ORIGINAL RESEARCH
Obesity education for nurse practitioners: Perspectives from nurse practitioner faculty Mary Madeline Rogge, PhD, RN, FNP-BC (Associate Professor) & Emily Merrill, PhD, RN, FNP-BC, FAANP (Professor and Department Chair for Nurse Practitioner and Nurse Midwifery Studies) Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Keywords Obesity; nurse practitioner; education; research. Correspondence Mary Madeline Rogge, PhD, RN, FNP-BC, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX 79430-6264. Tel: 806-743-2730, ext 255; Fax: 806-743-1198; E-mail: [email protected] Received: November 2010; accepted: March 2011 doi: 10.1111/j.1745-7599.2012.00785.x
Abstract Purpose: The purpose of the study was to investigate curriculum content and teaching practices about obesity in graduate nursing programs in the United States. Methodology: A survey of 1202 faculty members teaching in nurse practitioner (NP) programs was conducted using an investigator-created instrument with items based on the National Institutes of Health Obesity Education Initiative guidelines. Objective items were analyzed using descriptive and nonparametric statistics, and the open-ended questions were analyzed using content analysis. Findings: NP faculty emphasized existing clinical practice guidelines, but revealed a large disparity between what is emphasized in schools of nursing and the state of the science regarding obesity etiology and management. Faculty place a priority on teaching obesity as a key factor in the development of comorbidities, and weight loss as a means of treating these comorbidities. Teaching about the pathophysiology of obesity, management of bariatric surgery patients, and pharmacologic therapy are de-emphasized. Four main themes about obesity teaching practices were identified from subjects’ comments to open-ended items. Conclusions: Additional education and support are needed for faculty to teach about obesity in a way that advances the care of obese patients based on emerging scientific principles.
Research problem Although the overall rates of increase in obesity prevalence have slowed or stabilized in recent years for children, adolescents, and adults, obesity remains a leading U.S. health priority (Flegal, Carroll, Ogden, & Curtin, 2010; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Among children and adolescents aged 2 through 19 years, 16.9% were at or above the 95th percentile of body mass index (BMI) for age and sex (obese), and 31.7% were at or above the 85th percentile (overweight) (Ogden et al., 2010). For adult women, the prevalence of obesity, or a BMI ≥ 30, is 35.5% and the prevalence of overweight (BMI ≥ 25) and obesity combined is 68.0%. In adult men, the prevalence of obesity is 32%, and the prevalence of overweight and obe-
C 2012 The Author Journal of the American Academy of Nurse Practitioners 00 (2012) 1–9 C 2012 American Academy of Nurse Practitioners Journal compilation
sity combined is 72% (Flegal et al., 2010). An exception to the trend toward stabilization of obesity prevalence was found in an increase in the BMI ≥ 97th percentile in 6- through 19-year-old boys, but not at the 85th or 95th percentile cut points, indicating a “slight but statistically significant increase in obesity between 1999 and 2006” (Ogden et al., 2010, p. 248). Based on the sheer number of overweight and obese patients nurses can expect to encounter in clinical settings, the need for nurse practitioners (NPs) to be educated in the care of patients with obesity is clearly evident. Research has shown that obese patients are less likely to obtain preventive health services and exams (Adams, Smith, Wilbur, & Grady, 1993; Wee, McCarthy, Davis, & Phillips, 2000), and are more likely to delay and cancel appointments (Drury & Louis, 2002; Olson,
1
Obesity education for nurse practitioners
Schumaker, & Yawn, 1994). These avoidance behaviors are likely related to patients’ experiences of being shamed, belittled, and stigmatized by healthcare providers, including nurses (Merrill & Grassley, 2008; Puhl & Brownell, 2006; Rogge, Greenwald, & Golden, 2004). Unfortunately, many nurses and physicians hold negative attitudes about obese patients, viewing them as noncompliant, lacking in self-control, lazy, unintelligent, sloppy, and disgusting (Bagley, Conklin, Isherwood, Pechiulis, & Watson, 1989; Brown, 2006; Hoppe & Ogden, 1997). At least one study has shown nursing and medical students hold negative stereotypes of obese patients (Petrich, 2000), but there has been no investigation of how educational programs address the subject of obesity within the nursing curriculum. Surprisingly little is known about what nurses—or any other group of healthcare professionals—are taught about obesity within their formal educational programs. Garvis (2004) found NPs did not follow obesity management guidelines. Snow (2006) reported NPs experienced difficulty in approaching patients about weight concerns. Within the literature there is an emerging call for additional education about obesity for nurses (Merrill & Grassley, 2008; Rogge et al., 2004; Story et al., 2002).
