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NP student encounters with obesity bias in clinical practice

Hauff, Caitlyn, PhD; Fruh, Sharon M., PhD, RN, FNP; Graves, Rebecca J., PhD, NP-C; Sims, Brook M., MS; Williams, Susan G., PhD, RN; Minchew, Leigh A., DNP, WHNP-BC, PMHNP-BC; Hall, Heather R., PhD, NNP, RNC; Platt, Terrie H., DNP, RN, WHNP-BC, NCMP; Barclay, Mi'Asia

doi: 10.1097/01.NPR.0000558157.76596.c7

Abstract: This study explores NP students' encounters with obesity stigma and bias in their clinical environment as well as recommendations to decrease obesity stigma and bias. Results indicate a need for continued education on the topic of weight management within NP curricula.

This study explores NP students' encounters with obesity stigma and bias in their clinical environment as well as recommendations to decrease obesity stigma and bias. Results indicate a need for continued education on the topic of weight management within NP curricula.

Caitlyn Hauff is an assistant professor at the University of South Alabama, College of Education and Professional Studies, Mobile, Ala.

Sharon M. Fruh is a professor and associate dean for research, evaluation, and development at the University of South Alabama, College of Nursing, Mobile, Ala.

Rebecca J. Graves is an assistant professor and director of special projects and evaluation at the University of South Alabama, College of Nursing, Mobile, Ala.

Brook M. Sims is a doctoral candidate in the clinical and counseling psychology program at the University of South Alabama, Mobile, Ala.

Susan G. Williams is an assistant professor at the University of South Alabama, College of Nursing, Mobile, Ala.

Leigh A. Minchew is an associate professor and Chair of the Maternal Child Nursing Department at the University of South Alabama, College of Nursing, and an NP at the USA Health Mitchell Cancer Institute, Mobile, Ala.

Heather R. Hall is Dean of the College of Nursing and a professor at the University of South Alabama, Mobile, Ala.

Terrie H. Platt is an assistant professor at the University of South Alabama, College of Nursing, Mobile, Ala.

Mi'Asia Barclay is an undergraduate student at the University of South Alabama, Mobile, Ala.

Funding source: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR001417. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

The authors have disclosed no other financial relationships related to this article.



Data from the 2015-2016 National Health and Nutrition Examination Survey suggest that 31.8% of adults in the US have a body mass index (BMI) in the overweight category (25 to 29.9), 39.8% have a BMI in the obese category (30 to 39.9), and 7.6% have a BMI in the severe obesity category (40 or higher).1,2 Although the conditions of overweight and obesity affect all genders, ages, and racial and ethnic groups, women of lower socioeconomic status are 50% more likely to have obesity when compared with women of higher socioeconomic status.3-5 Factors associated with overweight and obesity are multifaceted and include metabolic, genetic, behavioral, environmental, cultural, and socioeconomic influences, yet family practice providers often hold negative attitudes and beliefs toward individuals with obesity.6-10

Obesity bias is a negative, often discriminatory belief or behavior based on the weight of an individual.11 This occurs in many medical settings and can impact patients' willingness to seek healthcare.10 Providers may stigmatize patients with obesity, blaming them for their inability to engage in health-promoting behaviors.9,12 For instance, implicit bias, an automatic, uncontrolled reaction or bias, was found among exercise professionals and healthcare providers with antifat attitudes who stereotyped individuals with overweight as being lazy, unintelligent, and worthless.13,14

Nurses, the frontline providers of healthcare, are not exempt from holding biases against patients with obesity.9,15 One investigation uncovered that some nurses believed patients with obesity lacked self-control, rarely expressed their true feelings, and were less successful.16 Furthermore, those nurses viewed working with patients with obesity to be physically exhausting and stressful, and they preferred to not care for these patients.16 Negative attitudes often perpetuate healthcare disparities between patients with a BMI in the normal category versus those with a BMI in the overweight or obese categories.17 Medical providers have reported altering their medical practices and choices of treatment when interacting with patients with a BMI in the overweight or obese categories, especially if the patient is female. One such example is a provider declining to perform a pelvic exam in patients with obesity.7,8,11 Such implicit bias, as well as explicit bias (a controlled, intentional reaction or bias), affects rapport-building and reduces empathy, although patients with obesity may benefit from more motivational skills enhancement and medical counseling.18

