Abstract
Background:
The rise in obesity in the United States has led to an increase in the number of bariatric procedures performed annually to treat obesity. It has become the only treatment method that provides significant and sustained weight loss in obese patients with resultant improvement in obesity-related comorbidities. 1
Objective:
The aim of this project was to evaluate the knowledge and attitudes of the nurses regarding aspects of bariatric surgery at a hospital that is a Center for Excellence for bariatric surgery.
Methods:
A voluntary survey was conducted using SurveyMonkey® to assess the nurses' current knowledge of bariatric surgical procedures and attitudes toward patients undergoing bariatric surgery.
Results:
The results of the survey showed that 66.7% had no previous experience of caring for bariatric surgical patients, 3.3% did not understand gastric bypass surgery, 6.7% did not understand the sleeve, and 26.7% did not understand the duodenal switch surgery. In addition, 43.3% felt that bariatric surgery improves the quality of life for some obese patients who are compliant with diet and postoperative instructions, but 6.7% of nurses surveyed did not agree with bariatric surgery as a means for improving quality of life.
Conclusion:
Since bariatric surgery has become more popular in recent years to treat obesity, it is imperative that nurses understand the procedures and how to care for this patient population. The results of this survey were used to educate the nurses further at this facility about bariatric surgery and the duodenal switch procedure.
Introduction
Obesity is complex; it is a chronic condition that is influenced by genetic predisposition, with endocrine, metabolic, environmental, behavioral, and psychological components. 1 Obesity is the leading cause of preventable death, and it is also associated with increased length of hospital stay and overall health costs. 2 Many obese individuals struggle with weight throughout their lifetime. Even with diet and exercise, many individuals find it hard to lose weight and/or keep the weight off for sustained periods of time.
Bariatric surgery is currently the only modality that provides significant sustained weight loss for patients who are obese and improves obesity-related comorbidities. 1 Bariatric surgery is a treatment for morbid obesity and obesity-related diseases. It limits the amount of food that the stomach can hold and/or limits the amount of calories absorbed, by surgically reducing the stomach's capacity to a few ounces. 3 According to the American Society for Metabolic and Bariatric Surgery (ASMBS), approximately 220,000 people with morbid obesity had bariatric surgery in 2009, which is only 1% of the clinically eligible population in the United States. 3
The goal of bariatric surgery is to reduce caloric intake by either restricting the amount of calories an individual can take in or by reducing the amount of calories absorbed from the gastrointestinal tract. The four common surgical procedures that are currently being used in the United States are gastric bypass (also known as Roux-en-Y), adjustable gastric banding, biliopancreatic diversion with duodenal switch, and sleeve gastrectomy.
Following bariatric surgery, acute and chronic postoperative complications can occur. It is essential that the patients and healthcare providers are committed to achieving positive outcomes following bariatric surgery. The challenges for nurses are to be knowledgeable about bariatric operations and to plan for the care of bariatric patents to achieve optimal results and outcomes. 4 It is essential for nurses to be educated on the surgical procedures and signs of complications, as well as progressive care, if patients are to have positive postoperative outcomes.