Purpose The purpose of this research was to conduct a nationwide survey to assess curricular content and teaching practices about obesity in graduate NP programs. The survey of the faculty teaching in NP programs will provide information about how NP students are prepared to care for obese patients.
Methodology Study design A descriptive study was conducted using survey procedures.
Subjects The target population was nurse educators in masters and doctor of nursing practice programs in the United States. The investigators created a sampling list from the 2008 to 2009 and 2009 to 2010 membership directories for the National Organization of Nurse Practitioner Faculties provided at national conferences in 2008 and 2009. This list was supplemented by the addition of faculty members involved in NP education programs, as identi-
2
M. M. Rogge & E. Merrill
fied by searching faculty directories and web pages of accredited Schools of Nursing. All identified faculty members were contacted via e-mail and invited to participate in the study. The subjects were informed of the purpose of the study, their participation was completely voluntary, and their answers were collected anonymously. The study was reviewed and acknowledged as exempt by the relevant Institutional Review Board.
Procedures An author-constructed survey tool was used to collect responses to multiple-choice, Likert-scale, and openended questions. Because no tool to assess graduate curricula or teaching practices has been found in the literature, survey items were constructed based on the National Institutes of Health Obesity Education Initiative guidelines (1998, 2000) and were reviewed for content validity by two faculty content (obesity) experts against current obesity clinical practice guidelines. All items were constructed to elicit information regarding what faculty teach about obesity, including assessment modalities, obesity comorbidities, attitudes toward obesity, psychological and socioeconomic effects of obesity, treatment options, and problems of recidivism. Teaching practices, including the placement of obesity as a chronic illness within the graduate curriculum, pedagogical practices used to teach about obesity, and the perceived need for additional knowledge on the subject of obesity were also assessed. The survey was pilot-tested by five graduate NP faculty members not associated with the study for comprehension, logical consistency, and ease of use for the subjects. The faculty subjects who pilot tested the survey instrument were masters or doctorally prepared educators, and had specialization as acute, family, or pediatric NPs. These pilot subjects completed the surveys to identify problems in using the tool; their feedback was used to revise the survey instrument to eliminate redundant items and clarify ambiguous items. Their responses to the pilot survey are not included in the data reported here. The survey was found to take approximately 15–20 mins to complete. The survey was administered via a commercial survey tool (Survey MonkeyTM ). The survey contained 16 items. Eight items were single answer items, such as teaching major and amount of time spent per semester teaching about obesity. Three of the items allowed multiple answers, including teaching methods used, and barriers to teaching about obesity. Three of the items required faculty to rate the importance they placed on teaching 19 separate obesity topics; the 19 topics rated by the faculty are presented in Table 3. One item required the subjects to rate their level of comfort
Obesity education for nurse practitioners
M. M. Rogge & E. Merrill
and confidence teaching about nine areas of obesity, for example, pathophysiology, assessment, and management of comorbid conditions. For three items, participants were asked to provide additional comments, including a description of their experience with obesity, barriers to teaching about obesity, and additional thoughts regarding teaching about obesity. The subjects were contacted by e-mail and invited to participate in the study. Data were collected electronically via a commercial survey service (Survey MonkeyTM ) and a uniform resource locator (URL) link to the survey instrument was embedded in the recruitment e-mail. Surveys were available to the participants for a period of 1 month, and a follow-up reminder was sent to nonresponders 2 weeks after the initial contact. Subjects were informed of the purpose and nature of the survey, and their completion of the survey served as their consent to participate in the study.
Data analysis Descriptive statistical analyses were performed on multiple-choice and Likert-scale items. Stata (v 8.0) statistical software was used for the data analysis. Chisquare tests were performed to determine independence between the subjects’ region, NP majors taught, clinical practice, personal experience with obesity, and content emphasis. Level of significance for all statistical tests was set at p < .05. The investigators performed content analysis of the open-ended questions to identify themes about teaching modalities used, and barriers encountered, in teaching about obesity. Open-ended responses also were analyzed using hermeneutic phenomenology to identify themes in the respondents’ answers to open-ended questions about their personal experiences with obesity and their thoughts about teaching obesity in graduate nursing programs.
