indulgent. Seldom____________________________________________________Often 26. Obese adults are unkempt. Seldom____________________________________________________Often 27. Obese adults are lazy. Seldom____ ________________________________________________Often 28. Obese adults are self confident. Seldom____________________________________________________Often 29. Obese adult patients are depressed. Seldom____________________________________________________Often 30. Ob ese adults feel socially accepted. Seldom____________________________________________________Often 31. Obese adults experience unresolved anger. Seldom____________________________________________________Often 32. Fatigue is a problem for obese adults. Seldom____ ________________________________________________Often 33. Obese adult patients are the subjects of ridicule. Seldom____________________________________________________Often 34. Obese adult patients feel guilty. Seldom_____________________________________________ _______Often 35. I would rather work with a normal weight person than an obese person. Disagree___________________________________________________Agree 36. Obese people have a lower opinion of themselves than normal weight people. Seldom_________________________ ___________________________Often

PAGE 125

1 25 NURSES ATTITUDES TOWARD O BESITY AND OBESE PATIENTS SCALE ( NATOOPS ) DEMOGRAPHIC DATA QUESTIONNAIRE 1. Gender ___Female ___Male 2. Age in years _________ 3. Race _____ White _____ Black/African American _____ Hispanic _____ Latino _____ Asian/Pacific Islander _____ Native American _____ Other Please specify ___________________________________ 4. Highest level of education (check one) ___ Diploma in Nursing ___ ___ s degree in Nursing ___ Doctorate degree in Nursing ___ Specialty certificate ___ Degrees other than in Nursing (please specify): ___________________________________________________________ 5. Please estimate your annual household income: ______________ ____________ 6. Area(s) of nursing in which you are currently employed (please specify): __________________________________________________________ 7. Shift you predominantly are scheduled to work: ____________________ 8. How many years have you be en employed as a nurse? ____________________________ 9. Have you attended any educational program that focused on obesity? ___ no ___ yes (explain the type and state the approximate hours) _____________________________ ____________________

PAGE 126

126 10. On a daily basis how many people do you care for whom you think are overweight or obese? ___ none ___ 1 or 2 ___ 3 or more 11 Please label each of the diagrammatic figures below according to your interpretation of normal weig ht (NW), overweight (OW), or obese (OB). a)______ b)______ c)______ d)______ f)______ 12 Height ______in Weight _____lbs

PAGE 127

127 APPENDIX B NURSES ATTITUDES TOW ARD O BESITY AND OBESE PATIENTS S CALE ( NATOOPS ) INFORMED CONSENT Protocol Title: A ssessing attitudes toward obesity in nurses and its effect on quality of care. Please read this consent document carefully before you decide to participate in this study. Purpose of the research study: To determine if attitudes exist towards obese pati ents among registered nurses (RN), licensed practical nurses (LPN), and certified nursing assistants (CNA) in a rural hospital setting and to identify the factors that effect quality of patient care in an effort to establish the need for an obesity related patient care competency. What you will be asked to do in the study: You will be asked to comple Overweight and Obese Patients Survey using a secure link and private IP address. The survey should take no longer than 20 mi nutes to complete. Risks and Benefits: Minimal risk is associated with participation. Potential benefits include providing the rationale for designing an obesity related patient care competency for nurses (RNs, LPNs) and clinical support staff (CNAs) t o improve nursing care and patient outcomes. The study will also give insight into the factors and barriers that contribute to weight bias providing the participants the opportunity to have their confidential and anonymous opinions and recommendations hea rd by the administration without risk of penalty or termination. Compensation: You will not be compensated for participating in this research. Confidentiality: Your identity will be kept confidential to the extent provided by law. Your information will be assigned a code number. The codes and corresponding survey responses will be and the data have been analyzed, the list will be destroyed. Your name or code will not be used in any report and your personal responses will not be disclosed to your supervisor or hospital administration. We will not record your name or email address or

PAGE 128

128 connect them with your responses unless you choose to participate in a volunta ry, one on one interview with the PI. The PI, Co PI, and Supervisor will not log IP addresses, track IP addresses, or attach IP addresses to information. Your name will not be used in any report, presentation, or publication. Voluntary participation: Yo ur participation in this study is completely voluntary. There is no penalty for not participating. Right to withdraw from the study: You have the right to withdraw from the study at anytime without consequence. Whom to contact if you have questions about the study: Janelle Garcia, Doctoral Candidate, Principal Investigator Department of Health Education and Behavior University of Florida garciajt@hhp.ufl.edu (352)392 0583 ext. 1283 Christine Stopka, PhD Department of Health Education and Behavio r University of Florida cbstopka@hhp.ufl.edu (352)392 0583 Whom to contact about your rights as a research participant in the study: IRB02 Office, P.O. Box 112250, University of Florida, Gainesville, FL 32611; (352)392 0433. Agreement: I have read th e procedure described above. I voluntarily agree to participate in the study and I have received a copy of this description. Please select the appropriate box:

PAGE 129

129 APPENDIX C SEMI STRUCTURED INTERVIEW INFORMED CONSENT I NFORMED C ONSENT F ORM to Participate in Research, and A UTHORIZATION to Collect, Use, and Disclose Protected Health Info rmation (PHI) I NTRODUCTION This is a research study of the attitudes of nurses toward obesity and its effects on quality of care. Could participating in this study offer any direct benefits to you? No, as described on page 131 Could participating cause you any discomforts or are there any risks to you? No, as described on page 3. Please read this form which describes the study in some detail. I will also describe this study to you and answer all of yo ur questions. Your participation is entirely voluntary. If you choose to participate you can change your mind at any time and withdraw from the study. You will not be penalized in any way or lose any benefits to which you would otherwise be entitled if you choose not to participate in this study or to withdraw. If you have questions about your rights as a research subject, please call the University of Florida Institutional Review Board (IRB) office at (352) 846 1494. If you decide to take part in this study, please sign this form on page 135 G ENERAL I NFORMATION ABOUT THI S S TUDY 1. Name of Participant ("Study Subject") ___________________________________________________________________

PAGE 130

130 2. What is the Title o f this research study? Assessing attitudes toward obesity in nurses and its effects on quality of care. 3. Who do you call if you have questions about this research study? Janelle Garcia, Principal Investigator. Telephone: (352)392 0583 ext. 1283. Email : garciajt@hhp.ufl.edu 4. Who is paying for this research study? There is no sponsor for this study. 5. Why is this research study being done? The purpose of this research study is to determine what attitudes exist towards obese patients among regi stered nurses (RN), licensed practical nurses (LPN), and certified nursing assistants (CNA) in a rural hospital setting and to identify the factors that effect quality of patient. You are being asked to be in this research study because of your unique exp eriences and perspectives as a nurse who has cared for an overweight or obese patient. W HAT C AN YOU E XPECT IF YOU P ARTICIPATE IN THIS S TUDY ? 6. What will your role be as a participant in this study? Nurses who choose to enroll in this study will par ticipate in a one on one interview where they will have the opportunity to share their thoughts about caring for overweight and obese patients and the factors that affect the quality of their care. Interviews will be audio taped and a note taker will be p resent during the interview. The audio taped information will be transcribed without your name. The tapes will be destroyed at the end of the study. If you have any questions now or at any time during the study, please contact Janelle Garcia, in quest ion 3 of this form. 7. How long will you be in this research study? The interview will last approximately 30 to 45 minutes.

PAGE 131

131 W HAT ARE THE R ISKS AND B ENEFITS OF THIS S TUDY AND W HAT ARE Y OUR O PTIONS ? 8. What are the possible discomforts and risks from taking part in this research study? You may feel uncomfortable talking about your experiences during the interview. If you feel uncomfortable at any time during the interview, we will stop the discussion. You may leave the room at any time. You do not have to answer anything that you do not wish to answer. Also, if you state something and would prefer to have it stricken from the transcription and the subsequent data analyses please let the interviewer know at any time before, during or after the inte rview and they will make a note to remove your comment. If you wish to discuss the information above or any discomforts you may experience, please ask questions now or call the PI or contact person listed on the front page of this form. 9a. What are the p otential benefits to you for taking part in this research study? There is no direct benefit to you for participating in this research study. 9b. How could others possibly benefit from this study? Information learned through this study may provide infor mation about the barriers nurses face when caring for an overweight or obese patient and provide the rationale for increased resources and empathy training. 10c. How could the researchers benefit from this study? In general, presenting research results hel ps the career of a scientist. Therefore, Janelle Garcia will complete the research requirements necessary for her doctoral degree and may benefit if the results of this study are presented at scientific meetings or in scientific journals. 11. What other c hoices do you have if you do not want to be in this study? The option to taking part in this study is doing nothing. If you do not want to take part in this study, tell the Principal Investigator and do not sign this Informed Consent Form.

PAGE 132

132 12a. Can you withdraw from this study? You are free to withdraw your consent and to stop participating in this study at any time. If you do withdraw your consent, you will not be penalized in any way and you will not lose any benefits to which you are entitled. If you decide to withdraw your consent to participate in this study for any reason, please contact Janelle Garcia at (352)392 0583. If you have any questions regarding your rights as a research subject, please call the Institutional Review Board (IRB) of fice at (352) 846 1494. 12b. If you withdraw, can information about you still be used and/or collected? If you withdraw, information about you will not be used or collected. 12c. Can the Principal Investigator withdraw you from this study? You may be wi thdrawn from the study without your consent for the following reasons: (1) You did not qualify to be in the study because you do not meet the study requirements. Ask the Principle Investigator if you would like more information about this. W HAT ARE THE F INANCIAL I SSUES IF Y OU P ARTICIPATE ? 13. If you choose to take part in this research study, will it cost you anything? It will not cost you anything to participate in this research study. 14. Will you be paid for taking part in this study? After completion of the intervi ew, you will be given a $10 Wal Mart gift card. 15. How will your information be collected, used and shared? If you agree to participate in this study, the Principal Investigator will collect information about your attitudes towards obese patients. In or der to do this, the Principal Investigator needs your authorization The following section describes what information will be collected, used and shared, how it will be collected, used, and shared, who will collect, use or share it, who will have access to it, how it will be secured, and what your rights are to revoke this authorization. The following information may be collected, used, and shared with others: The interview will be tape recorded and ongoing field notes will be taken associated with your responses. Only Janelle Garcia will listen to the tape recordings. You will