Review of Literature
History of bariatric surgery
The first effective surgery for obesity in the United States was performed in 1954 by Kremen and Linner. The procedure performed was a jejunoileal bypass, which connected the proximal jejunum directly to the distal ileum. Approximately 90% of the small intestine was bypassed. This procedure was a malabsorptive procedure, which led to significant weight loss. However, many of the patients developed serious complications because of the malabsorption. Some of these complications included steatorrhea, diarrhea, severe vitamin deficiencies, and oxalosis. Overgrowth of bacteria in the bypassed intestines led to liver failure, severe arthritis, and skin problems. Because of the many complications associated with this surgical procedure, patients were required to have a reversal of the procedure, and the procedure was subsequently abandoned. Since then, many modifications have been implemented, making bariatric surgery less complex. 1
Anatomy of bypass, sleeve, and switch
The gastric bypass, also known as the Roux-en-Y, is formed by partitioning the stomach by using a stapling device. There is a very small portion of the stomach that is just distal to the esophagus, termed the pouch, away from the main reservoir of the stomach, termed the remnant pouch. The ligament of Treitz is the spot where the division is made. The distal jejunal limb is brought up to and anastamosed to the pouch with a limited-sized stoma. The bypassed segment, which includes the remnant stomach, duodenum, and proximal jejunum, is anastamosed at a different location down the roux limb. Therefore, gastric bypass is restrictive and malabsorptive. 5
The sleeve gastrectomy is performed by resecting more than 80% of the stomach, and the gastric remnant is tabularized, with an initial filling volume of less than 100 mL. The sleeve is classed as restrictive surgery. The duodenal switch has two steps. The first is to perform a sleeve gastrectomy. Next, the duodenum is divided distal to the pylorus, and the jejunum is divided 250 cm proximal to the ileocecal valve and anastomosed to the duodenum. The other end is connected to the ileum 100 cm proximal to the ileocecal valve. The duodenal switch has a high degree of malabsorption and restriction. 6
Rationale for having bariatric surgery
According to ASMBS, bariatric surgery improves or resolves more than 30 obesity-related conditions, including type 2 diabetes, heart disease, sleep apnea, hypertension, and high cholesterol. Gastric bypass resolves type 2 diabetes in nearly 90% of patients. It cuts the risk of developing coronary heart disease in half, and resolves obstructive sleep apnea in more than 85% of patients. 3 Studies have also shown that bariatric surgery increases the lifespan of bariatric surgery patients compared with those who do not have surgery. Patients may improve life expectancy by 89%, and reduce the risk of premature death by 40%. 3
Bariatric surgery is not a cosmetic procedure. It involves reducing the size of the gastric reservoir, which improves eating behaviors. Patients learn to modify their diets and eat small amounts slowly. Mentally, patients have a better self-image, feel more self-control, and have an enhanced quality of life following bariatric surgical procedures. Studies have also shown that heart function improves with sustained weight loss from surgery. 3
Postoperative complications associated with bariatric surgery
Postoperative complications associated with bariatric surgery vary depending on comorbid conditions prior to surgery. Early postoperative complications occur within the first 30 days following surgery; late postoperative complications occur thereafter. Some early complications associated with bariatric surgery include wound infection, sepsis, deep vein thrombosis, pulmonary embolism, anastomotic leak, vomiting, and diarrhea. Some late complications associated with bariatric surgery are hernias, nutritional deficiencies, and cholelithiasis.
Wound infection is the most common postoperative complication. 4 Obese individuals generally have poor blood supply to adipose tissue. They commonly have excessive moisture and accumulation of bacteria in skin folds and dehiscence of wounds can also occur. 4 Wounds that become infected can lead to sepsis if not treated immediately. Signs of an infected wound include smell, green/yellow drainage, redness, tenderness, and incisions that are warm to touch.
Impaired mobility following surgery for obese individuals makes them at a higher risk for blood clots and pneumonia. Therefore, it is imperative that this population of patients ambulate as soon as possible following surgery. Hydration and deep breathing using an incentive spirometer are also strongly encouraged to prevent postoperative pneumonia.
Anastomotic leak is the most serious complication associated with bariatric surgery and the most common cause of death. 4 If a leak develops early within the first 10 postoperative days, signs and symptoms of toxicity such as tachycardia, fever, and leukocytosis may be present. Patients with anastomotic leak have increasing pain in the back, left shoulder, abdomen, and pelvis, and substernal pressure. Other warning signs of a leak include hiccups, belching, an unexplained heart rate greater than 120 bpm, oliguria, and restlessness. Treatment is primarily surgical stenting or suturing the area. 4
Incisional hernias occur in about 15% of patients with bariatric surgery. It is the most common late postoperative complication associated with open bariatric surgery. It is caused by increased tension at the wound edge and increased abdominal pressure. If the hernia is causing obstruction or pain, surgery is necessary. 4
Nutritional deficiencies occur because of the inability to mobilize fat stores for energy. The body uses protein for energy; this is why it is important that patients increase their protein intake following surgery. Iron, calcium, and vitamin B12 deficiencies occur because of the bypass of primary absorption sites after gastric bypass and duodenal switch procedures. 4 It is also common for patients to develop gallstones because of the rapid weight loss after surgery. 4 Therefore, many bariatric patients require a cholecystectomy after surgery.