Findings The survey was distributed to 1287 NP faculty, with 85 returned as not deliverable. Of the faculty receiving the survey, 149 completed it, for a response rate of 12%. Characteristics of the faculty respondents are presented in Table 1. Most of the subjects teach in Family (56%) or Adult Health (14%) NP majors. Responses came from all regions of the country, with the greatest number of responses coming from Western states (31.5%). Eightynine percent of the subjects engage in a clinical practice, and two-thirds (67.1%) of them reported personal experience with obesity. Faculty teaching in Family NP and multiple majors were more likely not to engage in clinical practice than faculty teaching in other majors (p < .001),
Table 1 Characteristics of respondents Characteristic Region North Atlantic (CT, DE, DC, ME, MA, NH, NJ, NY, PA, RI, VT) South (AL, AR, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV) Midwest (IL, IN, IA, KS, MI, MN, NE, ND, OH, SD, WI) West (AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR UT, WA, WY) US Territories or International Total Teaching major Acute Care Adult Family Gerontological Neonatal Pediatric Women’s Health Multiple Majors Total Clinical practice No Yes Total Personal experience with obesity No Yes Total
Number
Percentage
30
20
29
19.5
41
27.5
47
31.5
2 149
1 99.5
3 21 82 4 2 8 10 17 147
2 14 56 3 1 5 7 12 100
16 133 149
10.7 89.3 100
47 96 143
32.9 67.1 100
and faculty who had personal experience with obesity were less likely to maintain a clinical practice than faculty without personal experience with obesity (p < .02). Trends in implementing obesity education are presented in Table 2. Half of the respondents estimated spending 2–5 h per semester teaching about obesity, but 54% thought not enough time is spent teaching about obesity in their programs. The NP major had no influence on the amount of time spent teaching about obesity. All of the instructors who teach about obesity do so in integrated courses; there were no stand-alone courses on obesity. The predominant modes of delivering content to students were through lectures (81.5%), class discussion (82.2%), and reading assignments (71.2%). Several respondents also commented they use case studies in their teaching about obesity. The overall attitude faculty attempt to convey to their students about obese patients is that patients should be able to maintain a weight loss 5–10% below their starting weight to improve health (56.6%), or they can achieve a normal BMI through healthy eating (23.1%). Neither the NP major, clinical practice, nor personal experience of obesity was related 3
Obesity education for nurse practitioners
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Table 2 Implementing teaching about obesity Structure Time spent per semester 0–1 h 2–5 h 6–10 h 11–15 h More than 15 h Total Relative time Not enough time Right amount of time Too much time Total Delivery Part of integrated course Stand-alone course Not taught Total Pedagogies used Lecture or slide presentation Reading assignment Interviews with obese patients Class discussion Clinical mentorship Other Total (multiple answers allowed) Instructor attitude about obese patients Are usually noncompliant and will not follow through with diet and exercise regimens Can achieve normal weight or BMI through healthy eating Should be able to sustain a weight loss of 5–10% of starting weight to improve health May be healthy without losing weight Are usually unable to control their weight Total
Number
Percentage
42 75 24 4 4 149
28.2 50.3 16.1 2.7 2.7 100
81 66 2 149
54.4 44.3 1.3 100
140 0 8 148
94.6 0 5.4 100
119
81.5
104 16
71.2 11.0
120 52 22 433
82.2 35.6 15.1
1
0.7
33
23.1
81
56.6
25
17.5
3
2.1
143
100
to the attitude the teachers attempted to convey to their students about obesity. Faculty expect students to be able to use adult and pediatric BMI criteria (98.6% and 71.5%, respectively) to assess obesity, and to use standard scales (84.7%). Assessment by waist–hip circumference, skinfold calipers, and bioimpedance monitors are taught less frequently.