PAGE 133

133 be assigned a code name prior to the interview preventing your name from being used in the tapes and transcripts. This information will be stored in locked filing cabinets or o n computer servers with secure passwords, or encrypted electronic storage devices. 16. For what study related purposes will your information be collected, used, and shared with others? Your information may be collected, used, and shared with others to m ake sure you can participate in the research, through your participation in the research, and to evaluate the results of the research study. More specifically, your information may be collected, used, and shared with others for the following study related purpose(s): To gather information about the attitudes and barriers of nurses who care for overweight or obese patients. Once this information is collected, it becomes part of the research record for this study. 17. Who will be allowed to collect, use and share your information? Only certain people have the legal right to collect, use and share your research records, and they will protect the privacy and security of these records to the extent the law allows. These people include the: the study Princ ipal Investigator, Dr. Christine Stopka, and Dr. Beth Chaney associated with this project. the University of Florida Institutional Review Board (IRB; an IRB is a group of people who are responsible for looking after the rights and welfare of people taking part in research).

PAGE 134

134 18. Once collected or used, who may your information be shared with? Your information may be shared with: the study sponsor Institutional sponsor the University of Florida (who is not paying for this study) Otherwise, your research records will not be released without your permission unless required by law or a court order. 19. If you agree to take part in this research study, how long will your information be used and shared with others? Your information will be used b y Janelle Garcia, Dr. Christine Stopka, and Dr. Beth Chaney until the end of the research study, May 2012. You are not required to sign this consent and authorization or allow researchers to collect, use and share your information. Your refusal to sign wil l not affect your employment. However, you cannot participate in this research unless you allow the collection, use and sharing of your protected health information by signing this consent and authorization. You have the right to review and copy your info rmation. However, we can make this available only after the study is finished. You can revoke your authorization at any time before, during, or after your participation in this study. If you revoke it, no new information will be collected about you. How ever, information that was already collected may still be used and shared by Janelle Garcia, Dr. Christine Stopka, and Dr. Beth Chaney if the researchers have relied on it to complete the research. You can revoke your authorization by giving a written re quest with your signature on it to the Principal Investigator.

PAGE 135

135 S IGNATURES the purpose, the procedures, the possible benefits, and the risks of this r esearch study; collected, used, and shared with others: Signature of Person Obtaining Consent and Authorization Date s purpose, procedures, possible benefits, and risks; the alternatives to being in the study; and how your protected health information will be collected, used and shared with others. You have received a copy of this Form. You have been given the opportun ity to ask questions before you sign, and you have been told that you can ask questions at any time. You voluntarily agree to participate in this study. You hereby authorize the collection, use and sharing of your protected health information as descr ibed above. By signing this form, you are not waiving any of your legal rights. Signature of Person Consenting and Authorizing Date

PAGE 136

136 APPENDIX D SEMI STRUCTURED INTERVIEW DEMOGRAPHIC SHEET 1. Gender ___Female ___Male 2. Age in years ________ 3. Race _____ White _____ Black/African American _____ Hispanic _____ Latino _____ Asian/Pacific Islander _____ Native American _____ Other Please specify _____________________________ 4. Highest level of education (check one) ___ High school diploma/GED ___ CNA certification ___ LPN certification ___ A.S. in Nursing (RN certification) ___ ___ ___ Doctorate degree in Nursing ___ Specialty certificate ___ Degrees other than in Nur sing (please specify): _____________________________________ 8. Please estimate your annual household income (circle the choice that best fits): $5,999 or less $48,000 $59,999 $6,000 $11,999 $60,000 $89,999 $12,000 $23,999 $90,000 $119,999 $24,00 0 $35,999 $120,000 or more $36,000 $47,999 9. Full time Per diem Part time Seasonal 10. Area(s) of nursing in which you are currently employed (circle the choice that b est fits): Emergency Department Obstetrics/Labor & Delivery/Nursery Intensive Care Operating Room/Recovery Room Medical/Sur gical Other (please specify): ___________________

