Incorporating Obesity Education into Adult Primary and Acute Care Nurse Practitioner Programs

Introduction

Obesity has reached an epidemic level in the United States. According to the Center for Disease Control 2010 statistics, no states have obesity prevalence rates less than 20% and 12 states have obesity rates at 30% or greater. ¹ More than two-thirds of adult Americans are overweight or obese. ² It is projected that 51.5% of American adults will be obese by 2030 and that 100% of adults will be obese by 2102. ³ Obesity-associated conditions significantly increase mortality and morbidity, as well as hospital length of stay and overall healthcare costs.^4,5 Obesity is linked to numerous chronic health conditions including hypertension, hyperlipidemia, sleep apnea, type 2 diabetes, and heart disease. ⁵ In addition, there are a multitude of psychosocial aspects affected by obesity, such as well-being and quality of life.^6–8 As a leading cause of preventable death, obesity must be addressed as a chronic health condition by healthcare providers.

The high prevalence of obesity has created a ripple effect throughout healthcare, and healthcare organizations have taken great strides to address obesity-related issues such as sensitivity training and adjustments to the environment of care (e.g., bariatric equipment). ⁹ Studies suggest, however, that nurses, physicians, and their respective students need additional obesity education and training.^10–16

Nurse practitioners play an integral role in the care of patients with obesity. In fact, a team-based approach to healthcare has been recommended by many organizations, including the Institute of Medicine (IOM) and the Agency for Healthcare Research and Quality (AHRQ).^17,18 There are currently more than 148,000 nurse practitioners practicing in the United States, and enrollment in nurse practitioner programs is on the rise. ¹⁹ In the face of a continuing shortage of healthcare providers and the epidemic nature of obesity, nurse practitioners caring for obese patients will likely be the rule rather than the exception. It is imperative that nurse practitioners are well educated on this topic.

Current Recommendations for Obesity Education

Professional and governmental organizations often make recommendations for key content that is to be included in healthcare provider education. Using genetics as an example, the National Coalition for Health Professional Education in Genetics (NCHPEG) and the National Institutes of Health (NIH) have recommended competencies and curricular guidelines for incorporating genetics into healthcare professional education.^20,21 Another example is palliative care, hospice, and end-of-life. A Google search for palliative care yields countless organizations and articles, including competencies from the American Association of College of Nurses and the American Academy of Hospice and Palliative Medicine. Similar curricular and competency recommendations have been made for diseases such as HIV/AIDS, diabetes, and tobacco abuse.^22–24

Given that obesity is the most common disease in the United States today, it stands to reason that competencies for healthcare professional education on obesity would also be as prevalent. However, a review of the current literature found a paucity of information on competencies and curricular recommendations regarding obesity in healthcare provider curricula.

Medical and Allied Health Education

In 2005, the National Heart Lung and Blood Institute (NHLBI) published recommendations from a working group on obesity competencies in medical education. The report included recommendations for incorporating obesity content into undergraduate medical education (UME), graduate medical education (GME), and continuing medical education (CME). No further detailed competencies were developed after this workgroup. The Nutrition in Medicine Project published by the University of North Carolina Chapel Hill has a curriculum designed to educate medical students on prevention and therapeutic perspectives of nutrition, as well as the biochemical basis of nutrition, nutrition epidemiology, clinical nutrition (including nutrition assessment), and nutrition-related preventive healthcare. ²⁵ Despite being an excellent resource for nutrition education, it is not specific to obesity nor does it cover obesity as a unique disease.

Other allied health professionals such as physical therapists, dieticians, and pharmacists are active participants in the healthcare of obese patients as well. While the core competencies for these professions mention obesity, none have competencies or guidelines on how to incorporate obesity into their educational curricula.