4
The survey provided a baseline for what content faculty emphasize in their courses when teaching about obesity. The relative importance of obesity topics are summarized in Table 3. Content topics faculty rated as receiving moderate or high emphasis in their teaching about obesity were: (a) the role of economic disparities in controlling obesity, (b) obesity comorbidities, (c) the benefits of physical activity, (d) behavioral and psychosocial influences on obesity, (e) the importance of a 5–10% weight loss to reduce health risks, and (f) the role of overeating and portion size control in obesity and its management. Topics receiving low emphasis were (a) genetics of obesity; (b) hypothalamic regulation of hunger, satiety, and weight; (c) indications for bariatric surgery consultation; (d) nondietary stimuli for adipogenesis; (e) characteristics of commercial weight loss programs; (f) common complications of bariatric surgery; and (g) assessing clinical facilities for barriers to care. Respondents did differ in the emphasis they placed on obesity content topics when compared by their predominant teaching major, as shown in Table 3. Participants teaching in Pediatric NP or multiple majors were more likely to place moderate or high emphasis on the role of the hypothalamus in regulating hunger, satiety, and weight than the faculty teaching in Acute Care, Adult, Family, Neonatal, or Women’s Health majors (p < .05). Faculty teaching in Family NP and Women’s Health majors were more likely than teachers in other majors to place moderate or high emphasis on teaching about the characteristics of commercial weight loss programs (p < .05). Faculty with teaching responsibilities primarily in Acute Care, Family, Pediatric, and Women’s Health majors were more likely to report moderate or high emphasis on teaching about the complications of bariatric surgery than faculty teaching in Adult, Gerontological, Neonatal, or multiple NP majors (p < .001). Faculty also differed slightly in their content emphasis when compared by whether or not they engage in clinical practice (Table 3). Those who maintain a practice were more likely to give moderate or high emphasis to teaching about (a) the metabolic effects of weight loss (p < .05); (b) comorbidities associated with obesity (p < .001); (c) beneficial effects of exercise (p < .01); (d) behavioral, emotional, cultural, and family influences (p < .001); and (e) risks and benefits of pharmacological therapy (p < .05) than subjects who do not engage in clinical practice. Subjects who had personal experience with obesity showed no differences in their content emphasis when compared to faculty who did not have personal obesity experience.
Obesity education for nurse practitioners
M. M. Rogge & E. Merrill
Table 3 Obesity content emphasis Emphasis by teaching major, clinical practice, and personal experience with obesity (Pearson’s chi square)
Overall emphasis on topic Obesity topic Topic
Not taught (1)
Low (2)
Moderate (3)
High (4)
Total
Rating average
Teaching major
Clinical practice
Personal experience
Genetics and the role of common polymorphisms in obesity Role of economic disparities in accessing healthy foods or safe exercise in controlling obesity Metabolic effects of weight loss Comorbidities associated with obesity Beneficial effects of physical activity Behavioral, emotional, cultural, and family influences on obesity Importance of a 5–10% weight loss to lower health risks Assessing patients’ readiness to change behaviors Effects of mild, moderate, and vigorous activity on energy expenditure in obesity Likelihood and processes of weight recovery after weight loss Benefits and risks associated with pharmacological interventions for obesity Hypothalamic regulation of hunger, satiety, and weight Role of overeating and portion size control in obesity When to make a referral for bariatric surgery consultation Characteristics of commercial weight loss programs (Weight Watchers, Jenny Craig, NutriSystem, etc.) Assessing health care facility to barriers to care for obese patients Nondietary stimuli for adipogenesis Common complications of bariatric surgery and how to manage them Effects of healthcare provider attitudes
