Attitude Isn`t the Only Thing, It`s Everything: Humanistic Care of the Bariatric Patient Using Donabedian`s Perspective on Quality of Care

Comprehensive care of bariatric patients is challenging. Although structural knowledge exists about safe care given correct equipment and supplies, care processes also must be humane. The literature suggests morbidly obese patients may fear the health system because of past negative experiences. The purpose of this literature review was to examine quality issues in the care of bariatric patients in light of Donabedian’s structure-process-outcomes model, emphasizing process components.Using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO; the criteria English language and years 2005 to 2017; and the search terms morbid obesity, obesity, bariatric, attitudes, health professionals, health clinicians, and patient care yielded 150 articles. Of those, 35 were pertinent to the review. A subsequent search using the terms Donabedian, care, and quality in MEDLINE and CINAHL resulted in 68 and 36 citations, respectively; 4 were used. When the searches were combined, no articles were identified. Findings show care providers generally understand structure aspects (knowledge or what to do) but need increased understanding of optimal care interventions (process issues or how to perform an intervention), including physical and psychological aspects. Organizations have a responsibility to ensure appropriate equipment and supportive services are available to achieve desired outcomes. Structure components will not overcome barriers or prevent complications if uncaring attitudes (processes) interfere with interpersonal interactions. Implications for clinical practice include requisite reflection on personal belief systems and empathetic understanding of precursors to morbid obesity development. Research needs to analyze what process issues are hampering quality care delivery and how to eradicate deficiencies.  Health professionals can promote optimal bariatric patient outcomes by developing necessary insight and clinical wisdom. Obesity is a worldwide epidemic and those affected deserve improved care now.

American football coach Vince Lombardi is widely attributed to have said, “Winning isn’t everything: it’s the only thing.” (Actually, these words first were spoken by University of California at Los Angeles football coach Henry Russell “Red” Sanders).¹ The assertion regarding the importance of winning has been touted as a basic tenet of American sports. Although many people do not agree with this perspective, they do support the idea of positive attitudes in attaining athletic excellence. A similar process occurs in health care.

For bariatric patients, attitudes of health care providers can be “everything” for promoting or decimating quality in patient care delivery. Care of bariatric or morbidly obese patients can be exceptionally challenging due to a variety of factors. Knowledge is not enough to overcome these challenges and ensure quality care outcomes when poor attitudes interfere with care delivery.

A pioneer in examining medical care quality, Avedis Donabedian, MD, developed a model of structure-process-outcomes and scrutinized barriers to quality care in each component.^2-5 Process issues appear to be assuming greater importance in a variety of care situations. For example, in a recent research study6 regarding predictors of satisfaction with elderly care, researchers analyzed results from a national survey of 95 000 elderly people in Sweden concerning their satisfaction with care. Using Donabedian’s model for analysis, their findings identified that quality in elder care was primarily determined by factors pertaining to process — that is, “how caregivers behave towards the older person.”⁶

In a published description of a lawsuit outcome,⁷ a morbidly obese patient alleged substandard postoperative care due to perceived discrimination by nurses due to her excessive weight. The patient believed they failed to move and reposition her, resulting in pressure injuries. The patient instituted litigation against the nurses and ultimately lost, but the legal action revealed gaps in care processes.

Donabedian’s model^2-4 revealed challenges in process issues in a cancer care stem cell transplantation program where patients experienced multiple transitions of care. Incorporating this model, a performance improvement project⁸ at a cancer care treatment center in the western United States demonstrated gaps in process issues (eg, patient education, lack of coordination). Once these gaps were addressed, patient satisfaction with care increased.

The purpose of this literature review was to examine quality issues in the care of bariatric patients in light of Donabedian’s structure-process-outcomes model, emphasizing process components.