Nursing Education

It is well accepted that obesity is a predictor of morbidity and mortality across the life-span, yet little attention has been paid to the specific educational and training needs of students enrolled in Adult-Gerontology Nurse Practitioner (AGNP) primary and acute care programs in regard to the diagnosis and management of overweight and obese patients. This is probably due to the lack of national competencies or guidelines regarding specific obesity education that should be included in nursing curricula. The lack of national competencies may be due to the fact that the medical community at large often fails to identify obesity as a unique disease state (despite straightforward diagnostic criteria and treatment guidelines), insufficient reimbursement for obesity treatment (e.g., diet and/or exercise counseling, medication), a continued perception that obesity is a self-inflicted condition, and the sensitive nature of discussing weight-related issues. No recommendations have been made regarding how to incorporate obesity content into AGNP primary and acute care education. According to the Consensus Model for Advanced Practice Registered Nurse Regulation (APRN): Licensure, Accreditation, Certification, Education (LACE) ²⁶ recommendations, all APRNs are to be educationally prepared to provide a scope of services across the health wellness–illness continuum. Guided by the educational component of the Consensus Model, nursing faculty are to prepare APRN graduates who can apply their respective scope of practice competencies across multiple settings. ²⁷ Indeed, the care provided by entry-level APRNs requires not only a vast body of knowledge of acute and chronic illnesses, it also requires the acquisition of advanced skill sets such as motivational interviewing. Clinical competencies for the adult-gerontology population, as outlined by the National Organization of Nurse Practitioner Faculty (NONPF), provide not only a foundation for academic curricula, but also a consistent model for clinical entry.^28–30 These competencies are generally broad (e.g., “assessment of health status”) with provision of some detail and/or examples for clarification (e.g., “obtains relevant health history, which may be comprehensive or focused”). Although specific disease states are generally not delineated within the NONPF core and population-specific competencies, there are several adult-gerontology primary care examples that are provided. ³¹ While it is understood that such examples are utilized for clarification and not meant to be all inclusive, it is striking that obesity and obesity-related measures are notably absent throughout these documents. For example, among 16 specific examples of health-related items that APRN students should be competent to assess and measure prior to graduation, ³⁰ neither body mass index (BMI) nor any other anthropometric measurement are listed as examples. Current practice guidelines recommend adult primary care patients be screened for overweight and obesity using BMI, the “gold standard”’ for diagnosis.^32,33 Absence of this measurement as a clinical competency is worrisome, particularly since it is assumed that an entry-level AGNP graduate is prepared to implement the full scope of care in their role (as regulated by their state board of nursing). ³⁴ Given the increasing health consequences associated with increasing BMI, comorbidities, and the benefits of weight loss, it is critical to ensure learning opportunities for primary and acute care AGNP students. Awareness and documentation of a patient's current BMI may prompt motivational interviewing and other obesity-related management strategies. ³⁵

Obesity Content in Certification Examinations

Benefits of Incorporating Obesity Content into Curricula

There are few studies that demonstrate the need or benefit of incorporating obesity education into educational curricula; there are none specific to nurse practitioner curricula. Several articles can be found in medical school literature, although a significant majority of them are outside the United States or are related to pediatric obesity. One study by Banasiak and Murr ³⁸ found that medical residents who had rotations in bariatric surgery were significantly more likely to answer questions correctly related to clinical management and treatment of obesity. ³⁸ Another recent publication described a significant improvement in student attitudes and understanding of obesity and obesity surgery after a longitudinal experiential learning program with patients undergoing bariatric surgery. ³⁹ While there are no specific studies addressing the impact of incorporating obesity education in to an APRN curriculum, knowledge from medical education can guide our recommendations for incorporating obesity into the primary and acute care AGNP curriculum.