38 (26.4%)
50 (34.7%)
49 (34.0%)
7 (4.9%)
144
2.17
26.85
2.85
4.44
6 (4.2%)
24 (16.8%)
74 (51.7%)
39 (27.3%)
143
3.02
15.95
0.77
2.97
7 (4.9%) 2 (1.5%) 4 (2.8%) 1 (0.7%)
34 (23.9%) 3 (2.1%) 2 (1.4%) 19 (13.3%)
60 (42.3%) 36 (24.8%) 53 (36.8%) 68 (47.6%)
41 (28.9%) 104 (71.7) 85 (59.0) 55 (38.5%)
142 145 144 143
2.95 3.67 3.52 3.24
28.04 22.57 15.71 18.35
8.75∗ 17.62∗∗∗ 10.82∗∗ 13.49∗∗
3.01 0.63 3.29 0.87
7 (4.9%)
14 (9.8%)
60 (42.0%)
62 (43.4)
143
3.24
18.85
8.91∗
2.27
5 (3.5%)
18 (12.7%)
62 (43.7%)
57 (40.1%)
141
3.20
10.90
3.86
2.29
6 (4.2%)
38 (26.6%)
64 (44.8%)
35 (24.5%)
143
2.90
23.39
1.46
1.59
19 (13.3%)
53 (37.1%)
56 (39.2%)
15 (10.5%)
143
2.47
18.05
3.09
2.18
18 (12.6%)
49 (34.3%)
56 (39.2%)
20 (14%)
143
2.55
15.54
8.58∗
4.26
24 (17.1%)
69 (49.3%)
40 (28.6%)
7 (5.0%)
140
2.21
33.78∗
2.96
2.43
6 (4.3%)
23 (16.3%)
65 (46.1%)
47 (33.3%)
141
3.09
21.07
5.66
3.13
42 (29.6%)
55 (38.7%)
40 (28.2%)
5 (3.5%)
142
2.06
31.30
1.73
1.40
43 (30.3%)
62 (43.7%)
33 (23.2%)
4 (2.8%)
142
1.99
32.48∗
1.89
0.85
34 (24.5%)
55 (39.6%)
43 (30.9%)
7 (5.0%)
139
2.17
10.96
1.06
0.32
52 (37.4%) 54 (38.0%)
62 (44.6%) 58 (40.8%)
20 (14.4%) 28 (19.7%)
5 (3.6%) 2 (1.4%)
139 142
1.84 1.85
31.09 47.74∗∗∗
5.27 3.66
0.80 1.49
16 (11.3%)
39 (27.5%)
55 (38.7%)
32 (22.5%)
142
2.73
24.76
2.16
1.47
∗
p
Obesity education for nurse practitioners: Perspectives from nurse practitioner faculty Mary Madeline Rogge, PhD, RN, FNP-BC (Associate Professor) & Emily Merrill, PhD, RN, FNP-BC, FAANP (Professor and Department Chair for Nurse Practitioner and Nurse Midwifery Studies) Anita Thigpen Perry School of Nursing, Texas Tech University Health Sciences Center, Lubbock, Texas
Keywords Obesity; nurse practitioner; education; research. Correspondence Mary Madeline Rogge, PhD, RN, FNP-BC, School of Nursing, Texas Tech University Health Sciences Center, Lubbock, TX 79430-6264. Tel: 806-743-2730, ext 255; Fax: 806-743-1198; E-mail: [email protected] Received: November 2010; accepted: March 2011 doi: 10.1111/j.1745-7599.2012.00785.x
Abstract Purpose: The purpose of the study was to investigate curriculum content and teaching practices about obesity in graduate nursing programs in the United States. Methodology: A survey of 1202 faculty members teaching in nurse practitioner (NP) programs was conducted using an investigator-created instrument with items based on the National Institutes of Health Obesity Education Initiative guidelines. Objective items were analyzed using descriptive and nonparametric statistics, and the open-ended questions were analyzed using content analysis. Findings: NP faculty emphasized existing clinical practice guidelines, but revealed a large disparity between what is emphasized in schools of nursing and the state of the science regarding obesity etiology and management. Faculty place a priority on teaching obesity as a key factor in the development of comorbidities, and weight loss as a means of treating these comorbidities. Teaching about the pathophysiology of obesity, management of bariatric surgery patients, and pharmacologic therapy are de-emphasized. Four main themes about obesity teaching practices were identified from subjects’ comments to open-ended items. Conclusions: Additional education and support are needed for faculty to teach about obesity in a way that advances the care of obese patients based on emerging scientific principles.
