A Qualitative Study to Explore the Impact of Simulating Extreme Obesity on Health Care Professionals` Attitudes and Perceptions

Extremely obese patients pose significant challenges for those who strive to provide care. The prevalence and consequences of weight bias and stigma in health care have been well documented, but research on how to reduce weight bias and stigma is limited. To assess the impact of simulating obesity on the attitudes and perceptions of health professionals toward extreme obesity, a qualitative study involving 6 registered nurses and 1 registered physiotherapist was conducted between November 2015 and May 2016.Health professionals who had regular contact with persons with obesity were recruited through poster advertisement in 1 hospital and 2 universities. Participants completed a demographic survey that included their physical measurements (height, weight, and waist circumference). They then wore a suit simulating the shape and size of a person with extreme obesity for approximately 2 hours and engaged in activities such as taking public transport or visiting a café. Audiotaped, semistructured interviews were conducted before and after the suit exercise and transcribed verbatim for conventional content analysis that identified 3 main categories: 1) insights into the physical challenges facing people with extreme obesity; 2) awareness of social consequences for people with extreme obesity; and 3) changes in participants’ attitudes toward people with extreme obesity. Following the exercise, personal attitudes were found to be less judgmental and more empathetic. Using a simulation suit may increase awareness among health professionals regarding issues facing persons with obesity and may be a positive influence on diffusing weight stigma and bias in health care settings, particularly in the area of wound prevention and management where excess weight often requires additional nursing care that may exacerbate existing biases. Ethical guidance needs to be developed in conjunction with further research to explore the risks and benefits of using simulation suits in clinical practice and education.

Extreme obesity is defined by the Centers for Disease Control and Prevention¹ as class 3 body mass index (BMI) of 40 kg/m² or higher. Reviews of the literature^2,3 have shown extreme obesity can pose significant challenges for those who strive to provide care for larger, heavier patients. In terms of skin and wound care, for example, extra attention must be paid to cleanliness, skin fold management, perigenital care, odor management, and effective pressure redistribution.² The complexity of care for the patient with extreme obesity makes the knowledge and skills of the clinician, caregiver, and patient essential to patient satisfaction and therapeutic outcomes.² Preplanning is an essential component of safe patient care, and education is a critical part of the care plan as a strategy to ensure basic skills or competencies are understood and met.³ Health professionals providing care to this population not only have to attend to the patient’s specific physical health needs, but they also need to address the challenges posed by their own attitudes and any stigma and bias toward larger-bodied people.

The prevalence and consequences of weight bias and stigma in health care have been well documented in the literature.^4-6 Negative attitudes, social awkwardness, and behavioral bias toward people with obesity have been demonstrated in self reported questionnaires, implicit and explicit bias-validated tools, and observational and simulation studies among a range of qualified and trainee health care professionals, including doctors and nurses,^7-12 dietitians,^13,14 physiotherapists,¹⁵ and those specializing in obesity management.¹⁶ This is concerning; a systematic search of the literature¹⁷ relating to professional or patient experiences with obesity noted impacts on health care interactions, and qualitative studies^18,19 have shown weight bias impacts subsequent health outcomes and quality of care for people with obesity. According to studies involving self-reported questionnaires, implicit and explicit bias validated tools, and phenomenological accounts, patient experiences with weight stigma by health professionals have been associated with patient anxiety, negative psychobehavioral responses,^20-22 and avoidance or delays in accessing health care.^15,18,23

Several studies^18,24,25 have noted that establishing trusting and respectful relationships with health professionals is important to patients in accessing timely health care. Improving the quality of care through the provision of safe, appropriate, nonjudgmental approaches is an urgent priority across the health sector.

The National Institute for Health and Care Excellence²⁶ recommends that to address the issues of weight stigma, health professionals need to develop a better understanding of the experiences people with obesity face with regard to their weight. Despite evidence of weight bias among health professionals, research on how to reduce weight bias and stigma is limited.²⁷ One approach to addressing weight stigma and increasing the understanding of the lived experience of people with extreme obesity is to simulate this experience for health professionals. Simulation suits have been used in emergency responder training to develop skills and to practice techniques for the safe and empathetic rescue of people with extreme obesity.²⁸ Although newsletters and news items report on the use of simulation suits, limited research has been undertaken to measure and assess their actual application. In Minneapolis, Minnesota and Providence, Rhode Island, simulation programs are partnered with safe patient handling and mobility training to improve staff and patient education; in these instances, trainers report simulation suits helped achieve goals of safer patient care along with proper selection and usage of equipment, effectively enhanced appreciation for the challenges faced by people with extreme obesity, and positively affected staff attitudes and behaviors.^29,30 Leicester, United Kingdom similarly introduced such suits for bariatric care training of health professionals.³¹