The lack of attention to obesity education and related communication training in the AGNP primary and acute care curriculum only complicates the expectation that students will be culturally sensitive, competent communicators with obese patients and their families. In a similar fashion to the specific and sensitive communication training needs for palliative and end-of-life care, limited educational opportunities in bariatric sensitivity and education training could result in negative healthcare provider attitudes and poor patient outcomes (e.g., delay in seeking treatment based on past interactions and/or experiences with healthcare providers). ⁴⁰

Recommendations for Incorporating Obesity Content in Adult APRN Education

Since the obesity epidemic is not reflected within the current national APRN competencies and certification exam blueprints as key information necessary for clinical entry, it is not surprising that obesity is not well incorporated within respective APRN curricula. Obesity is often not documented as a clinical diagnosis when, in fact, the patient is obese. Lack of documentation could be a reflection of education and training indicating a need for national guidelines and competencies to guide faculty in curriculum development. Recommendations for incorporating obesity into APRN education include competencies and content.

Nurse practitioner education should be evidence-based, and recommendations for APRN education and training should include a strong basic science foundation, including pathophysiology, pharmacology, physical assessment, current obesity research, and clinical practice guidelines. Specific competency recommendations for the adult-gerontology nurse practitioner in primary and acute care settings are outlined (Table 1). At completion of the program, the AGNP primary care and acute care graduate should possess these competencies. Other resources to assist faculty in APRN curriculum development are included in Box 1.

Pathophysiology, pharmacology, and physical assessment, often referred to as the ‘three Ps' in AGNP curricula, must include obesity content. Pathophysiology should include a detailed understanding of primary and secondary causes of obesity. In particular, the genetic basis for obesity, as well as the impact of obesogenic environments, should be discussed as opposed to the moral failure or lack of willpower of obese patients. Instruction specific to pharmacokinetic and pharmacodynamic changes associated with obesity could improve medication prescribing and dosing practices. In addition, pharmacology should include all medications used to treat obesity, and the metabolic effects of all medications and their propensity to cause weight loss and gain should be incorporated. A course in comprehensive health assessment should include detailed history-taking skills related to obesity, including diet, exercise, weight loss attempts, family history, genetic conditions, medications, and psychosocial factors. In addition, students should understand the use of and limitations of BMI and waist circumference as a measure of obesity. Students must understand physical findings associated with primary and secondary obesity. Knowledge of ongoing research will help the student process the basic science foundation of this disease.

A thorough understanding of clinical practice guidelines is crucial for evidence-based management of all diseases. Many professional organizations and governmental agencies have statements or guidelines regarding screening, diagnosis, and treatment of obesity. The U.S. Preventative Services Task Force (USPSTF) recommends that all adults are screened for obesity using BMI as the measurement. BMI is used to describe the degree to which a person has excess adipose tissue and gives numeric values to body weight categories such as overweight and obese. BMI, calculated by weight in kilograms divided by height in meters squared, is routinely used to classify body weight and correlates with total body adiposity. The American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Diabetes Association, and the American College of Preventive Medicine all have recommendations for measurement of height and weight or BMI.

The USPSTF recommends that clinicians offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. ³³ The NHLBI Obesity Education Initiative published clinical guidelines on the identification, evaluation, and treatment of overweight and obese adults. ³² In 2000, The Practical Guide to Interventions, Evaluation and Treatment of Overweight and Obesity in Adults was published to give practitioners a practical guide and tools to assist their patients. ⁴¹ The guide includes an algorithm that begins with identification of the condition and assessment of the patient including BMI, waist circumference, and analysis of risk factors. The algorithm continues with treatment beginning with diet therapy, behavioral therapy, and physical activity, and includes consideration of pharmacotherapy and bariatric surgery. ⁴¹ The guidelines are currently being updated with a proposed publication date in 2012.

While the above guidelines address primary care chronic disease management, there are no guidelines addressing the overall management of obese patients in the acute care setting. Multiple reports, however, describe management of other conditions in hospitalized patients who are overweight or obese. These conditions could potentially serve as key content within an obesity-focused curriculum; subsequent educational opportunities can be infused throughout the curricula in many innovative ways.