Research problem Although the overall rates of increase in obesity prevalence have slowed or stabilized in recent years for children, adolescents, and adults, obesity remains a leading U.S. health priority (Flegal, Carroll, Ogden, & Curtin, 2010; Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Among children and adolescents aged 2 through 19 years, 16.9% were at or above the 95th percentile of body mass index (BMI) for age and sex (obese), and 31.7% were at or above the 85th percentile (overweight) (Ogden et al., 2010). For adult women, the prevalence of obesity, or a BMI ≥ 30, is 35.5% and the prevalence of overweight (BMI ≥ 25) and obesity combined is 68.0%. In adult men, the prevalence of obesity is 32%, and the prevalence of overweight and obe-
C 2012 The Author Journal of the American Academy of Nurse Practitioners 00 (2012) 1–9 C 2012 American Academy of Nurse Practitioners Journal compilation
sity combined is 72% (Flegal et al., 2010). An exception to the trend toward stabilization of obesity prevalence was found in an increase in the BMI ≥ 97th percentile in 6- through 19-year-old boys, but not at the 85th or 95th percentile cut points, indicating a “slight but statistically significant increase in obesity between 1999 and 2006” (Ogden et al., 2010, p. 248). Based on the sheer number of overweight and obese patients nurses can expect to encounter in clinical settings, the need for nurse practitioners (NPs) to be educated in the care of patients with obesity is clearly evident. Research has shown that obese patients are less likely to obtain preventive health services and exams (Adams, Smith, Wilbur, & Grady, 1993; Wee, McCarthy, Davis, & Phillips, 2000), and are more likely to delay and cancel appointments (Drury & Louis, 2002; Olson,
1
Obesity education for nurse practitioners
Schumaker, & Yawn, 1994). These avoidance behaviors are likely related to patients’ experiences of being shamed, belittled, and stigmatized by healthcare providers, including nurses (Merrill & Grassley, 2008; Puhl & Brownell, 2006; Rogge, Greenwald, & Golden, 2004). Unfortunately, many nurses and physicians hold negative attitudes about obese patients, viewing them as noncompliant, lacking in self-control, lazy, unintelligent, sloppy, and disgusting (Bagley, Conklin, Isherwood, Pechiulis, & Watson, 1989; Brown, 2006; Hoppe & Ogden, 1997). At least one study has shown nursing and medical students hold negative stereotypes of obese patients (Petrich, 2000), but there has been no investigation of how educational programs address the subject of obesity within the nursing curriculum. Surprisingly little is known about what nurses—or any other group of healthcare professionals—are taught about obesity within their formal educational programs. Garvis (2004) found NPs did not follow obesity management guidelines. Snow (2006) reported NPs experienced difficulty in approaching patients about weight concerns. Within the literature there is an emerging call for additional education about obesity for nurses (Merrill & Grassley, 2008; Rogge et al., 2004; Story et al., 2002).
Purpose The purpose of this research was to conduct a nationwide survey to assess curricular content and teaching practices about obesity in graduate NP programs. The survey of the faculty teaching in NP programs will provide information about how NP students are prepared to care for obese patients.
Methodology Study design A descriptive study was conducted using survey procedures.
Subjects The target population was nurse educators in masters and doctor of nursing practice programs in the United States. The investigators created a sampling list from the 2008 to 2009 and 2009 to 2010 membership directories for the National Organization of Nurse Practitioner Faculties provided at national conferences in 2008 and 2009. This list was supplemented by the addition of faculty members involved in NP education programs, as identi-
2
M. M. Rogge & E. Merrill
fied by searching faculty directories and web pages of accredited Schools of Nursing. All identified faculty members were contacted via e-mail and invited to participate in the study. The subjects were informed of the purpose of the study, their participation was completely voluntary, and their answers were collected anonymously. The study was reviewed and acknowledged as exempt by the relevant Institutional Review Board.
Procedures An author-constructed survey tool was used to collect responses to multiple-choice, Likert-scale, and openended questions. Because no tool to assess graduate curricula or teaching practices has been found in the literature, survey items were constructed based on the National Institutes of Health Obesity Education Initiative guidelines (1998, 2000) and were reviewed for content validity by two faculty content (obesity) experts against current obesity clinical practice guidelines. All items were constructed to elicit information regarding what faculty teach about obesity, including assessment modalities, obesity comorbidities, attitudes toward obesity, psychological and socioeconomic effects of obesity, treatment options, and problems of recidivism. Teaching practices, including the placement of obesity as a chronic illness within the graduate curriculum, pedagogical practices used to teach about obesity, and the perceived need for additional knowledge on the subject of obesity were also assessed. The survey was pilot-tested by five graduate NP faculty members not associated with the study for comprehension, logical consistency, and ease of use for the subjects. The faculty subjects who pilot tested the survey instrument were masters or doctorally prepared educators, and had specialization as acute, family, or pediatric NPs. These pilot subjects completed the surveys to identify problems in using the tool; their feedback was used to revise the survey instrument to eliminate redundant items and clarify ambiguous items. Their responses to the pilot survey are not included in the data reported here. The survey was found to take approximately 15–20 mins to complete. The survey was administered via a commercial survey tool (Survey MonkeyTM ). The survey contained 16 items. Eight items were single answer items, such as teaching major and amount of time spent per semester teaching about obesity. Three of the items allowed multiple answers, including teaching methods used, and barriers to teaching about obesity. Three of the items required faculty to rate the importance they placed on teaching 19 separate obesity topics; the 19 topics rated by the faculty are presented in Table 3. One item required the subjects to rate their level of comfort
Obesity education for nurse practitioners
M. M. Rogge & E. Merrill
and confidence teaching about nine areas of obesity, for example, pathophysiology, assessment, and management of comorbid conditions. For three items, participants were asked to provide additional comments, including a description of their experience with obesity, barriers to teaching about obesity, and additional thoughts regarding teaching about obesity. The subjects were contacted by e-mail and invited to participate in the study. Data were collected electronically via a commercial survey service (Survey MonkeyTM ) and a uniform resource locator (URL) link to the survey instrument was embedded in the recruitment e-mail. Surveys were available to the participants for a period of 1 month, and a follow-up reminder was sent to nonresponders 2 weeks after the initial contact. Subjects were informed of the purpose and nature of the survey, and their completion of the survey served as their consent to participate in the study.