Postoperative care
Patients are evaluated before and after surgery to make sure that the appropriate level of nursing care is provided. Most patients are sent directly to a general surgical care area after surgery. However, admission to an intensive care unit is common after bariatric surgery. Patients who have comorbid conditions such as congestive heart failure or severe sleep apnea may spend several days in an intensive care unit to monitor cardiopulmonary status closely. 4
Patients typically remain in the hospital for 2 to 4 days after surgery, depending on whether there are any complications. Ambulation after surgery is extremely important in helping with abdominal gas pain and the prevention of blood clots. Depending on the preferences of the surgeon or hospital policies, surgical patients are given subcutaneous blood thinners, as well as airflow devices, to lower extremities to help the prevention of blood clots. 4
Airway and pulmonary management are important postoperatively, since many patients suffer with sleep apnea. Incentive spirometry is encouraged every hour while awake to prevent pneumonia. Monitoring and recording of intake, output, and vital signs are essential after surgery because changes in vital signs may herald an impending complication. Daily serum evaluations are also performed to ensure electrolyte balance, and to assess for infection and anemia. 4
Patients who have bariatric surgery are prescribed a strict diet postoperatively that regulates the consistency, volume, and nutritional value. Food is gradually reintroduced. Sugar is avoided, as it causes dumping syndrome. Carbonation is avoided because the bubbles stretch the pouch in the early postoperative phase; even flat soda, when ingested, will produce bubbles in the pouch due to increased temperature. 4 Patient compliance with the diet is essential for safety and successful weight loss. Nurses who care for bariatric patients need to monitor and report any nausea and vomiting, a heart rate greater than 120 bpm, hypotension, oliguria, a fever greater than 101 F, hypoxia, and any changes in appearance, as these may be indicative of a potential anastamotic leak.
Maintaining dignity and respect of bariatric patients
Discrimination and bias still exist in treating obesity. The psychological impact associated with negative attitudes toward obese patients can be devastating. 7 Societal biases include the belief that if obese patients ate less and exercised more, they could control their weight or that these individuals actually choose to be obese. Research has shown that obesity is a disease of multifactorial origin that is strongly associated with a genetic predisposition. 7
Bariatric patients require special care. If healthcare providers are aware of these special needs, it is more likely that the patient will be treated with dignity. Caring for the bariatric patient can be physically challenging for healthcare professionals. Education, equipment, and protocols ensure that bariatric patients do not feel outcast. Healthcare professionals may have their own bias regarding obesity, and concerns about receiving personal injuries while providing care. 7 If bariatric patients do not believe they are being treated with dignity in a hospital setting, they may be reluctant to seek further medical care because of feelings of embarrassment and shame. 7
A key element in providing dignified care for a bariatric patient is building a relationship with the patient through compassionate communication. Respectful and nonbiased communication can be achieved by using supportive language. Annual bariatric sensitivity training can improve nursing attitudes toward obese patients. 8 Education and training about the challenges of caring for the bariatric patient can alter the personal biases regarding obesity. Providing size-appropriate furnishings, equipment, supplies, and instruments will ensure the dignity of the bariatric patient. 7 Nursing care activities should be performed in a manner that promotes their dignity and respect. Bariatric surgery should be viewed by hospital staff as a positive health-promoting and life-sustaining intervention.