PAGE 137

137 11. Shift you predominantly are sched uled to work (circle the choice that best fits): 7a 7p 7a 3p 9a 5p 10a 10p 7p 7a 3p 11p 5p 1a Other (please specify): ________ 12. How many years have you been employed as a RN/LPN/CNA? (circle the choice that best fits): 1 5 years 16 20 years 6 10 years 21 25 years 11 15 years >25 years 13. Have you attended any educational program that focused on obesity? ___ no ___ yes (explain the type and state the appr oximate hours): _______________________________________________________ 14. On a daily basis how many people do you care for whom you think are overweight or obese? ___ none ___ 1 or 2 ___ 3 or more

PAGE 138

138 APPENDIX E SEMI STRUCTURED INTERVIEW SCRIPT Shared with Interview Participants Pr ior to Beginning the Interview Discussion receiving a copy of this note for your references. The purpose of this study is to determine what attitudes exist towards obese patients among registered nurses (RN), licensed practical nurses (LPN), and certified nursing assistants (CNA) in a rural hospi tal setting and to identify the factors that effect quality of patient. This project was reviewed by the University of Florida Institutional Revi ew Board 02 This is a voluntary s tudy and you may leave the interview at any time. Your responses are conf idential. The discussion will be audio recorded and the recording will be destroyed once it is transcribed. There will be no identifiers used when the recording is transcribed. Please contact the Princ ipal Investigator Janelle Garcia Doctoral student a t the College of Health and Human Performance, University of Florida, FLG building RM 71, PO Box 118210 Gainesville, Florida 32611 or by email at garciajt@hhp.ufl.edu or by phone (352) 392 0583 with any question s. One last thing, because we are taping our discussion I ask that you please try to avoid drumming your fingers on the table, or tapping your pen or pencil on the table. Also, try to avoid tapping your feet on the table legs or chairs. I want to avoid anything that may affect the quality of our tape recording. Thank you again for your participation and cooperation! Are you ready to begin? Questioning: To start I would like to give you an identifying number. The sole reason for this is to aid in the transcription process. Please write your number on the tent card provided so I can identify you by this number. OK great 1. Can you describe the process of admitting an overweight or obese patient to your unit? 2. Can you describe the feelings or thoughts that you or your peers experience when an overweight or obese patient is going to be admitted to your unit? Can you explain why you or your peers have these feeli ngs? Do any specific characteristics of the patient cause you or your peers to have these feelings?

PAGE 139

139 3. Can you describe the feelings or thoughts that you or your peers experience when caring for an overweight or obese patient? Can you explain why you or y our peers have these feelings? Do any specific characteristics of the patient cause you or your peers to have these feelings? Does any particular patient related task cause you or your peers to have these feelings? 4. What barriers do you face when carin g for an overweight or obese patient? 5. What other factors a ffect how you care for an overweight or obese patient? 6. Can you discuss how quality of care may differ between overweight/obese patients as opposed to normal or underweight patients? We are almo st at the end of our time. I am going to summarize what we have talked about today and you can tell us if I have interpreted your thoughts correctly. Closing Comments: e topic of caring for overweight and obese patients as we have described it today. Is there Is there anything you would like to have stricken from the record? You will not be penalized in an y way. Thank you so much for coming today. Your time is very much appreciated and your insights have been very helpful.

PAGE 140

140 LIST OF REFERENCES Agency for Healthcare Quality and Research. (2005). National Healthcare Quality Report (pp. 79 82). Aiken, L. H., Clarke, S. P., & Sloane, D. M. (2002). Hospital staffing, organization, and quality of care: cross national findings. International Journal for Quality in Health Care, 14 (1), 5 14. doi: 10.1093/intqhc/14.1.5 American Hospital Ass ociation. (2012). Section for Small or Rural Hospitals. 2012, from http://www.aha.org/about/membership/constituency/smallrural/index.shtml American Nurses Associatio n. (1994). Safety & Quality Initiative: American Nurses Association. American Nurses Association. (2001). ANA Code of Ethics for Nurses, 2011, from http://www.nursingworld.org/MainMenuCategories/EthicsStandards/CodeofEthicsf orNurses/Code of Ethics.aspx Amy, N. K., Aalborg, A., Lyons, P., & Keranen, L. (2006). Barriers to routine gynecological cancer screening for White and African Americ an obese women. International Journal of Obesity (London), 30 (1), 147 155. Anderson, D. A., & Wadden, T. A. (2004). Bariatric patients' views of their physicians: weight related attitudes and practices. Obesity Research, 12 (10), 1587 1595. Andreyeva, T., Puhl, R. M., & Brownell, K. D. (2008). Changes in weight discrimination among Americans: 1995 1996 through 2004 2006. Obesity (Silver Spring), 16 1129 1134. ATLAS.ti Scientific Software Development. (2010). ATLAS.ti: Qualitative data analysis (Version 6 ). Berlin, Germany. Bagley, C. R., Conklin, D. N., Isherwood, R. T., Pechiulis, D. R., & Waston, L. A. (1989). Attitudes of nurses toward obesity and obese patients. Perceptual and Motor Skills, 68 954. Baum, C. L., & Ford, W. T. (2004). The wage effect s of obesity: a longitudinal study. Health Economics, 13 885 899. Behan, D. F., & Cox, S. H. (2010). Obesity and its Relation to Mortality and Morbidity Costs: Society of Acturaries. Bejciy Spring, S. M. (2008, 2008/03//). R E S P E C T: a model for the sensitive treatment of the bariatric patient. Bariatric Nursing and Surgical Patient Care, 3, 47 56.