Obesity and morbid obesity are distinguished as body mass index (BMI) of 30 and >40, respectively.⁹ A descriptive, phenomenological study¹⁰ revealed morbid obesity is a major risk factor for multiple comorbidities and premature mortality. Developing this condition has negative consequences for psychological health and often is linked to lower quality of life, depression, smoking, drinking problems, and poverty. Two (2) comparative, descriptive correlational design studies examined psychological and psychosocial aspects in morbidly obese patients seeking bariatric surgery. One¹¹ (1) involved 50 morbidly obese patients (11 men and 39 women) versus 25 normal weight patients, and another¹² included 149 extremely obese women (Class III or >40 BMI) versus 90 women with Class I (30 to 34.99 BMI) or Class II (35 to 39.99 BMI) obesity.⁹ Both studies found obese and morbidly obese persons reported more psychiatric and stress issues related to their physical status. Notably, the degree of psychopathology was related to BMI, with greater psychological aberrations as weight increased.

Morbid obesity and obesity are challenging in terms of the long-term health and activities of daily living of affected individuals and their caregivers. Morbid obesity and obesity will increasingly impact the American health care system’s resources related to care of comorbidities.^9,13 In 2008, annual medical costs of obesity in the US were $147 billion.13 Currently, 37.5% of adults in the US are obese.¹³ A state review¹³ in New Hampshire found a 2.5% prevalence of morbid obesity in 2007.

Perceptions of obese persons are influenced by cultural considerations. In a cross-sectional study¹⁴ conducted among 586 persons with BMI >30, researchers surveyed participants for perceived threats to health and found morbidly obese people may view themselves as “normal” depending on the standards of ideal body size inherent in their culture.

Several reviews of the literature^15,16 support that morbid obesity is a multifaceted condition that is considered a chronic disease. The disorder involves gender, lifestyle, dietary habits, genetics, ethnic factors, and sleep deprivation/apnea. The authors of a literature review¹⁷ of evidence-based strategies to treat adult obesity call the American culture an “obesogenic” environment (ie, an environment that comprises factors that support being obese¹⁸). Obesogenic environments are not conducive to walking, physical activity, and healthy food access; they promote weight gain and do not promote weight loss within the home or workplace. Some aspects involve the built environment (buildings and spaces created), and some are functions of people’s communities (eg, lack of safety).

Drug therapy involving antipsychotics, antidepressants, diabetic drugs, seizure control drugs, and steroids (glucocorticoids) is associated with substantial weight gain.¹⁵ A case study¹⁹ involving a morbidly obese woman described how patients can become morbidly obese in ways that are entirely out of their control despite health provider perceptions to the contrary whereby they blame the patient.

Donabedian’s model^2-4 proposes that health care or medical care quality can be examined in 3 domains: structure, process, and outcomes. The model suggests that all 3 domains are important and that they may have to be viewed collectively to monitor quality over time. Some authors⁸ suggest the framework is useful as a road map for discussing and evaluating the dynamics associated with planning and implementing care across care setting transitions. The model can identify gaps in care and promote standardization.

In the model, structure is defined as the relatively stable characteristics of the providers of care and their facilities, including organizational elements, personnel elements, and program operations (money, budgetary processes). This component includes factors such as facility type, resources (eg, beds), qualified professionals including specialists (eg, nurses, wound specialists, physical therapists), and special medical/technical equipment (eg, dressings, binders, lifts, and moving devices).

Process involves the delivery of care — that is, providing and receiving care — in terms of both providers and recipients. Providers implement care; patients seek care and (hopefully) adhere to treatment recommendations. Process also  involves technical and interpersonal aspects of care. Activities can include patient education, preventive therapies, ongoing assessment, and motivation/collaboration activities and the patients’ response to them.

Outcomes are the changes resulting from health care, including patient health status, patient knowledge, and patient satisfaction. Outcomes also can include staff and system outcomes and are considered the ultimate validation of the effectiveness and quality of health care. A visual of the model applied to bariatric care is displayed in Table 1. 