Obesity stigma prevents healthcare providers from effectively managing patient obesity.11,19,20 Implicit and explicit biases and environmental cues may engender in some patients a reluctance to seek treatment for overweight and obesity (fear of being shamed, embarrassed, or marginalized in the office), only to cause exacerbation of weight-related issues as well as other conditions unrelated to weight.11,19,21 For example, women with overweight or obesity have delayed clinical breast exams, gynecologic exams, and Pap smears, and received fewer mammography exams compared with women of normal weight.11,22 Additionally, anticipatory stress and acute reactions from stigmatizing environments may reduce the quality of the encounter with the provider, creating immediate health detriment and long-term consequences.11 For instance, stress during the encounter may impact the patient's ability to engage with the provider and process treatment information properly. Patients with obesity and those who feel embarrassed are less likely to seek weight-loss advice or initiate a weight-related conversation with the provider.21,23 In turn, patients may not recall advice or instructions given by the provider, reducing adherence to weight management plans, or may become defensive and entirely disregard feedback from the provider.24 Patients may also cancel or not show up for appointments if they feel that the provider is frustrated or disappointed with their inability to manage their weight.24,25

Obesity bias in the healthcare center also affects future healthcare professionals.26 Students completing clinical rotations and practicums are easily impressionable and may themselves develop obesity bias and stigmatization if not educated properly.27 To best address the obesity crisis in America, overweight and obesity management instruction and training should be embedded within healthcare education to better equip future medical and nursing professionals and frontline providers.27-29 As such, the guiding objective of this research study was to encourage NP students to reflect and report on their clinical experiences. An exploratory approach was used to examine potential obesity bias and stigma, specifically within women's health clinics.

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In this descriptive, qualitative study, the researchers explored obesity bias witnessed by women's health NP students in the clinic setting during their practicum experiences. The study was approved by the university's institutional review board before data collection commenced. A lesson on weight bias and an accompanying assignment were embedded in an online course in the women's health NP program. Participants were asked to create a brief initial post within the course's online discussion board to explain any circumstance of obesity bias they observed in training and any problems identified with these findings. Participants were then asked to reflect on another student's initial post. Students in the course were located across the US because this was an online-based NP education program. The course was provided through a university on the US Gulf Coast. The students received course credit for both their initial post and response to a classmate's post.

Participants. Participants were women's health NP students, most of whom were also full-time RNs at acute and/or ambulatory care obstetrics/gynecology facilities across the nation. A total of 44 female NP students (mean age = 34; SD = 7.9) participated in this online classroom forum. The racial/ethnic composition of the sample was 53% White, 40% Black, 4% Hispanic/Latino, and 2% Asian. Self-reported BMI ranged from 18 to 43 (mean = 27.5; SD = 5.9).

Procedure. The NP students were assigned two recently published peer-reviewed research articles about obesity bias in healthcare settings.19,30 After reading the articles, the students were instructed to create an original initial post on the course's online discussion board addressing their encounters with overweight or obesity bias in their current women's health clinic environments, which varied substantially based on student location, demographics, and socioeconomic status. Posters were also asked to include details about what strategies the student would recommend implementing in the practice setting to decrease obesity stigma and bias.

Data analysis. When the online discussion board was closed, the submission responses were deidentified and compiled. Using a directed content analysis approach, two members of the research team coded the submitted student responses.31 Each coder was familiarized with the prompted questions and source material. Using an open-coding procedure, the researchers then coded the responses independently in order to gain a descriptive understanding of each participant's experience and recommendations. The two-person coding team met to discuss findings and reach a consensus on the themes that emerged. After consensus was met, two additional members of the research team reviewed the code groupings and provided feedback on the themes to enhance the trustworthiness and rigor of the data analysis process.32 These methods serve to triangulate the data and strengthen the credibility of the interpretations.33,34

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Within the two overarching categories, 1.) encounters with obesity bias, and 2.) clinical recommendations for practice settings, the researchers identified several specific themes. The first overarching category (encounters with obesity bias) contained three themes: issues in the built and social environment, awareness of obesity bias, and perceptions of individuals with larger bodies. The second overarching category (recommendations for practice settings) also contained three themes: improving training programs, creating size-inclusive office settings and obtaining size-inclusive equipment, and redefining perceptions of obesity.