PAGE 141

141 Berryman, D., Dubale, G., Manchester, D., & Mittelstaedt, R. (2006). Dietetic students possess negative attitudes towards obesity similar to nondietetic st udents. Journal of the American Dietetics Association, 106 1678 1682. Bertakis, K. D., & Azari, R. (2005). Obesity and the use of health care services. Obesity Research, 13 (2), 372 379. Bocquier, A., Verger, P., Basdevant, A., Andreotti, G., Baretge, J ., Villani, P., & Paraponaris, A. (2005). Overweight and obesity: knowledge, attitudes, and practices of general practitioners in France. Obesity Research, 13 787 795. r eview. Journal of Advanced Nursing, 53 (2), 221 232. Brown, I., Stride, C., Psarou, A., Brewins, L., & Thompson, J. (2007). Management of obesity in primary care: nurses' practices, beliefs, and attitudes. Journal of Advanced Nursing, 59 329 341. Brown, I., Thompson, J., Tod, A., & Jones, G. (2006). Primary care support for tackling obesity: a qualitative study of the perceptions of obese patients. British Journal of General Practice, 56 (530), 666 672. Burhans, L. M., & Alligood, M. R. (2010). Quality nu rsing care in the words of nurses. Journal of Advanced Nursing, 66 (8), 1689 1697. Cahnman, W. J. (1968). The stigma of obesity. The Sociological Quarterly, 9 283 299. Camden, S. G., Brannan, S., & Davis, P. (2008). Best practices for sensitive care and the obese patient. Bariatric Nursing and Surgical Patient Care, 3 (3), 189 196. Campbell, K., & Crawford, D. (2000). Management of obesity: attitudes and pratices of Australian dieticians. International Journal of Obesity, 24 701 710. Campbell, K., Engel H., Timperio, A., Cooper, C., & Crawford, D. (2000). Obesity management: Australian general practitioners attitudes and practices Obesity Research, 8 (459 466), 459. Carter, L. C., Nelson, J. L., Sievers, B. A., Dukek, S. L., Pipe, T. B., & Holland, D. E. (2008). Exploring a culture of caring. Nurse Administration Quarterly, 32 (1), 57 63. Cawley, J. (2004). The impact of obesity on wages. Journal of Human Resources, 39 451 474. Center for Disease Control and Prevention. (2011a). Genomics and health: o besity and genomics.

PAGE 142

142 Center for Disease Control and Prevention. (2011b). Obesity: causes and consequences Retrieved 4/25/12, 2012, from http://www.cdc.gov/obesity/causes/index.html Center for D isease Control and Prevention. (2011c). U.S. obesity trends: Trends by state 1988 2009, 2011, from http://www.cdc.gov/obesity/data/trends.html#State Center for Disease Control and Preventio n. (2012a). Adult BMI Calculator: English Retrieved 5/19/12, 2012, from http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/english_bm i_calculator /bmi_calculator.html Center for Disease Control and Prevention. (2012b). Adult obesity Retrieved 4/25/12, 2012, from http://www.cdc.gov/obesity/data/adult.html Centers for Disease Co ntrol and Prevention. (2010). Defining overweight and obesity, 2011, from http://www.cdc.gov/obesity/defining.html Centers for Disease Control and Prevention. (2011). About BMI for Adults, 2011, fro m http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html Centers for Medicare and Medicaid Services. (2005). Quality improvement roadmap, executive summary, 5 /14/12, from http://medicaldevices.org/public/issues/documents/cmsmedicareroadmap.pdf Centers for Medicare and Medicaid Services. (2012). Hospital value based purchas ing overview Retrieved May 31, 2012, from https:// www.cms.gov/Medicare/Qua lity Initiatives Patient Assessment Instruments/hospital value based purchasing/index.html?redirect=/Hospital Value Based Purchasing/ Chambliss, H. O., Finley, C. E., & Blair, S. N. (2004). Attitudes towards obese individuals among exercise science studen ts. Medicine and Science in Sports and Exercise, 36 468 474. (2001). An Attribution value model of prejudice: Anti fat attitudes in six nations. Personality and So cial Psychology Bulletin, 27 (30), 30 37. Crandall, C. S., & Reser, A. H. (2005). Attributions and weight based prejudice. In K. D. Brownell, R. M. Puhl, M. B. Schwartz & L. Rudd (Eds.), Weight bias: Nature, consequences, and remedies (pp. 83 96). New York NY: Guilford Press. Crosnoe, R. (2007). Gender, obesity, and education Social Education, 80 241 260. Devellis, R. F. (2003). Scale development: Theory and applications Thousand Oaks, CA: Sage.