Donabedian also described 7 attributes (pillars)20 of quality health care (see Table 2). One (1) critical characteristic is acceptability, wherein patients and families have care adapted to their wishes. Even in 1990, Donabedian stressed that patients are vitally concerned about how practitioners and everyone else they encounter when seeking and receiving care behave toward them.²⁰ 

A comprehensive review of the literature was conducted using the databases Cumulative Index of Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO. Delimiting characteristics were publications between 2005 to 2017 and English language articles. Search terms included morbid obesity, obesity, bariatric, attitudes, health professionals, health clinicians, and patient care. A second search in MEDLINE and CINAHL for 2005 to 2017 used the terms Donabedian, care, and quality. Bariatric or morbid obesity or obesity then were added to these previous terms by combining the searches, and closely linked articles were included for analysis (eg, safe patient handling and mobility and the Donabedian model).²¹

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 reviews^16,17,22-24 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 literature^33,34 suggests ACE survivors benefit from sharing their past experiences and that it is not traumatic as some have feared.

Lifting. Research proposes that patient care safety literature for bariatric patients has specific suggestions. For example, according to federal and professional guidelines,36,37 health care providers generally should not lift more than 35 lb. In the case of morbid obesity, teamwork has to be written into patient assignments to promote better care processes. Single-care provider assignments can be altered to multiple personnel assignments to avoid having an assigned caregiver always having to search for assistance.

Humor. Humor also can help with altering care processes. Appropriate humor that incorporates humanity and nonjudgment can work very well and is frequently valued by bariatric patients.19 Health care providers have a chance to demonstrate their caring talents and have their finest hour in dealing with obese and morbidly obese persons.

Human touch. Because bariatric patients may encounter negativity and avoidance due to their excess weight, caregivers need to consider the power of therapeutic touch. It is worth thinking about how much human contact the patient experiences, especially if the care milieu is chronic in nature. When was the last time the patient received a “dose” of hugs? “Low tech” does not mean low effect. Human contact may help morbidly obese patients feel safe, accepted, and welcome in the health care setting.

Clinicians’ attitudes can be everything in promoting success or engineering failure. By learning about and reflecting on both structural and processual components of care, clinicians can promote best available outcomes for bariatric patients.

What needs to be studied. Implications for future research pervade the need for improved quality in bariatric care. What components play a critical role in promoting or hindering quality care delivery in specific organizations? How can health facilities prepare for the increasing numbers of morbidly obese patients? How can health professionals gain insight into personal biases and the lived experiences of morbidly obese persons? What outcomes are organizations aiming for in terms of patients, staff, and system functioning for bariatric patients?

Donabedian’s model of structure-process-outcomes for patient care quality was beneficial in surveying the literature on bariatric care. Structural issues (knowledge, evidence) are not as problematic as process components (interpersonal interactions, implementing care). To achieve outcomes of safe, effective care of bariatric patients who are satisfied with their care quality, process care challenges need greater scrutiny, including research initiatives. Are staff prepared to identify biases, acknowledge hazards in care implementation, and reflect on risk for morbid obesity development? Do staff know how to interact therapeutically? Are protocols established to promote these outcomes? Are they even being measured? Given the enlarging prevalence of obesity and morbid obesity across the world, these questions need to be addressed.

Obesity is a worldwide disease epidemic that is debilitating and ultimately fatal. The purpose of this literature review was to examine care challenges and barriers to safe effective care of bariatric patients in light of Donabedian’s model of patient care quality assessment. Findings suggested that structure issues (knowledge, expertise) are not as deficient as process issues (interpersonal interactions, biases, hazardous care approaches). Despite well-established structure components and clinical knowledge, obese and severely obese persons may avoid the health care system and its clinicians because of embarrassment, fear for their safety, and resentment regarding how they are treated. Research is needed on how best to influence the process aspects for bariatric patients. Health care providers can change perceptions (and sometimes reality) by understanding structure and process issues inherent in bariatric care and promote positive outcomes for obese patients, involved staff and caregivers, and health systems. 

Dr. Beitz is a Professor of Nursing, WOCNEP Director, School of Nursing-Camden, Rutgers University, Camden, NJ.

Please address correspondence to: Janice M. Beitz, PhD, RN, CS, CNOR, CWOCN-AP, CRNP, ANEF, FAAN, WOCNEP Director, School of Nursing-Camden, Rutgers University, 530 Federal Street, Camden, NJ 08102; email: Janice.beitz@camden.rutgers.edu.