Women's Health,Size,and Safe Patient Handling: What Are the Ethical Issues?

Introduction

Most would agree that women of size are at risk for a number of delays in basic healthcare. This is evidenced in delays in cancer diagnosis, access to prenatal care, and inadequate preventive well-woman care. In the acute care setting, weight-loss surgery programs generally are able to successfully accommodate the morbidly obese woman having uneventful metabolic surgery. However, in general medical, surgical, emergency, critical care, and other areas there are still challenges in basic intervention necessary to prevent what is recognized as the common, costly, and preventable complications associated with care of the obese woman. Further, the risks of nursing injuries related to caring for women of size compound the issue. The impact of nursing injuries in the United States is serious, yet processes to date fail to address the real-life demands of nursing care especially when caring for heavier individuals irrespective of setting. This challenge is debated herein using an ethical framework to present the issues nurses face on a daily basis pertaining to the concern of women's health, size, and safe patient handling.

The Woman of Size

The specialty of bariatrics is becoming more important, as the number of obese Americans is increasing. Further, the specialties of both bariatric gynecology and bariatric obstetrics are emerging disciplines. ¹ This interest, from a health perspective, arises from the fact that obesity is thought to be the second-leading cause of preventable, premature death—second only to cigarette smoking in the United States. More than 400,000 people in the United States die as the result of weight-related issues each year. ² Some contend this high degree of morbidity and mortality is due to co-morbid conditions; others suggest this is because of inadequate care or delays in necessary prevention, diagnostic methods, or therapeutic intervention.

Threats to Women's Health

Excess weight is thought to be linked to nearly 100,000 U.S. cancer deaths each year. ³ The American Cancer Society suggests that obesity is responsible for 20% of all cancer deaths in women living in the United States. ⁴ Although the mechanism of incidence is debatable, the severity of cancer at initial diagnosis may be due to delays in diagnosis. ⁵ For example, one study, which specifically examined the relationship between breast and cervical cancer and unrecognized barriers to screening among obese women, presents the threat of delays in preventive and early intervention. ⁶ The severity of cancer on initial diagnosis may occur because either the examining primary care provider is reluctant because of the complexities in performing proper examinations or because the patient is hesitant to allow a comprehensive assessment. Others suggest that most Americans do not realize being overweight is a risk factor for many forms of cancer, further leading to inadvertent delays. ⁷ Regardless, researchers explain that early diagnosis is key and is a factor in survival rate. ⁵

Prenatal care is equally affected by issues of weight. For example, 38% of obstetricians and gynecologists identified excess weight as a primary health problem for women of child-bearing age. ⁸ Excess body weight is a threat to health because it is associated with an increase of cardiovascular disease, type II diabetes mellitus, hypertension, stroke, hyperlipidemia, degenerative joint disease, deep vein thrombosis, urinary stasis, pain management challenges, and situational depression. In the acute care setting, immobility also contributes to pulmonary complications such as atelectasis, pneumonia, and exacerbates pre-existing conditions such as obesity hypoventilation syndrome or sleep apnea. ⁹ This is especially problematic during pregnancy. Women who are overweight or obese during the gestational period are at an increased risk for pregnancy-induced hypertension, gestational diabetes, labor induction, cesarean births, and failed vaginal birth after cesarean. During the postpartum period, woman experience increased rates of puerperal infection and decreased rates of breastfeeding initiation or continuation. Their infants experience a higher incidence of congenital anomalies or being stillborn. ¹⁰ Specifically, obese women are at significantly increased risk for their offspring developing open neural tube defects and congenital heart disease. To compound the issue, impaired sonographic visualization in this population may impede prenatal diagnosis of these serious birth defects. ¹¹

Pregnancy and childbirth are significant human events. Emotional aspects, which accompany all pregnancies, may be confusing to the pregnant woman and her partner. Physical changes that occur during the pregnancy can affect emotions. This may be particularly true when the new mother is obese. Comorbidities listed earlier may be exacerbated by a pregnancy. Most women fear weight gain; however, this is a greater concern to an already overweight woman. Physical limitations due to size cause unwanted emotional and physical concerns. Further, prenatal care in obstetrical offices can threaten the patient's dignity and safety, as can well-woman care in a gynecologist's office. To the same extent, the birthing experience can prove dangerous without proper safety precautions in place to protect both the mother and the delivery team.^12,13 Seeking creative safe handling strategies to accommodate the very overweight mother properly in a dignified manner is essential to the maternal/paternal–child experience.

Regardless of the reason for access to the acute care facility, women—like all patients—have a right to safe, respectful nursing care. Although, this seems to go without having to be said, the reality is that many women of size express concerns about nurses who fail to provide safe, sensitive care. This may, in fact, occur because nurses are ill-prepared with either improper training or equipment.^14,15 Immobility in the acute care setting can lead to a number of clinical problems, as described earlier. Many nurses are reluctant to turn, lift, or reposition the woman properly because of the realistic fear of injury. However, failure to provide basic nursing tasks lead to well-documented adverse outcomes.^16–18

