Nurses' Perceptions of Safety Concerns When Caring for Morbidly Obese Patients

Introduction

Since publication of the Institute of Medicine's “To Err Is Human,” ¹ the safety of hospitalized patients has become a national priority. The numerous resulting initiatives will benefit obese patients as well as those who are not obese.

The dependent hospitalized obese patient may be a particular safety risk for falls. The large body mass as well as the need for assistive equipment and additional personnel make mobilizing these patients difficult and possibly hazardous.

There is a voluminous literature on patient safety, but little work specific to obese patients is reported. The importance of attention to their safety concerns has been stressed by several experts.^2–5 The National Association of Bariatric Nurses (NABN), in its position paper “NABN Position Paper: Our Voice, Our Mission,” ⁶ stressed the importance of safety as well. Algorithms for patient handling and also practical suggestions for their use in patient handling have been developed by Baptiste, ⁷ as have practical suggestions for their use by Muir and Heese. ⁸ The NABN also developed best practice guidelines to assist in safe handling of obese patients. ⁹

We do not have detailed information about the nature of safety incidents with obese patients. Such information would enhance understanding and assist in the design of prevention strategies.

Purpose

The purpose of this study was to describe nurses' perceptions of safety-related events they experienced when caring for hospitalized obese patients.

Methodology

This descriptive study used a survey design. Researchers sought participants both by telephone and in person at the national meeting of the NABN, and 23 nurses agreed to participate. They were subsequently telephoned by five nurse graduate students who were trained for this purpose by the research team. Participation in the telephone interview was taken as consent to participate.

The instrument was designed by the researchers around three types of safety events described in the literature. They were adverse events, near misses, and out-of-control events. Participants were asked to recall their experiences in caring for morbidly obese patients (BMI > 35) and to respond to questions concerning safety issues related to their care.

Adverse events are “occurrences during clinical care that result in physical or psychological injury or harm to a patient or harm to the mission of the organization.” ¹⁰

A near miss, the second type of event, is often called a “close call” and is a situation where “unwanted consequences were prevented because there was a recovery by identification and correction of the failure, either planned or unplanned.” ¹⁰

The term out-of-control situations is one coined by the research team to encompass those situations in which the nurse recognizes that the situation is potentially unsafe but proceeds nonetheless with no untoward results. ⁴

An example would be a situation in which an obese patient is being transferred from stretcher to bed. If the nurse cannot visually determine that the patient's center of gravity is sufficiently transferred to safely remove the stretcher, then the situation is one of heightened risk and it is not under complete control. In this study, the out-of-control incidents did not result in a fall or other adverse event, but the potential for such was deemed high.

A semistructured format with open-ended questions was used to elicit in-depth responses about each type of event. Content validity was determined by a group of nurse experts with modifications made based on their recommendations. The instrument was also pilot tested with a group of nurse experts, and appropriate revisions made. Participants were assigned numbers in order to maintain confidentiality. The combined institutional review boards of the university and the hospital approved the study.

Results

Twenty-three participants, all nurses, were telephoned. There were four participants who indicated that they had no direct patient contact, so their responses were eliminated from the analysis. The 19 remaining respondents reported a wide variety of current positions, including bariatric program director or coordinator (5), staff or bariatric nurse (6), acute care nurse practitioner (1), clinical nurse specialist (2), nurse manager or director (3), operating room nurse (1), and nurse office manager (1). All participants were female, 95% were white, and 5% were Hispanic. Mean age of respondents was 49.9 years.

Adverse Events

The 19 nurses reported 11 adverse events and all were falls. In addition, one fall was reported under the category of near miss, but since the patient did actually fall to the floor, this was included in the analysis of adverse events, bringing the total to 12. Six could be attributed to equipment failure, and five to unknown causes. One event occurred because the patient became weak while walking and, although partially supported by the nurse, slumped to the ground. The remaining five events were those in which the nurse came into the room and found the patient on the floor. We termed these falls from unknown causes.

Examples of equipment failures:

Wrong type of bed or inadequate bed: A restless patient fell out of bed three times while turning in bed because the rails were too low.

Examples of what the researchers termed unknown causes included one in which the patient attempted to stand on his or her own before the nurse came to assist and the patient fell. Several instances were reported in which the nurses simply found the patient alone on the floor when they entered the room.