PAGE 143

143 Drury, C., & Louis, M. (2002). Exploring the association b etween body weight, stigma of obesity, and health care avoidance. Journal of the American Academy of Nurse Practitioners, 14 (12), 554 561. Epstein, R. M., Franks, P., Fiscella, K., Shields, K. G., Meldrum, S. C., Kravitz, R. L., & et al. (2005). Measuring patient centered care in patient physician consultation: theoretical and practical issues. Social Science and Medicine, 61 1516 1528. Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program fo r the social, behavioral, and biomedicla sciences,. Behavior Research Methods, 39 175 191. Feather, N. T. (1996). Reactions to penalities for an offense in relation to authoritarianism, values, perceived responsibility, perceived seriousness, and deservi ngness. Journal of Personality and Social Psychology, 71 571 587. Fielding, N., & Fielding, J. (1986). Linking data Beverly Hills, CA: Sage. Foster, G. D., Wadden, T. A., Makris, A. P., Davidson, D., Swain Sanderson, S., Allison, D. B., & Kessler, A. (2 003). Primary care physicians' attitudes about obesity and its treatment. Obesity Research, 11 1168 1177. Frank, A. (1993). Futility and avoidance: medical professionals in the treatment of obesity. Journal of the American Medical Association, 269 2132 2133. Gallagher, R. M. (2010). The Impact of Nursing Care on Quality (National Center for Nursing Quality, Trans.): American Nurses Association,. Garcia, J. T., Stopka, C. B., Chaney, E. H., Chaney, J. D., & Neff, D. F. (2012a). Assessing weight bias in n urses toward obese patients and its effect on quality of care Doctoral dissertation. Department of Health Education and Behavior. University of Florida. Garcia, J. T., Stopka, C. B., Chaney, E. H., Chaney, J. D., & Neff, D. F. (2012b). Qualitative analy sis of weight bias in nurses working in rural inpatient hospital settings Department of Health Education and Behavior. University of Florida. Glanz, K., Lewis, F. M., & Rimer, B. K. (2002). Health behavior and health education : theory, research, and pr actice San Francisco: Jossey Bass. Glanz, K., Rimer Barbara, K., & Institute, N. C. (2005). Theory at a glance : a guide for health promotion practice Bethesda, Md.?: U.S. Dept. of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute. Glaser, B. G., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research Chicago: Aldine.

PAGE 144

144 Gunther, M., & Alligood, M. R. (2002). A discipline specific determination of high quality nu rsing care. [Article]. Journal of Advanced Nursing, 38 (4), 353 359. doi: 10.1046/j.1365 2648.2002.02201.x Han, E., Truesdale, D. R., Cai, J., Juhaeri, J., & Stevens, J. (2009). Impact of overweight and obesity on hospitalization: Race and gender difference s. International Journal of Obesity, 33 249 256. Hare, S. W., Price, J. H., Flynn, M. G., & King, K. A. (2000). Attitudes and perceptions of fitness professionals regarding obesity. Journal of Community Health, 25 5 21. Harvey, E. L., & Hill, A. J. (20 01). Health professionals' views of overweight people and smokers. International Journal of Obesity, 25 1253 1261. Harvey, E. L., Summerbell, C. D., Kirk, S. F. L., & Hill, A. J. (2002). Dieticians' views of overweight and obese people and reported manag ement practices. Journal of Human Nutrition and Dietetics, 15 331 347. Hebl, M. R., & Xu, J. (2001). Weighing the care: physicians' reactions to the size of the patient. International Journal of Obesity Related Metabolic Disorders, 25 (8), 1246 1252. Hei der, F. (1958). The Psychology of Interpersonal Relations. Social Psychology 106 108. Hoskins, A. B. (2006). Occupational injuries, illnesses, and fatalities among nursing, psychiatric, and home health aides, 1995 2004. Retrieved from http://www.bls.gov/opub/cwc/sh20060628ar01p1.htm Institute of Medicine. (2001a). Crossing the quality chasm: a new health system for the 21st century Retrieved 5/14/12, from http://iom.edu/object.File/Master/27/184/Chasm 8pager.pdf Institute of Medicine. (2001b). Envisioning the national health care quality report Retrieved 5/14/12, from http://newton,app.edu/execsumm_pdf/10073.pdf Karnehead, N., Rasmussen, F., Hemmingsson, T., & Tynelius, P. (2006). Obesity and attained education: cohort study of more than 700,000 Swedish men. Obesity (Silver Spring), 14 1421 1428. Larrabe e, J. H., & Bolden, L. V. (2001). Defining patient perceived quality of nursing care. Journal of Nursing Care Quality 34 60. Lauver, D., Ward, S., Hedrick, S., & et al. (2002). Patient centered interventions. Research in Nursing and Health, 25 (4), 246 25 5.