Theoretical Model
Jean Watson's theory of caring
According to Jean Watson, caring and nursing exist in every society. A caring attitude is transmitted by the culture of the profession as a unique way of coping with its environment. Nursing is concerned with promoting health, preventing illness, caring for the sick, and restoring health. 9 Watson believes that holistic healthcare is central to the practice of caring in nursing. She views the human being as a valued person in and of him or herself to be cared for, respected, nurtured, understood, and assisted. The human is viewed as greater than and different from the sum of his or her parts. 9
Watson's theory works well for nurses caring for bariatric patients. As a care provider, the nurse promotes the health of the patient following surgery, and focuses on preventing illness or infection postoperatively. However, if or when there is a complication following surgery, the nurse will care for the sick patient and work to restore health. The purpose of the surgery is not for cosmetic purposes; it is to promote a healthier lifestyle and well-being. A caring environment promotes health and individual growth. A caring environment allows the patients to maintain dignity and hope, and allows them to choose the best actions for themselves. A helping and trusting relationship between nurses and patients is essential in promoting health.
Method
A survey was distributed to nurses on the medical surgical unit at a local bariatric center designated as a “Center of Service Excellence.” The purpose of the survey was to evaluate nurses' current knowledge of bariatric surgeries and to identify opportunities for performance improvement education and sensitivity training (see Appendix). An email describing the study and providing a SurveyMonkey® link was sent to the nursing staff; the survey was available for 7 days. The chief nursing officer also distributed hard copies of the survey during a mandatory staff meeting. These hard copies were then submitted to the nurse manager, and these data were then entered into SurveyMonkey®. The hard copies were shredded. Participation was voluntary.
Results
Approximately 50 nurses from the hospital either viewed the email or attended the mandatory staff meeting. There were 30 respondents to the voluntary survey. A total of 26.7% of the respondents stated that they had been employed at the hospital for 4 years or more. Only 16.7% had been employed at the facility for less than 1 year. When asked if they had previous bariatric experience, 66.7% said no. When the nurses were asked to rate their understanding of gastric bypass and gastric sleeve surgeries, 66.7%–70% reported that they understood most aspects of the procedure. However, when rating their understanding of the duodenal switch procedure, only 30% understood most aspects, 40% understood some aspects, and 26.7% reported no understanding. A total of 66.7% of the nurses reported that they believed the gastric sleeve was the surgery of choice with the least amount of complications.
All nurses were all able to list three warning signs of a gastric leak. These included tachycardia, pain, elevated white count, decreased urine output, and shortness of breath. This indicated that no further education was needed regarding the signs and symptoms of a leak. The nurses were also able to state one other possible complication of bariatric surgery. Those listed included malnutrition, vitamin deficiency, bowel obstruction, blood clots, ileus, nausea and vomiting, dumping syndrome, and hernia. This indicated that no further education was needed regarding complications of bariatric surgery.
The last question on the survey evaluated the nurses' perceptions of bariatric surgery. The majority of the nurses felt that bariatric surgery improved the quality of life for either some (43.3%) or most (30%) of the patients who were compliant with diet and postoperative instructions. In addition, 6.7% (n=2) of the nurses surveyed did not support bariatric surgery.
Discussion
The majority of the survey results were positive and reassuring. The hospital is a small hospital that has a low turnover in nursing staff. Many of the nurses (26.5%) working at the hospital have been employed there since it opened in 2005. Another 26.7% of the nurses have been employed at the hospital for 4 years. A low turnover rate in the nursing staff may indicate that staff enjoy working at the facility. The facility has been open for 5 years and has been performing bariatric surgeries since its opened. It obtained the “Center of Excellence” status approximately 4 years ago.
The majority of the nurses felt that bariatric surgery improved the quality of life for all, most, or some patients, as long as the patients were compliant with diet and instructions. Watson's theory relates to this because she believed in holistic health and caring for patients, yet making sure the patients value themselves and care for themselves in the healing process.