Near Misses

The nurses reported six near misses, that is, the adverse event was averted by the action of the nurse. They were as follows:

One other situation was reported in which two transferring devices were placed under the patient rather than just one by the transporters and the nurse felt this was a dangerous situation. This did not fit the definition of a near miss because no action was taken by the nurse and thus was not included in the analysis for this section.

One situation was reported as a near miss in which the doorframe would not admit the bariatric wheel chair. This was deemed an out-of-control situation by the research team rather than a near miss, and it was included below.

Out-of-Control Situations

There were three types of situations reported. No patient injuries were reported, but the nurses recognized that the hazard level may have increased.

One involved an unanticipated facility issue. A patient in a bariatric wheelchair was transported to a unit in which the doorframe was not wide enough to accommodate the chair. The patient was 540 pounds and had great difficulty standing, but the nurses had to stand the patient, collapse the wheelchair, get through the door, and reopen the chair.

Three respondents noted that toileting had the potential to become an out-of-control situation. Moving the patient to the commode was identified as oftentimes out of control because of difficulty determining whether the patient's center of gravity is over the commode. Similarly, a transfer back from bedside commode to bed was cited as possibly out of control because of difficulty determining if the patient is sufficiently moved back into the bed. Respondents noted also that the patient on a toilet in the bathroom is very difficult to assist because of the narrow space and the difficulty getting equipment in such a limited space.

Respondents noted that use of improperly sized equipment, such as stretchers that are too narrow, has the potential to harm patients.

Desired Equipment

Respondents were asked what pieces of equipment they could or would use were they available. Two respondents just noted basic bariatric equipment they needed such as bariatric beds, lifts, and commodes. In addition, the following items were named:

Equipment with large weight capacity (2) (Lifts accommodating weights over 1,000 pounds and wheelchairs accommodating weights over 800 pounds)

Discussion and Recommendations

The conceptual model guiding this research postulates that effective care of the obese patient in hospital involves variables from three domains. The first set relates to the obese patient him or herself, such as the patient's large body mass or the diminished vascularization of the obese patient's skin. A second set relates to the nursing domain and includes techniques nurses use to transfer patients or specialized equipment required for the obese such as longer needles and tracheostomy tubes. The third category lies in the domain of the nursing administration and includes policies, the availability of appropriate equipment, sufficient staff, and other environmental factors. Variables from all three must interact to assure appropriate care for the obese patient.

Results of this study suggest that prevention of falls while caring for the obese patient begins in the domain of nursing administration. Equipment maintenance is an administrative responsibility as are facilities assessment and modification and assuring proper nurse-staffing levels.

In the nursing domain, the data suggest that nurses must attempt to deal with problem situations before they become adverse events. The data also suggest that greater nursing surveillance may be appropriate for these patients. Any patient can fall while the nurse is not in the room, but further study would be needed to determine if there are causes specific to the obese patients that bring about this situation.

There are several blueprints for facility assessment in the literature.^11,12 These blueprints point to areas that should be assessed such as the width of doorways and the availability of appropriate scales, bariatric operating room tables, and so on. Such assessment is needed to prevent potentially hazardous situations.

A dedicated bariatric unit would be a possible solution to some safety problems. In such a unit, the necessary equipment, facilities modification, and adequate numbers of staff would be brought together in one place. This might, in turn, reduce the number of falls or other safety issues. A dedicated unit would not insure safety totally, however, because as the patient leaves the dedicated unit for tests or treatments, the risk may then increase.

Our earlier work demonstrated that “it takes more people” to provide care for the obese patient. ¹³ Models used to determine appropriate levels of nurse staffing should be reviewed to take this into account when obese patients are on a nursing unit.

The reporting and analysis of safety events are important. While hospitals do analyze adverse events, the literature makes note of the fact that for every reported adverse event there are most likely dozens of near misses. The failure to report and analyze these data represents a missed opportunity. ¹⁴ Report and analysis of these events in the case of obese patients could point the way to a safer environment.

Lastly, there are several models in the literature for identifying what patients are at high risk for falls. Factors such as gait instability, confusion, and urinary frequency are listed, but obesity is not studied as an independent risk factor. ¹⁵ Further research should be conducted to determine whether or not obese patients are at greater risk for falls than nonobese patients. Should investigation validate that fact, then these models should be revisited for inclusion of the obese patient.