Simulation suits have been used outside of the health care setting with sport and exercise students to explore physical activity and body image. A phenomenological study³² that involved 8 sport and exercise undergraduate university students investigated the experience of extreme obesity in a physical activity environment to explore mobility limitations associated with physical activity. The authors found the World Health Organization³³ recommendation to exercise 30 minutes per day was not realistic for people with restricted mobility. In a qualitative study³⁴ among female dancers (N = 15 undergraduate sport, dance, and performing arts students), simulation suits were utilized in a way that potentially could add to weight stigma (ie, making the larger body something to avoid). By wearing the suit, dancers felt more comfortable and confident with their own bodies. Such suits also were used in a randomized, controlled trial³⁵ involving 109 undergraduate psychology students to investigate how weight stigma affects eating behavior, physiology, and psychological well-being. The study found nonobese participants can experience some consequences of weight-related stigma by wearing an obesity simulation suit. However, the study did not show an effect on antifat attitudes of participants after wearing the suit. The authors of that study believe their findings will contribute to better understanding of the harmful effects of weight stigma and could inform future interventions to reduce weight stigma. Weight stigma scholars have argued that the use of such suits raises methodological and ethical questions; they refer to studies reporting findings based on a thin person wearing a simulation suit and bearing no relationship to the responses of a higher weight person, thus perpetuating weight stigma and discrimination.³⁶

Given that simulation suits continue to be utilized in health professional training, a qualitative study was conducted to explore whether wearing a simulation suit influenced the attitudes and perceptions of health professionals toward persons living with extreme obesity.

Sampling and recruitment. Health care staff who self-identified as regularly working with or caring for people with obesity were eligible for this study. Prospective participants were recruited between November 2015 and May 2016 through poster advertising within an urban New Zealand tertiary hospital serving a population of approximately 513 900 people and nearby universities where continuing education is offered. Posters were placed in strategic locations such as department/ward staff rooms, research bulletin boards, health professional offices, and common rooms within the hospital and university departments that provided undergraduate and postgraduate health education.

Participants were asked to complete a short questionnaire consisting of 5 open-ended questions that focused on perceived difficulties a person with obesity may face on a daily basis, during exercise, and when engaging with health care services; perceived feelings when in public places; and what health care professionals should know or try to find out from people with obesity. Additionally, the questionnaire included items on personal demographics and physical measurements (credentials and height, weight, and waist circumference) that were completed by the researcher. This was followed by a semistructured interview that focused on reasons for participating in the study and provided an opportunity for the participant to elaborate on the 5 items in the questionnaire.

The interview schedules were developed based on previous research.^10,37 Interviews were conducted by the third author and a research assistant with specific experience in interviewing people with obesity and other vulnerable populations. Interviews lasted between 20 and 40 minutes and were conducted 1 participant at a time in a private research room. All interviews were audiotaped and transcribed by a member of the research team.

Following completion of the questionnaire and semi-structured interview, participants then were asked to wear the simulation suit for approximately 2 to 3 hours and undertake a series of activities. The suit weighed approximately 7.5 kg (20 lb) and simulated the shape and size of a person with extreme obesity, although not the actual weight. Participants were asked to engage in activities such as walking up and down stairs, tying shoelaces, taking public transport, visiting a café, or going food shopping in a large metropolitan supermarket. Following the activities, the participants, while still wearing the suit, were interviewed about their experiences. The second interview focused on exploring the physical and social experiences of the participants and how these experiences may have changed their perceptions of people with obesity and future health care practices.

Physical considerations. To ensure participants were appropriately fit and healthy to undertake the study, they completed a health screening questionnaire at the time of consent to identify any underlying physical or mental health issues that could be exacerbated by wearing a simulation suit. In addition, given the possibility that the experience of wearing the simulation suit might undercover some surprising, unanticipated, or negative emotions, all participants were offered the opportunity to be accompanied by a research assistant on their activities during the experience, and provision was made for counseling services if required after the experience.

