A Student Nurse's Perspective: Obesity Education—Time for a Change?

In nursing school, students have several “firsts”. You may remember your first patient, bed bath, IV medication, or operating room experience. I have had two “firsts” in nursing school, that have made an impression on my perspective, both which included patients with obesity. My first experience to shadow in the operating room included an opportunity to observe a laparoscopic gastric band procedure performed on a 22-year-old woman who was 5′6″ and weighed 266 lb. In addition, my first patient working as a nursing student at a large academic medical center in Boston was a female, 5′7″, 295 lb., postoperative patient who had undergone debridement of a stage 4 decubitus ulcer. Frequently, over three years of nursing school, I have witnessed firsthand the challenges of obesity for patients and nursing staff. I have been struck by the obesity epidemic and its staggering costs to American healthcare, decreased quality of life for and longevity of patients, and increased time and physical effort required by nursing staff to meet patient care needs.

Overwhelmed with the amount of nursing care required to accommodate obesity-related comorbidities in the patient care setting, I began to investigate the infrastructure in place to educate student nurses about obese patients and their specialized needs. Questioning the possibilities for modification in the educational process to meet these demands, I wondered, what is the best way to prepare my generation of nurses to develop more sophisticated care and prevention strategies to improve patient outcomes?

Surveying my education as a student nurse, I considered what I have learned during class, clinical settings, and work in hospital settings about obesity and its nursing implications. If a patient is obese, he or she is at greater risk for skin breakdown, infection, slower wound healing, and other comorbidities. As a nursing student, these concepts have been drilled into lectures by most of my professors. Throughout my studies at Northeastern University, I have learned the fundamental implications of obesity. In Nursing Interventions I and II, we studied the use of lifts and special devices to keep yourself and the patient safe during transfers, foot and skin care for the diabetic patient, and reviewed detailed protocols for staging of and wound care for skin ulcers. Due to changing insurance reimbursement, retracting coverage for inpatient-acquired stage 3 and 4 pressure ulcers, newly graduated nurses are leaving school with a strong message: if a patient develops skin breakdown on your watch, you are at fault.

In my classes we are taught to turn and reposition patients every two hours, maintain skin integrity with appropriate bathing habits and consistent use of barrier creams, and mobilize patients as soon as possible postoperatively, specifically related to obese patients. Wound care was the first and most detailed topic taught in my Interventions Lab, and we practiced debriding, packing, and sterile-dressing techniques on simulation wounds. Although we did not have an obese mannequin in our simulation lab, which would have been a useful tool, our lab has equipment used for obese patients for our practice such as lifts and special chairs.

Nutrition and Biology, courses I took during my first semester of college, introduced the concept of lipids or fats in our body, how we metabolize them, and why we need them. Learning the fundamental science behind excess fat, we were taught its connection to overeating and genetics. In Nutrition, I was also introduced to the concepts of Body Mass Index (BMI), energy balance, and weight control. Reviewing the staggering statistics regarding our nation's childhood and adult obesity epidemic and its connection to diabetes and heart disease, our professor outlined nutritional guidelines and recommended caloric intake to reach and maintain a BMI within normal parameters. Our syllabus included the difference between unsaturated and saturated fats, trans and polyunsaturated fats, the diet needs of a diabetic and associated Glycemic Index, and cholesterol recommendations for patients with heart disease. During our unit on lifestyle choices, the importance of cardiovascular exercise at least three times a week for 20 minutes or more combined with 20 minutes of weight-bearing exercise to strengthen bone health and increase calcium stores was emphasized.

In Pathophysiology and Medical/Surgical Nursing, the Northeastern curriculum focused on comorbidities associated with obesity primarily related to type 2 diabetes and heart disease. When introducing diabetes to our class, my Medical Surgical Nursing professor said, “When you admit an obese patient with comorbidities, ask one question: ‘Would you like to talk about your weight?’ ” We were taught that even if the patient refuses, one sentence from an outsider implying there is a problem, formally called a brief intervention, is a good place to start. As a result, if each succeeding nurse asks the same question, that patient is more likely to ask for information, seek help, and even modify his or her lifestyle.

Although heart disease and diabetes are most commonly associated with obesity, I also learned how many other disease processes are exacerbated or influenced by an obese state. It came as a shock to learn that obesity has been linked to cataracts, glaucoma, maculopathy, and diabetic retinopathy. ¹ Additionally, gastrointestinal disorders such as gastrointestinal reflux disease, metabolic syndrome, and cancers of the endometrium and esophagus are strongly linked to obesity.

However, my real shock came in the clinical setting. As a Northeastern student, I have the privilege of participating in the cooperational education program, or “co-op,” during which students submit applications to employers in Boston that correlate with their major, and work for three separate semesters throughout the undergraduate program. I had the opportunity to work on a surgical acute unit that specializes in burn, trauma, and kidney transplant at Brigham and Women's Hospital, and a pediatric medical acute unit that specializes in diabetes, eating disorders, and cystic fibrosis at Children's Hospital of Boston. It was in these two clinical settings that I experienced the life and challenges of an obese patient firsthand, the management of diabetes, end-stage renal failure, heart disease, and mobility restrictions. My education was solidified in the clinical settings, where I could observe and participate in the care of patients with invasive pressure ulcers that resulted in extensive inpatient stays due to increased infection and poor wound healing.

I witnessed the physical strain on the nursing staff that cared for these patients, bathed them thoroughly, performed skin assessment, and promoted circulation all while they protected their own bodies from injury during patient handling. I saw adolescent patients, primarily from underserved homes, with poor eating and sedentary lifestyles. These children were pre-diabetic or new-onset diabetics, now plagued with the burden of medically managing a chronic illness with little resources and understanding of the topic.

I have also had a Medical/Surgical clinical course at Boston Medical Center and a Women and Family clinical course at Brigham and Women's Hospital, both of which have reinforced my lessons from three years of nursing school and co-op that obesity is an epidemic with staggering severity. I have been inspired by my educational experience to contribute to healthcare education and reform as a future nurse, to protect my generation from dying younger than the previous, and to change our nation's lifestyle choices and habits.

The topic of obesity was integrated into many aspects of my nursing curriculum, painting a general picture of the condition for my peers and me. Most classes focused upon obesity as a related factor, but did not spend time on the condition itself as an entity. If obesity were presented as a disease model, with a cause, risk factors, assessments, associated interventions, and treatments, students may have more a comprehensive understanding of caring for an obese patient. We spend hours in class learning about rare diseases that are mandated by our syllabi. Yet, one could argue we still do not spend enough time talking, in a complete way, about a condition that plagues at least one-third of our nation.

While looking at the NANDA Chronicle, the inclusive set of nursing diagnoses taught in all nursing programs, I noticed there are only two small references to the issue of obesity: “Nutrition: altered, risk for more than body requirements” and “body image disturbance.” ² Nationally, nursing curricula center education on what nurses are able to diagnose. If NANDA, the fundamental infrastructure from which schools of nursing derive their teaching content, does not include a more deliberate and holistic approach to obesity, will nursing schools be able to evolve education about obesity to meet our national needs?

With the growing obesity epidemic, nursing curricula need flexibility to add concepts and topics such as the latest evidence to support best nursing practices for obese patients, devices to aid the obese patient in the healthcare setting, and updated research regarding healthy lifestyle choices. This level of flexibility would require course time and content devoted to the complete and comprehensive care of the obese patient. It is only then that we will come closer to the level of competence new graduates need to effectively treat and manage obesity in all realms of patient care.