1. Encounters with obesity bias. Issues in the built and social environments. Results revealed that a variety of bias-related issues occur not only in the built environment but socially among individuals in these clinical environments as well. Student responses identified three major issues that occurred in their practice settings that contributed to weight bias: inappropriate equipment, inadequate privacy, and unsuitable language use. Regarding inappropriate equipment, one student stated, “In the clinical setting [they do] not carry bigger gowns for patients, and nurses are often searching for larger BP cuffs because they are not kept in every room.” Another participant mentioned that her practicum clinic only uses paper gowns, which are thin, small, and lacking in coverage. The use of a paper gown could cause a larger patient to be uncomfortable if the gown does not properly cover the body.

Students also addressed the lack of privacy in the clinics, particularly regarding weighing patients. Many NP students reported that not only are scales in open areas, but many nurses say the patient's weight out loud, which may lead some to feel uncomfortable or self-conscious. One student noted, “The scale is in a wall nook that is only 32 inches wide. Even for a patient that is in the upper level of normal BMI this width is rather narrow. When a [patient with obesity] needs to be weighed, the scale must be pulled out of the nook for the patient to step on it, leading to unnecessary embarrassment.”

The final issue mentioned was more social in nature and dealt with the type of language used in a practice setting. Students noted that clinicians and nurses alike make negative comments about patients with overweight and obesity. One NP student explained a scenario she experienced on the first day of her clinical rotation: “One of the medical assistants was preparing to bring a patient into an exam room. When she reviewed her medical record and noticed she was diagnosed with obesity, the assistant asked another staff member if there were any extra-large speculums because the patient was ‘huge.’”

A second NP student expressed that nurses would make negative comments about patients with larger bodies in an area where the patient could easily hear them. The student stated, “I have heard insults and stereotyping among the nonclinical staff/receptionists before and after seeing certain patients.” A third student noted, “My preceptor's colleagues in this clinic have made comments regarding patients with obesity as being lazy or unhygienic.” In a more extreme circumstance, a student reported that she “had watched a doctor shame a patient for gaining weight, get frustrated in front of a patient when the patient offers excuses for weight gain, and cut a patient's appointment off when the provider did not feel that the patient was making an effort to move forward in the program.”

Awareness of obesity bias. A positive outcome of the assignment related to the notion that NP students increased awareness of their own biases and the biases of others by reading the articles and completing the assignment. Some students admitted that they, along with their preceptors, show bias, although it might not always be explicit. One student explained, “I still hold a personal bias that is certainly not conducive to becoming a better healthcare provider. For example, I often feel frustrated when I am unable to easily assess for fetal heart tones, and the patient responds with, ‘People always have a hard time finding my baby.’ Sometimes I think, ‘No, it is because you are big.’ I have never said this out loud to any patient of mine, but I do feel it is wrong of me to have these thoughts.”

Another student acknowledged her own bias by stating, “I would much rather perform a wellness visit on a patient with a healthier weight than one with a very high BMI.” In addition to awareness of personal biases, some students stated that they do not believe that staff members in many of these clinic settings are aware of what obesity bias is, therefore, they engage in behaviors that are not size-inclusive.

Perceptions of individuals with larger body sizes. The last theme to emerge in the first overarching category suggested that some preceptors, students, and clinical staff members hold negative perceptions about individuals with larger bodies. Students reported, “The writer has also heard multiple provider assumptions that the patient will not be successful or will gain all of the weight back once the medication is discontinued,” and “...when I have larger patients, and I have to get fetal heart tones or NSTs [non-stress tests], I find myself becoming irritated because I automatically assume that it is going to be difficult because the patient has obesity.” Preconceived notions about individuals with overweight and obesity held by students and preceptors make treatment discriminatory and likely increase the odds that a patient will avoid future visits.

Unfortunately, one student gave an example of a preceptor teaching incorrect methods during a speculum exam, potentially stemming from obesity bias of the preceptor: “An incident occurred when attempting a Pap smear on a female patient with obesity that a proper speculum size was not available in the office. My preceptor changed out two different speculums in attempting to collect a pap smear, which was extremely difficult with what was available in the office setting.”

It should be noted that a woman who has overweight or obesity may need to change her position to assist the provider in a proper speculum exam (for example, pull her knees toward her chest until the cervix is visualized), but the body size of the woman does not designate the size of the speculum required.35,36

2. Clinical recommendations for practice settings. Improve training programs. Most student responses included the recommendation of improving graduate training programs that feature obesity bias and appropriate treatment of patients with overweight and obesity. The NP students suggested training on weight-related issues and sensitivity should be available for healthcare providers, staff, and students. Specifically, one NP student stated, “The key to decreasing the incidence of obesity bias is education. Education is a must in the medical community as well as the local community. Educating people on all levels allows those who discriminate to be knowledgeable of the consequences of these actions and how they impact the lives of others.”