PAGE 145

145 Lee, M. A., & Yom, Y. perceptions of the quality of nursing services, satisfaction and intent to revisit the hospital: A questionnaire survey. International Journal of Nursing Studies, 44 (4), 545 555. doi: 10.1016/j.ijnurstu.2006.03.006 Leech, N. L., & Onwuegbuzie, A. J. (2009). A typology of mixed methods research designs. Quality and Quantity, 43 265 275. Lerner, M. J. (1980). Belief in the trust world: a fundamental delusion New York: Plenum. Lynn, N. M., McMillen, B. J., & Sidani, S. (2007). Including the provider in the assesment of quality care: development adn testing of the nurses' assessment of quality scale acute care version. Journal of Nursing Care Quality, 22 (4), 328 336. Lyon, B. (1989). Negotiated care: nursing product is patient outcomes not the nursing process. Paper presented at the Health Potentials Unlimited, Elkhart, IN, Indiana University. McCormack, B. (2004). Researching nursing practice: does person centeredness matter? Nursing Philosophy, 4 (3), 179. McLeroy, K., Bibeau, D., Steckler, A., & Glanz, K. (1988). An Ecological Perspective on Health Promotion Programs. Health Education & Behavior, 15 (4), 351 377. doi: 10.1177/109019818801500401 McLeroy, K. R., Bibeau, D., Ste ckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly 15 351 377. Mold, F., & Forbes, A. (2011). Patients' and professionals' experiences and perspectives of obesity in health care settings: a s ynthesis of current research. Health Expectations 1 23. doi: 10.111/j.1369 7625.2011.00699.x National Association of Bariatric Nurses Position Statement. (2007). The NABN: our voice, our mission. Bariatric Nursing and Surgical Patient Care, 2 149 151. N ational Database of Nursing Quality Indicators. (2012). Frequently Asked Questions Retrieved 5/29/12, from https:// www.nursingquality.org/FAQPage.aspx#1 National Institutes of Health. (2012, 4/ 30/12). Aim for a healthy weight Retrieved 4/30/12, 2012, from http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm National Quality Forum. (2004). N ational voluntary consensus standards for nursing sensitive care: an initial performance measure set. Paper presented at the National Quality Forum, Washington D.C. Obesity. (2011) A.D.A.M. Medical Encyclopedia (Vol. 2012).

PAGE 146

146 Peternelj Taylor, C. A. (1989). perceptions: A proposed model of nurse withdrawal. Journal of Advanced Nursing, 14 744 754. Poon, M., & Tarrant, M. (2009). Obesity: attitudes of undergraduate student nurses and registered nurses. Journal of Clinical Nursing, 18 2355 2365. Puhl, R. M., Andreyeva, T., & Brownell, K. D. (2008). Perceptions of weight discrimination: prevalence and comparison to race and gender discrimination in America. International Journal of Obesity, 32 992 1000. Puhl, R. M., & Brownell, K. D. (2001). Bias, discrimination, and obesity. Obesity Research, 9 (12), 788 805. Puhl, R. M., & Brownell, K. D. (2003). Psychosocial origins of obesity stigma: toward changing a powerful and pervasive bias. Obesity Reviews, 4 (4), 213 227. Puhl, R. M., & Brownell, K. D. (2006). Confronting and coping with weight stigma: an investigation of overweight and obese adults. Obesity, 14 (10), 1802 1815. Puhl, R. M., & Heuer, C. A. (2009). The stigma of obesity: a review and update. Obesity, 17 (5), 941 964. doi: 10.1038/oby.2008.636 Puhl, R. M., & Heuer, C. A. (2010). Obesity stigma: important considerations for Public Health. American Journal of Public Health, 100 (6), 1019 1028. doi: 10.2105/AJPH.2009.159491 Puhl, R. M., Moss Racusin, C. A., Schwartz, M. B., & Brownell, K. D. (2008). Weight stigmatization and bias reduction: perspectives of overweight and obese adults. Health Education Research, 23 (2), 347 358. doi: 10.1093/her/cym052 Puhl, R. M., Wharton, C., & Heuer, C. A. (2009). Weight bia s among dietetics students: implications for treatment practices. Journal of the American Dietetics Association, 109 (3), 438 444. Qualtrics Labs Inc. (2011). Qualtrics (Version 22657). Provo, UT. Retrieved from https://new.qualtrics.com/ControlPanel/? Red fern, S., & Norman, I. (1999a). Quality of nursing care perceived by patients and their nurses: an application of the critical incident technique. Part 2. Journal of Clinical Nursing, 8 414 421. Redfern, S., & Norman, I. (1999b). Quality of nursing care perceived by patients and their nurses: an application of the critical incident technique. Part 1. Journal of Clinical Nursing, 8 407 413.