Incorporating Obesity Education into AGNP Curricula

Faculty responsible for educating AGNP students on the specific care needs of patients diagnosed with obesity need to reconsider the current teaching approach and present content from the whole-patient perspective rather than in segments (e.g., pulmonary/ventilator considerations for the patient who is obese). Adult learners may benefit from a change in presentation style as they are asked to consider potential complications in managing a patient who is obese. Presentation of content in a longitudinal fashion demonstrates the development of patient–provider relationships and disease trajectory (e.g., motivational interviewing, lifestyle and treatment interventions, obesity-related hospitalizations, bariatric surgery management/postop complications).

Clinical exposure to the care of the obese patient through clinical and residency experiences may help improve obesity understanding. Adult learning theory acknowledges that adult students bring a vast array of knowledge and experience to the learning environment. Experiential learning recognizes this and attempts to build on this foundation by utilizing their own beliefs, ideas, and experiences and integrating them with new more refined ideas ⁴² routed in evidence-based practice. The benefits of experiential learning were supported through Banasiak and Murr's work with medical students. Those students who were exposed to experiences with bariatric patients demonstrated not only a higher overall knowledge of obesity-related issues, but also a stronger knowledge of clinical management and treatment efficacy. ³⁸

Teaching strategies that target the adult learner (e.g., self-guided online learning, role playing, virtual patients, high-fidelity simulators, and objective structured clinical examinations) in addition to traditional didactic instruction can be used to incorporate obesity content into the curriculum. These strategies allow AGNP students the opportunity to engage and apply psychosocial skills (e.g., difficult conversations, counseling techniques), psychomotor skills (e.g., central line insertion), and critical thinking skills (e.g., ventilatory management) to the care of overweight and obese patients in a non-threatening, safe environment. ⁴⁰ Utilizing these unique teaching strategies, AGNP students can obtain an extensive understanding of the complex and challenging needs of patients with obesity (Table 2).

Role Play

Role-playing is an underutilized strategy for gaining expertise in critical psychosocial skills such as discussion with patients about their diagnosis of obesity and counseling them on health implications and treatment. Traditionally, strategies for this type of skill have been taught in a lecture-based environment, and the student is expected to practice them in the clinical setting. However, it has been demonstrated that experiences in the relatively uncontrolled setting of clinical do not always match the course objectives. ⁴³ Additionally, the student will often have these patient conversations without the preceptor present, therefore limiting consistent feedback on their performance. This feedback is invaluable when addressing the complex and sensitive issues surrounding patients with obesity.

Through the use of role play in a classroom setting, the student is able to work through increasingly difficult situations without demands of caring for an actual patient (e.g., time constraints of the clinical setting, worry about causing the patient harm). Students are able to get feedback from the instructor as well as their peers and repeat the experience to improve and strengthen their skills. Another advantage to the use of this strategy is that the instructor is able to call a “time-out” during the experience to have a dialog among the student and others in the class about what is going well and how the discussion could be improved.

This strategy is very effective. However, there are challenges. While an instructor can utilize role play in a large classroom setting, it is more effective in a smaller group of 8–12 students. This allows for more in-depth discussion of the scenario and allows all students to take an active role in the activity. There is also the cost of hiring actors to portray the patients, as well as the time to train them to the case. Although some control and structure of the scenario may be lost, this cost can be avoided by having the student or faculty member play the patient. In particular, faculty members and students may not be obese, decreasing some of the reality of the scenario. Despite these challenges, role play is an effective strategy to develop experience and expertise in psychosocial skills.

Virtual Patient Technology

The use of virtual patient technology is a teaching strategy that utilizes computer software to simulate clinical scenarios. Virtual patients can be defined as real-life clinical scenarios in which the student conducts the various components of a patient encounter (e.g., history-taking, physical examination, and management plan) via a computer program. ⁴⁴ There are numerous programs available for purchase or construction including DXR Clinician, Second Life, and Virtual Health Care Team. These programs offer a variety of case studies that allow the student to work through the case at their own pace to strengthen their diagnostic reasoning skills. Assigned cases can also be tailored to reinforce specific obesity-related content that students may have limited exposure to in the clinical setting. One unique feature of the virtual patient is that it allows for the student to have multiple “encounters” with the same patient. This gives the student the opportunity to experience case progression, which is frequently absent in the clinical environment.