Another student stated, “Learning more effective ways to manage obesity, such as regular nutrition counseling and referrals to a dietitian, community programs, and a bariatric surgeon when indicated, will provide patients with the guidance and tools needed to achieve weight loss.”

Students in this study found it imperative to create better training modules and procedures to best educate all those in the clinical environment on obesity bias. Those students who felt that bias was not present in their setting even suggested annual training to remind individuals to self-reflect on their biases to increase rapport when treating patients with overweight and obesity. It was suggested that individuals in clinical settings should also be educated on the outcomes of weight bias, so staff recognize the resulting harm of negative language and preconceived notions.

Create size-inclusive office settings and obtain size-inclusive equipment. As mentioned previously, one of the biggest instances of bias noted in clinical settings was inappropriate equipment and lack of size-inclusiveness in office settings. Thus, students suggested a need to provide equipment that was appropriate for individuals of all shapes and sizes. For example, each exam room should have equipment suitable for patients of all sizes. Having to send a patient down the hall to receive treatment elsewhere or causing the nurse or clinician to leave the room to find better equipment could easily make a patient feel self-conscious or excluded. Thus, students said, it is imperative to provide gowns, BP cuffs, exam tables, scales, and other equipment that will meet the needs of individuals with overweight and obesity. Students also recommended making changes to waiting room areas and areas where patients are triaged.

Redefining perceptions of obesity. The last theme was the recommendation to help students, practitioners, and staff alike redefine their perceptions of the term “obesity” and reconsider why obesity exists. Students recommended that clinicians discuss and view obesity as a chronic disease and not a personal issue (which is often the typical rhetoric in society). One NP student stated, “In the clinical setting, it is important to emphasize healthy lifestyles instead of focusing on achieving the ideal weight. This will encourage the patient to attain goals that lead them to successful weight loss without the pressure of obesity stigma.”

Another student suggested to “... help shift providers' view to recognizing obesity as a disease; understanding that not all patients chose to be overweight would inspire [healthcare] management in a similar tone as those with other diagnoses.”

Students expressed a need to create a person-centered approach when discussing obesity with patients. They also recognized the need to acknowledge obesity as a complex disease with multiple layers of influence. Understanding and acknowledging that obesity is not always a personal choice but is rather often a result of various biological, psychological, and environmental factors may shift the perceptions individuals have when treating patients with obesity.

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Women's health NP students are exposed to obesity bias in their clinical and educational experiences, enhancing the potential that they too may engage in obesity bias when caring for patients with obesity. Often, students and preceptors alike are unaware of their personal biases and their expression of them. However, the results of this study support that increasing awareness of implicit obesity bias can inspire the student and, thus, future provider, to decrease both implicit and explicit bias. It is important that both students and those teaching them are aware of how the language they use and the specific clinical environment may impact the patient. Preventing obesity stigma and bias is critical for high-quality patient care.

Unintentionally, the medical environment can be a space in which a negative stigma occurs for patients with overweight or obesity. Patients are vigilant to detect the possibility of being stereotyped or marginalized based on their physical size when visiting the medical office. The lack of accommodating space, equipment, and gowns may be perceived as unsupportive and insensitive to patients who are struggling to successfully incorporate healthier lifestyle changes to reduce their BMIs. Compounding this, perceived bias and judgment from healthcare providers and staff, both medical and nonmedical, whether overheard or sensed by patients, create barriers to their receptivity, comfort, and satisfaction when meeting with the provider, and increase the likelihood that the patient will not seek healthcare because of embarrassment, shame, or anger.

By improving training programs, restructuring office settings, obtaining size-inclusive equipment, and redefining perceptions of obesity, providers can better connect with patients who have overweight or obesity, ultimately providing better care and developing a better provider-patient rapport. Including instruction on obesity bias for future providers during their healthcare education programs could provide a lasting foundation helping them to identify issues in the built and social environments, awareness of obesity bias by oneself and clinical office staff, and perceptions of individuals with larger body sizes.

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      body mass index (BMI); explicit bias; implicit bias; obesity bias; overweight; size-inclusive

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