Ethical considerations. Informed written consent was obtained from all participants and ethical approval was given by the Victoria University of Wellington Human Ethics Committee (Approval Number 19686).

All participant data were anonymized and distinguishing participant features removed. No names were used in data presentation; individual participants were identified simply by a number.

Data collection and analysis. Data was collected via questionnaires and face-to-face interviews. NVivo 11 computer software (QSR, International, Burlington, MA) was used as a tool to facilitate management of all data during analysis and provide an audit trail of coding decisions. All written material was stored in a locked file, and all electronic information was password protected with access to written and electronic material restricted to investigators. Data are stored for 2 years before being securely destroyed.

Content analysis of the data was undertaken on the interview transcripts using semistructured interview schedule and coding schemes as described by Boyatzis.³⁸ This approach was chosen because it allows for a pragmatic way of reporting common issues identified in the data when undertaking exploratory research in areas where little is known.³⁹ Initial data analysis was conducted by the primary author and verified by the second and fourth authors following a conventional content analysis process.⁴⁰ This approach was adopted in response to the limited literature on the research topic under investigation. Participant responses closely reflected the specific questions asked in the semistructured interview schedule that was used to undertake initial coding. Codes were grouped and reduced with categories created to provide general descriptions of the participant experiences. All 4 authors then agreed to the emergent categories across transcripts.

Participants. Seven (7) health care professionals — 6 registered nurses and 1 registered physiotherapist — participated in the study. All participants were of European descent and all but 1 were female. Age and body size measurements, with and without the simulation suit, are provided in Table 1. Participants worked in a variety of health care settings including acute in-hospital services, palliative care, occupational health, and private practice plus tertiary education (university). Four (4) participants were in the healthy weight range for BMI, and 3 were in the range for overweight.

Interview results. Three (3) primary themes emerged from the content analysis of the interview data. These focused on: 1) insights into the physical challenges facing people with extreme obesity; 2) awareness of social consequences for people with extreme obesity; and 3) changes in participants’ attitudes toward people with extreme obesity.

Physical challenges. In presimulation interviews, participants identified physical and practical challenges they thought people with extreme obesity faced in everyday life, including mobility issues such as walking, climbing stairs, and getting in and out of chairs; and difficulties with activities of daily living such as toileting and personal hygiene, leaving the house, and equipment issues (eg, public transport seats and toilet cubicles being too small).

Despite their existing awareness, participants had not expected the extent of the physical challenges they experienced when wearing the simulation suit. The 6 female participants reported issues related to the physical effects of wearing the simulation suit and related mobility difficulties. They commented how their physical size affected their ability to safely and easily negotiate environments they had not previously regarded as challenging. Participants reported feeling really awkward walking (Participant 3), clumsy and uncoordinated (Participant 6), concerned about banging into things (Participant 4), and conscious of just how much more room I took up really …because of so much sticking out (Participant 6). One (1) participant described how embarrassing it was taking up 2 seats on the bus:

And at first I didn’t realize, I sat down on the seat and didn’t realize that a quarter of me was out into the aisle. And I had to move over. — Participant 6

Several comments related to how being a larger size made movement more uncomfortable, slower, and tiring:

And I was just, ‘Oh God, this is exhausting!’ Just getting a book out of my bag! — Participant 1

Very exhausted and hot. And uncomfortable… I just feel hot and bothered. — Participant 2

I could bend my knees alright, but I could also feel the weight of my stomach fold even as low as my thighs really… Which would also really prevent you from going fast. So everything really has to be done in slow motion. It just takes a lot longer… I would be out of breath very quickly as well. — Participant 5

Several comments reflected a new appreciation for the mobility challenges that people with extreme obesity face:

I see bigger people sitting on those seats (outside shops)… Now I realize they just have to sit there. Otherwise they can’t even go in the shops… Everything is just a big effort… I can see how you would just need to sit down in between little tasks here and there. — Participant 5

There’s a lot of stuff that’s actually in the way that I hadn’t realized before. Maneuvering around different people or trying to reach for things is much harder with the weight than just walking around the supermarket. It’s so much more tiring. — Participant 4

Similarly, comments highlighted how the lack of movement and suppleness made activities, such as eating, difficult:

I ordered a drink and it was really hard… so I was spooning it … it was an iced chocolate and I was trying to eat it and I thought, ‘I’m glad I haven’t ordered a meal’. ’Cause it’s really hard. I got chocolate all over my T-shirt. So I don’t think I’d eat. I wouldn’t eat out. — Participant 1