While virtual patients provide a unique opportunity to introduce a variety of content and teaching strategies, there are challenges to this learning environment. The first is the cost. The production of cases can cost from $10,000 to $50,000. ⁴⁵ Purchase of readymade programs cost upwards of $20,000. ⁴⁶ There is also the issue of updating the software as clinical practice guidelines change. Finally, the cases can be challenging and time consuming to grade, as there is a vast amount of information contained within the case and having an objective grading tool for an assignment that may have several correct approaches and management possibilities is complicated.

Simulation

The use of simulation for both formative learning as well as evaluation is being used with increasing frequency in the education of healthcare providers. This learning strategy utilizes high-fidelity simulators and/or standardized patients who portray patients in a realistic and consistent manner to provide AGNP students with the opportunity to develop and validate their ability to link theory with practice. ⁴⁷ Examples of simulation use include the development of communication skills (e.g., discussing sensitive topics, managing challenging families), demonstration of physical assessment and procedural skills, and synthesizing the objective and subjective data collected during the exercises to develop a plan of care based on clinical practice guidelines. Feedback from students has been positive, stating improved knowledge and confidence in clinical reasoning skills as a couple of the advantages. ⁴⁸

As with previously described forms of teaching strategies, simulation requires a significant amount of faculty time to develop. In addition, if simulation is for evaluation, standardized scoring of the patient experiences can be difficult and time consuming. The cost is also a consideration. Actors are generally paid $15–$25/hour, and training time must be factored into the overall expense. High-fidelity simulators can cost upwards of $30,000 depending on the model, with costs stretching into the thousands depending on the complexity of the model. Another challenge in using this technique for obesity-related education is that obese mannequins are not as well developed as normal-weight mannequins and are not as readily available on the market. Currently, a mannequin of “normal” body weight must often be retro-fitted with a padded overlay to simulate the care of the obese patient.

Conclusion

Not only is obesity a modifiable risk factor for morbidity and mortality, it contributes to the development of other disease states and conditions such as hypertension, cardiovascular disease, dyslipidemia, insulin resistance/type 2 diabetes, metabolic syndrome, obstructive sleep apnea/hypoventilation syndrome, osteoarthritis, depression, and disability. Despite these well-known adverse effects, rates of obesity continue to climb at an alarming pace. As educators of future primary and acute care AGNP providers, tackling this epidemic requires strategic planning, implementation of obesity education, and learning opportunities within the curricula.

While the actual practice of adult primary and acute care nurse practitioners may differ in many ways, there are also many similarities. The frequent overlap in the respective primary and acute care entry-level competencies emphasizes that the scope of practice should be based on adult-gerontology patient population care needs and not limited by setting. ²⁷ To date, national curricular guidelines and competencies regarding obesity in advanced practice education is notably absent, and should be considered an urgent curricular priority. Subsequently, primary and acute care AGNP graduates may learn about obesity management as on-the-job instruction (e.g., forced exposure). Education and learning opportunities in this venue may lack sensitivity and quality control for patient care needs.

Changes in how we educate future AGNPs through new and innovative teaching strategies and clinical experiences will foster critical-thinking skills and problem-solving strategies, which may improve outcomes among patients who are overweight or obese. The teaching strategies discussed utilize adult learning theory, which emphasizes the importance of building on past theoretical knowledge and experiences to demonstrate competency specific to the diagnosis and management of obesity. Further discussion regarding standardized obesity-focused content and core competencies is warranted, and methods of outcome evaluation should ensue. Based on our review of the current obesity literature, guidelines, and the authors' own academic and clinical practice experiences, we conclude that AGNP primary and acute care curriculum efforts should incorporate obesity education as a unique disease state and provide students with multiple sessions and opportunities for discussion, practice, reflection, and feedback. To do otherwise would leave our future graduates without the tools necessary to care for this vulnerable patient population.