When individuals interview for a position at the facility, they are made aware that the hospital does conduct a large number of bariatric surgeries. Background screening, drug tests, and reference checks are made prior to an individual being accepted for employment. All new employees have a one-on-one training session with the bariatric coordinator. She educates the employees about all of the bariatric care and the variety of surgical options. She provides training about equipment, weight limits, and where to find useful bariatric materials in the workplace. She also provides sensitivity training at this time. The bariatric coordinator provides ongoing training as needed, and is available 24/7 for education. The results of the survey indicate that adequate screening and education is done with new employees regarding bariatric surgery.
More than half of the respondents rated a good understanding of the surgical procedures. Those respondents who rated that they understood all or most of the procedures may have had more experience at the facility or greater nursing experience in general than the respondents who indicated that they understood some or none of the surgical procedures. Knowing that nurses who report confidence in their knowledge of the care of bariatric patients exist in the facility ensures that resources are available to support those who are less experienced. Survey responses indicated a need to provide additional education about the duodenal switch procedure, as more than half of the respondents reported little or no understanding of the procedure. This may be due to how few of these surgeries were performed prior to the administration of the survey.
The survey's results were discussed in detail with the center's bariatric coordinator and chief nursing officer. Plans to provide additional education during the hospital's annual competency fair were implemented. Further education about the duodenal switch procedure that includes the use of graphics and PowerPoint will be provided. The nurses will participate in a posttest to ensure they have learned the content and gained competency in the care of a patient who undergoes a duodenal switch operation.
Conclusion
Nursing care is an important factor in the postoperative care of bariatric surgical patients. Patients undergoing bariatric surgery are at risk for developing complications related both to the surgery and to the patients' preoperative comorbidities. Understanding the anatomy as well as the physiologic changes that occur after the various procedures helps nurses to understand the postoperative course and improves the care they provide, which enhances the postoperative experience.
Footnotes
Acknowledgments
The author gratefully acknowledges the academic support of the Family Nurse Practitioner faculty at Southeastern University in Louisiana for their assistance in the preparation of this manuscript. The author also acknowledges the support received at Southern Surgical Hospital in Slidell, Louisiana, for contributing and participating in collecting data to make this manuscript possible.
Disclosure Statement
No competing financial interests exist.
Appendix: Bariatric Survey
Please answer each of the following questions.
1. How long have you been an employee at Southern Surgical Hospital? • <1 year • 1 year • 2 years • 3 years • 4 years • 5 years • >5 years 2. Is Southern Surgical Hospital the first hospital that you have worked at to care for bariatric surgical patients? • Yes • No 3. Name several educational resources available to you at Southern Surgical Hospital pertaining to bariatric surgical care. 4. How would you rate your understanding of gastric bypass surgery? • Don't understand • Understand some aspects • Understand most aspects • Understand all aspects 5. How would you rate your understanding of gastric sleeve surgery? • Don't understand • Understand some aspects • Understand most aspects • Understand all aspects 6. How would you rate your understanding of the duodenal switch surgery? • Don't understand • Understand some aspects • Understand most aspects • Understand all aspects 7. With which of the following surgeries do you feel patients have the least amount of complications? • Sleeve • Bypass • Switch 8. Please state three warning signs of a gastric leak. 9. Besides a leak, please state one other possible complication associated with bariatric surgery. 10. Which answer best describes how you feel about bariatric surgery? • Bariatric surgery improves the quality of life for all obese patients who are compliant with postoperative instructions and diet. • Bariatric surgery improves the quality of life for most obese patients who are compliant with postoperative instructions and diet. • Bariatric surgery improves the quality of life for some obese patients who are compliant with postoperative instructions and diet. • Bariatric surgery improves the quality of life for few obese patients who are compliant with postoperative instructions and diet. • I do not agree with bariatric surgery as a means of improving the quality of life for obese patients.