Eating at the café without being able to get far enough forward so I could get over the plate… And so the risk of getting crumbs all down my front, and looking like I was, you know, eating at a less attractive manner. And how small the fork felt… it was like, ‘Oh no, I have this small cake fork and I can’t get forward. Argh, what’s gonna go on here’ … And so I’m getting crumbs in my folds. — Participant 7

Participants reported how their larger physical size prevented them from fitting into public spaces:

Couldn’t get in there (gift shop). I did not feel happy going, I sort of stayed at the main entrance. But I would have liked to have looked at the back of that shop. It has nice little things but you feel like an elephant in a china shop really. You just can’t get in. — Participant 5

Before I sat down I had to move the table out. So it was very obvious that I was very large. — Participant 6

Other comments related to how the lack of visibility impacted on mobility:

I went down the stairs… Um, a little bit scary ’cause I couldn’t see my feet. — Participant 3

I did not think it would be so difficult to be mobilizing when you cannot actually see anything below your boobs… You cannot see your feet. You cannot see where you’re going to step actually. I think that was the biggest surprise. Um, and anything really on your own body too. Whatever happens on your tummy, you cannot actually see. — Participant 5

Experience of social stigma. When wearing the simulation suit in public, participants became aware of the social stigma people with obesity experience. Some referred to feeling “invisible” and not being acknowledged:

To smile at people and to have them pretend that they haven’t seen you smile was really interesting. It was like, ‘OK, so why does my being fat mean that my smile has no value suddenly?’ — Participant 3

It was interesting as soon as I came out that front door I was like, ‘Oh my gosh, I’m not me anymore. I’m this other person that society doesn’t really like too much.’ By the time I got on the bus to come back I was thinking, ‘I’ve had enough now. I want to be myself again.’ It would be pretty awful actually. — Participant 1

These experiences of social stigma also were reported to occur within the hospital and were enacted by health professionals:

What I did notice was walking along the corridors in the hospital, hospital staff don’t look at you. Well they don’t look at your eyes. They don’t make eye contact. As they go past, they drop their eyes and look across at your body… And not a single person smiled at me. — Participant 3

You sort of felt very observed by people who were staff members in the hospital. Some patients, or visitors were quite conspicuous in their observation as well but not as much. There were a couple staff members who I really felt were observing me… it did feel like I was being judged a couple of times — Participant 7

Other comments reflected insights into how the experience of social stigma could result in socially isolating behaviors:

So now I know that I would not go back into that little shop again which is a shame really. — Participant 5

I wouldn’t go out. I’d probably do online shopping. I’d do my supermarket shopping online too. Yep, it’s not fun being out and about... Quite isolating I think. Really lonely. Miserable actually. I could be quite easily depressed in this suit if I had to wear it for ages. Awful… I feel really isolated in this suit. Nobody wants to be near you. — Participant 1

Participant attitudes toward people with obesity. In pre-activity interviews, participants expressed attitudes toward people with obesity that reflected judgments about their patients’ size. In particular, participants referenced the perceived impact of size on health professionals — that larger-sized patients increase staff safety concerns and require staff to work harder because of manual handling and moving patients with impaired mobility. Before the simulation activity, these health professionals were concerned about the challenges associated with caring for patients with obesity, which included having to talk about size and dealing with the distress and frustration because of the perception that patients did “not help themselves” when in hospital.

When asked about whether the experience of wearing the simulation suit had influenced their own attitudes toward people with obesity, participants reported intentions to be less judgmental and more empathetic and understanding of the specific needs of people with obesity:

I probably wouldn’t judge them as much now if I saw them walking slowly, ‘cause I realize you actually couldn’t walk very fast. And if I had seen someone walking up the stairs my size or going very slowly before, I may have thought, ‘Oh, they’re a bit lazy’ whereas now I would just think, ‘Oh, they’re doing quite well!’ I would feel yeah, more empathy. — Participant 2

Look at them. Make eye contact. Sit next to them on the bus. I’m aware of it now. I’m aware of how isolated you feel. I will sit next to them sitting at the bus stop. — Participant 1