PAGE 147

147 Robinson, J. H., Callister, L. C., Berry, J. A., & Dearing, K. A. (2008). Patient centered care and adherence: def initions and applications to improve outcomes. Journal of the Academy of Nurse Practitioners, 20 600 607. Roehling, M. V., Roehling, P. V., & Pichler, S. (2007). The relationship between body weight and perceived weight related employment discrimination: the role of sex and race. Journal of Vocational Behavior, 71 300 318. Schwartz, M. B., Chambliss, H. O., Brownell, K. D., Blair, S. N., & Billington, C. (2003). Weight bias among health professionals specializing in obesity. Obesity Research, 11 (9), 103 3 1039. SPSS Inc. (2009). SPSS 18.0 for Windows. New York. Teachman, B. A., & Brownell, K. D. (2001). Implicit anti fat bias among health professionals: Is anyone immune? International Journal of Obesity, 25 1525 1531. Thuan, J. F., & Avignon, A. (2005 ). Obesity management: attitudes and practices of French general practitioners in a region of France. International Journal of Obesity, 29 (1100 1106), 1100. Triandis, H. C. (1994). Culture and social behavior New York: McGraw Hill. Trusty, J., Thompson, B., & Petrocelli, J. (2004). Practical guide for reporting effect size in quantitative research. Journal of Counseling & Development, 82 107 110. U.S. Census Bureau. (2010). 2010 Interactive population search. U.S. Department of Agriculture. (2011). Die tary Guidelines for Americans, 2010 (pp. 13): Department of Health and Human Services. von Dietz, E., & Orb, A. (2000). Compassionate care: a moral dimension of nursing. Nursing Inquiry, 7 166 174. Wardle, J., Volz, C., & Jarvis, M. J. (2002). Sex differ ences in the association of socioeconomic status with obesity. American Journal of Public Health, 92 1299 1304. Watson, L., Oberle, K., & Deutscher, D. (2008). Development and psychometric testing s (NATOOPS) Scale. Research in Nursing and Health, 31 586 593. Wear, D., Aultman, J., Varley, J., & Zarconi, J. (2006). Making fun of patients: medical students' perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine, 81 454 462.

PAGE 148

148 Wear, D., Aultman, J., & Varley, J. Z., J. (2006). Making fun of patients: medical students' perceptions and use of derogatory and cynical humor in clinical settings. Academic Medicine, 81 454 462. Weiner, B. (1993). On sin versus sickness : a theory of perceived responsibility and social motivation. American Psychologist, 48 957 965. Weiner, B., Perry, R. P., & Magnusson, J. (1988). An attributional analysis of reactions to stigma. Journal of Personality and Social Psychology, 55 738 748 Welton, J. M. (2008). Implications of Medicare reimbursement changes related to inpatient nursing care quality. Journal of Nursing Administration, 38 (7/8), 325 330. Wengraf, T. (2001). Qualitative research interviewing: biographic narrative and semi st ructured interviews Wigton, R., & McGaghie, W. (2001). The effect of obesity on medical students' approach to patients with abdominal pain. Journal of General Internal Medicine, 16 262 265. Williams, A. M. (1998). The delivery of quality nursing care: a grounded theory study of Journal of Advanced Nursing, 27 808 816. Wolf, D. M., Lehman, L., Quinlin, R., Rosenzweig, M., Friede, S., Zullo, T., & Hoffman, L. (2008). Can nurses impact patient outcomes using a patient centered c are model? Journal of Nursing Administration, 38 (12), 532 540. Wolf, D. M., Lehman, L., Quinlin, R., Zullo, T., & Hoffman, L. (2008). Effect of Patient Centered Care on patient satisfaction and quality of care. Journal of Nursing Care Quality, 23 (4), 316 321.

PAGE 149

149 BIOGRAPHICAL SKETCH Janelle Garcia was born in Parma, Ohio. The fourth out of five children, she grew up mostly in Arcadia, Florida. Janelle graduated from DeSoto County High Sc hool in 2002. She earned a B achelor of Science in biomedical s cien ce with a minor in biomedical p hysics from the University of South Florida (USF) in 2005. After graduating Janelle worked as a Study Coordinator/Research Associate at H. L ee Moffitt Cancer Center and Research Institute in the Department of Health Outcomes and Behavior under Dr. Paul Jacobs en until she relocated for her graduate studies. Janelle received a Master of Science in applied physiology and k inesiology with a concen tration in human p erformance from the University of Florida ( UF) in 2008. During the strength and conditioning department under Coach Mickey Marotti. She also succe ssfully obtained her Certified Strength and Conditioning Specialist certification through the National Strength and Conditioning Association. Upon graduating with her m aster s degree Janelle entered a doctoral program at UF in the Department of Health Edu cation and Behavior As a doctoral student, she worked as a teaching and research assistant. Janelle received her Ph.D. in August 2012. Her research interests include obesity prevention, weight bias in the health professions, and physical fitness and we llness. Janelle plans to work in worksite health promotion and conduct obesity related research after graduating.