The Meaning of Safe Handling

The prevalence of people being overweight or obese is increasing nationally and globally, having reached epidemic proportions in the United States. In 2007–2008, based on measured weight and height, approximately 72.5 million adults in the United States were considered obese. ¹⁹ This increase has occurred regardless of age, gender, ethnicity, socioeconomic status, or race, and is reflected in healthcare settings, as well as the general population. These data suggests that primary care providers, outpatient centers, acute care facilities, and others face pressure to prepare for the needs of special patient populations—especially patients of size. ¹⁵ For example, one study, which occurred in the acute care setting, indicates that patients with a BMI >35 comprised only 10% of the patient population; however, handling patients with a BMI >35 was associated with 29.8% of injuries, 27.9% of lost time, and 37.2% of restricted time. ²⁰ In this study, lifting, turning, and repositioning was usually performed using manual techniques rather than equipment. Therefore, with increasing body weight and weight maldistribution of both patients and their caregivers, challenges inherent in lifting, moving, and repositioning the larger, heavier patient lends to hazards of immobility among the patient in the acute care setting because of the natural fear of injury. Nurses are among the professionals with the highest rates of work-related low back pain, and every year about 12% of nurses leave the profession as a result of back injury. Occupational risk factors for musculoskeletal back injuries include manual patient handling, which is made more difficult by the increasing frequency of obesity in the patient population, the pushing and pulling of wheelchairs, gurneys and beds, awkward positions, and extended working hours. With very little improvement in healthcare-worker injury rates, it seems that the only numbers that change in the Bureau of Labor Statistics (BLS) injury data over time are the years. ²¹ Together these data explain the hesitation in caring for women of size and therefore delays in access to women's health regardless of the setting.

The number of morbidly obese women has increased over the last decade. This group requires specialized care during their healthcare experience because of co-morbid conditions and the increased risk for poor outcome. Nurses must be prepared.^8,22 Safe handling practices are essential to every level of bariatric nursing care.

What About the Nurse?

Nurses are often the last group granted protection from harm in healthcare settings. Perhaps this is because of the altruistic nature of nursing care. Altruism is referred to as unselfish concern for the welfare of another person. It is the expression of selfless concern for others when there is no obvious reward to be gained for oneself, except the belief that someone else will benefit or avoid harm. ²³ Many nurses express that they become nurses because of their selfless concern for the welfare of others. Some state, “I am unselfish in giving myself and my time and attention to the patients in my care.” This is a common sentiment among nurses. But it raises the question of to what extent nurses are expected or willing to sacrifice themselves for the welfare of others. Research for at least the past two decades suggests that nurses are, in fact, more than willing to sacrifice themselves for the welfare of others. For instance, a 2007 BLS report names the top 10 professions most likely to receive a back injury on the job. This list includes CNAs, LVNs, RNs, PTs, radiology technicians, and health aides as separate categories, saturating this top 10 list with healthcare workers. If all nursing staff members were grouped together, they would rank number one as the top profession most likely to receive an occupational injury. ²⁴ Some 20% of nurses experience work-related pain on any given day, and 50% consider leaving nursing because of the physical stress and injury involved. The cause of these injuries is no mystery. Researchers have identified manual lifting, transferring, and repositioning of patients as the causes of musculoskeletal injury among healthcare workers. ²⁵

Further, consider the statement: “It is the most conscientious nurse who is injured first.” This anti-evolutionary concept explains the problem inherent with the more thorough or reliable nurse feeling compelled to provide necessary nursing care despite the fact he or she may be ill-equipped or ill-prepared. To compound this problem, the more reliable nurse will come to work injured and place not only herself but the patient at risk for injury. In a setting that fails to provide a pervasive culture of safety, the better nurses are removed from the patient care team because of unintended and sometimes career-ending injury.

Safe-handling outcomes research often measures reported nursing injuries as the benchmark to determine the success of a safe patient handling program. But is this really the best indicator? Is it safe to assume that a nurse may hesitate to report an injury at a facility that has just implemented lifting equipment, protocols, and training? Yet, cumulative injuries continue to occur if equipment is used improperly or size-appropriate training is misunderstood or a number of other barriers to success exist. Nurses continue to work with the tools provided to them and seldom mandate personal safety. This raises an important ethical debate, as nurses consider their altruistic goals for nursing care juxtaposed with not only their longevity in the workplace but immeasurable chronic or acute personal pain over time.

The Ethical Debate

Ethics is defined as the philosophic study of morality. It is the study of goodness, moral values, and right action. An ethical dilemma, on the other hand, exists when two or more equally unacceptable choices are available and a decision must be made. ²⁶ If endless resources were available to ensure access to women's health services across practice settings and across the life span to guarantee safe, preventive service and timely, appropriate intervention, then an ethical dilemma would not exist. However, this is not the case. Consider the following questions:

Safety in the workplace serves the needs of both women and the nurses who care for them. From an ethical perspective, it becomes essential to balance the good of the patient and the good of the nurse—certainly other stakeholders exist; however, the focus of this debate is the bariatric nurse.

Next Steps

Solutions to these dilemmas may involve the use of patient lifting and transferring equipment, proper training, size-appropriate rooms, and additional staff members. As Charney explains, such strategies help prevent injuries that lead to staff shortages, which further avoid incapacitating staff member injuries, which in turn avoid problems associated with staff shortages. ²⁷ Charney further argues these nurse injuries lead to quantifiable patient safety issues. ²⁷ Nursing researchers have pointed out that implementing a minimal or no-lift practice within healthcare institutions is associated with significant cost savings, as well as greater patient satisfaction, reductions in the number of nursing injuries, and decreases the ongoing challenge of retention and recruitment. Further, recent experience suggests a sophisticated well-orchestrated lift team may serve to complement a new or existing safe handling program. ²¹

Conclusion

As bariatric nurses consider the ethical dilemma posed by balancing nurse and patient safety, economic constraints, regulatory mandates, and more, it becomes important to recognize the rights and responsibilities of the underserved—whether these are nurses or the women they serve.