I’m going to make damn sure that they’re comfortable about sitting down! I’m going to make sure that there’s a big enough seat for them and that it’s not gonna move when they sit on it. I’m going to make sure that they’ve got thousands of tissues to mop up the sweat. That whole spatial thing of remembering that they can’t see their feet. And give them time. Because getting somewhere is going to be so exhausting that you can’t expect them to do anything straight away. ’Cause actually they’re going to need 5 minutes to recover. — Participant 3

The physical challenges experienced by study participants led to a deeper understanding of how shape and size impact activities of daily living and physical interactions with the environment. This is consistent with research findings from the phenomenological study³² regarding mobility challenges encountered by sport and exercise students when wearing a bariatric weighted suit that included an alarming 164% increase in heart rate after 2 minutes of low intensity exercise. Other research reported an unplanned outcome of increased awareness by the staff volunteering to wear the suit for the simulation exercise of the physical challenges that may be faced by people with obesity.²⁹

The altered social interactions experienced by participants in the current study led to a greater appreciation of how people with extreme obesity may become socially isolated and withdrawn from society. Simulation studies do not always positively impact on attitudes: for example, a randomized controlled trial involving psychology students did not appear to impact attitudes in a positive way.³⁵ Likewise, the dance student study³⁴ reaffirmed to those students how their own body was “not as bad” as a larger frame would be, thus reaffirming weight stigma in context of shape and size.

Weight stigma scholars challenge the use of simulation suits, arguing that attempts to manipulate the experience of obesity in this way devalues the well-being of those living with obesity.³⁶ The authors of the current study do not support the use of simulation suits in any situation that may actively or inadvertently promote weight stigma. The findings from this study are positive and suggest simulation suits have the potential to reduce weight stigma among health professionals toward patients. This may be particularly relevant to health workers in the area of wound prevention and management, because patients with extreme obesity may require additional nursing care interventions to help maintain skin integrity, which may exacerbate existing biases.

Learning based around a simulation suit activity may provide a safe environment in which to explore and subsequently educate to reduce biases. A systematic review⁴¹ and a meta-analysis⁴² have shown the effects of simulation-based health education can be significant. To contribute to reducing weight stigma, educators need to ensure the planned activities and intended learning outcomes involving simulation suits include weight stigma reduction. Simulation itself does not guarantee intended learning will occur⁴³; arrangements also must be in place to measure, monitor, and mitigate unintended consequences.

This small qualitative study has 3 main limitations: 1) a larger sample would have yielded more data and more robust results; 2) the participant demographics and number of participants did not allow for investigation of potential ethnic and gender differences; and 3) the scarcity of previous research on the use of simulation suits in this manner makes comparison difficult. In addition, mobility, temperature, and other difficulties using the simulation suit could be attributed to the suit itself, not necessarily to the cumbersomeness of excess simulated shape and size (ie, the additional weight of approximately 20 lb).

In this study, wearing a simulation suit enabled participants to experience, albeit briefly, a pseudo lived experience of people with extreme obesity, contributing to a better understanding of the physical and social challenges that may be faced daily by persons with excessive weight. Participants experienced physical and social impacts that had not been anticipated for the short period of time they wore the suit and reported intentions to be more empathetic regarding the needs of people with obesity.

Currently, the fact that simulation suits may be rented or purchased with no guidance as to their ethical use or the physical challenges that may be encountered by the wearer is concerning. The authors advise simulation suit use should be undertaken with caution in health care settings, and they propose ethical guidance needs to be developed in conjunction with further research to explore the risks and mitigation of increasing unintended weight bias when working with simulation suits in clinical practice and education.

A paucity of research exists regarding the use of simulation suits and their impact on weight bias and stigma across all health care settings. Studies to investigate the application of simulation suits in the area of wound prevention and management and how they can reduce weight stigma and bias are warranted. 

Funding support was provided by the Victoria University of Wellington for the employment of research assistants for this study.

Dr. Hales is a lecturer, Graduate School of Nursing, Midwifery and Health, Victoria University of Wellington, Newtown, Wellington, New Zealand. Ms. Gray is a Senior Lecturer, Department of Primary Health Care and General Practice, University of Otago, Wellington, New Zealand. Dr. Russell is a Researcher, Victoria University of Wellington, New Zealand. Dr. MacDonald is an independent researcher, Masterton, New Zealand.

Please address correspondence to: Lesley Gray, Department of Primary Health Care and General Practice, University of Otago, Wellington, PO Box 7343, Wellington, New Zealand; email: lesley.gray@otago.ac.nz.