The initial search identified 150 articles. Selected pertinent articles (ie, the 35 that clearly addressed the topic) were utilized. The second search of MEDLINE and CINAHL identified an additional 68 and 36 articles, respectively. A total of 39 ultimately were used. Adding bariatric and obesity and morbid obesity to the combination yielded no additional articles.
Multiple reviews16,17,22-24 have been written about the challenges of care for the morbidly obese that address structure issues in Donabedian’s quality model. These include knowledge about factors such as increased risk for pressure ulcers, skin infections, venous insufficiency, lymphedema, and surgical site infections.22 Interventions for optimal treatment and prevention of skin disorders such as skin fold management, good perigenital care, and exquisite attention to cleanliness are well known.22 Although a recent literature review24 suggested a strong need to develop an evidence-based approach to skin care in bariatric patients, 6 identified articles in the systematic review had common themes of clinical recommendations: 1) using materials to separate skin folds, 2) carefully drying deep skin folds, 3) inspecting the skin regularly, 4) avoiding excessive use of powders, 5) promoting clean perigenital areas and, very importantly, 6) seeking the patient’s views and expertise on care approaches. Consequently, knowledge (structure) is available to improve bariatric care.
Knowledge about the challenges of critical care for morbidly obese patients has been well described. Berrios23 uses a mnemonic to note the multisystem issues associated with bariatric care: A = airway; B = breathing; B = backs; B = bias; C = circulation; D = decubitus ulcers; D = drugs; D = diagnostics; D = diet; D = durable medical equipment. Morbid obesity affects the pulmonary system and capacity to breathe, alters drug metabolism and efficacy, and may interfere with diagnostic testing. Berrios suggests failure to understand the ABCDs of bariatric care can lead to catastrophic outcomes for both patients and care providers.23
The need for the availability of appropriate bariatric equipment and beds and effective bariatric movement equipment has been well identified; such equipment represents primarily structure components.19,23 Health systems and facilities that accept payment for the care of bariatric patients have a moral and ethical obligation to provide safety through appropriately sized equipment that has been designed and tested for persons who are in higher weight ranges. These facilities also have a corporate duty to have bariatric gowns, blood pressure cuffs, and other supplies (eg, bariatric beds and lifts) that fit the patient correctly; otherwise, the patient may feel uncomfortable or perceive a hostile environment.23 Patients, nurses, and other caregivers need to recognize hazards by being familiar with weight and size and equipment restrictions of, for example, commodes and stretchers.
Process issues involve interpersonal interactions between health professionals and patients. An important aspect of quality bariatric care is understanding the psychology of chronic illness. Chronic illnesses are known to affect self-efficacy — that is, a person’s belief in his/her capacity to perform behaviors necessary to produce a desired outcome.25 Morbidly obese persons may long for weight loss and improved health but believe it cannot happen. A recent explorative, longitudinal study26 in Norway showed the importance of paid work status on self-efficacy in morbidly obese people. Persons who were not able to work had significantly less self-efficacy. Health professionals should stop and think about what the person’s health state is doing to their employment status.
In an article on the experiences of an obese patient, Brass27 described her life as an obese and then morbidly obese person and offered a plea for health professionals to truly understand. To provide real help, obese persons need providers to understand the complexities of obesity and its psychological and emotional components, not add to the daily burdens of obese people through negative interactions.
Base-Smith28 conducted a phenomenological study of the lived experience of morbidly obese people. She found morbidly obese individuals endure stereotyping, prejudice, and discrimination and suggested health care providers’ conveyance of these attitudes culminates in substandard care delivery.
In a published personal narrative about obesity, Kwambai29 discussed stigma and how it affects care; she offered a plea for health professionals to change attitudes. She noted, “The association between obesity and chronic medical conditions like heart disease and diabetes has only given (health care) people more ammunition to voice judgment… People don’t look at me with sympathy… They look at me with disgust and hatred.”29
In a personal narrative on morbid obesity, Moore30 offered another insight when she reminded health professionals, “I’m your patient, not a problem.” She raised the issue that she doesn’t fit in health care settings (eg, doctor’s offices, stretchers, or too flimsy chairs) and that she is set apart unwillingly from others. In many instances, she has come to view health care as unsafe. She poignantly reminded health providers, “I am a person, not a problem for people to solve, not a disease, nor a moral failing.”
Attitudes. Process issues such as negative attitudes about morbidly obese persons can be addressed and altered. A major approach to altering one’s attitude is developing self-awareness. Envisioning oneself as facing the daily grind of living hampered by gross overweight or morbid obesity may assist with a sense of empathy. According to a recent enthnography,31 awareness that the morbidly obese person encounters fat stigma may assist with a development of mutual presence, wherein patient and care providers address the weight situation openly, honestly, and respectfully.
Another approach to altering attitudes is empathizing about bariatric disease. Research supports that genetic factors may limit weight loss and maintenance even in persons who have undergone bariatric surgery.16 Despite best efforts, some persons cannot lose weight nor maintain weight loss. Health care clinicians have the opportunity to ask respectful questions and learn about the patient’s care history.
Research also supports that obese and morbidly obese people have difficulty describing their emotions. Caregivers may recognize that they can work to promote emotional health by making patients feel safe to speak.32 It also is helpful to ponder the effect of having bariatric patients who are afraid of care providers (they may view the health system negatively) and that their fears are not entirely unreasonable.
Related to this emotional blockade is the role obesity/morbid obesity may play in managing past abuse or adverse childhood events (ACEs). Epidemiological reviews33 conducted at the Permanente Health System in California suggest obesity may have played a protective role physically, socially, and sexually in persons experiencing abuse in childhood. A review of research outcomes at a weight loss program at Permanente System34 suggested, “No one becomes fat out of joy.” Researchers submit that obesity is not the core problem; the problem is deeper psychodynamic issues. Health providers need to ponder the possible protective benefits34,35 and ask about life experiences. The literature33,34 suggests ACE survivors benefit from sharing their past experiences and that it is not traumatic as some have feared.