Data analysis Descriptive statistical analyses were performed on multiple-choice and Likert-scale items. Stata (v 8.0) statistical software was used for the data analysis. Chisquare tests were performed to determine independence between the subjects’ region, NP majors taught, clinical practice, personal experience with obesity, and content emphasis. Level of significance for all statistical tests was set at p < .05. The investigators performed content analysis of the open-ended questions to identify themes about teaching modalities used, and barriers encountered, in teaching about obesity. Open-ended responses also were analyzed using hermeneutic phenomenology to identify themes in the respondents’ answers to open-ended questions about their personal experiences with obesity and their thoughts about teaching obesity in graduate nursing programs.
Findings The survey was distributed to 1287 NP faculty, with 85 returned as not deliverable. Of the faculty receiving the survey, 149 completed it, for a response rate of 12%. Characteristics of the faculty respondents are presented in Table 1. Most of the subjects teach in Family (56%) or Adult Health (14%) NP majors. Responses came from all regions of the country, with the greatest number of responses coming from Western states (31.5%). Eightynine percent of the subjects engage in a clinical practice, and two-thirds (67.1%) of them reported personal experience with obesity. Faculty teaching in Family NP and multiple majors were more likely not to engage in clinical practice than faculty teaching in other majors (p < .001),
Table 1 Characteristics of respondents Characteristic Region North Atlantic (CT, DE, DC, ME, MA, NH, NJ, NY, PA, RI, VT) South (AL, AR, FL, GA, KY, LA, MD, MS, NC, OK, SC, TN, TX, VA, WV) Midwest (IL, IN, IA, KS, MI, MN, NE, ND, OH, SD, WI) West (AK, AZ, CA, CO, HI, ID, MT, NV, NM, OR UT, WA, WY) US Territories or International Total Teaching major Acute Care Adult Family Gerontological Neonatal Pediatric Women’s Health Multiple Majors Total Clinical practice No Yes Total Personal experience with obesity No Yes Total
Number
Percentage
30
20
29
19.5
41
27.5
47
31.5
2 149
1 99.5
3 21 82 4 2 8 10 17 147
2 14 56 3 1 5 7 12 100
16 133 149
10.7 89.3 100
47 96 143
32.9 67.1 100
and faculty who had personal experience with obesity were less likely to maintain a clinical practice than faculty without personal experience with obesity (p < .02). Trends in implementing obesity education are presented in Table 2. Half of the respondents estimated spending 2–5 h per semester teaching about obesity, but 54% thought not enough time is spent teaching about obesity in their programs. The NP major had no influence on the amount of time spent teaching about obesity. All of the instructors who teach about obesity do so in integrated courses; there were no stand-alone courses on obesity. The predominant modes of delivering content to students were through lectures (81.5%), class discussion (82.2%), and reading assignments (71.2%). Several respondents also commented they use case studies in their teaching about obesity. The overall attitude faculty attempt to convey to their students about obese patients is that patients should be able to maintain a weight loss 5–10% below their starting weight to improve health (56.6%), or they can achieve a normal BMI through healthy eating (23.1%). Neither the NP major, clinical practice, nor personal experience of obesity was related 3
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Table 2 Implementing teaching about obesity Structure Time spent per semester 0–1 h 2–5 h 6–10 h 11–15 h More than 15 h Total Relative time Not enough time Right amount of time Too much time Total Delivery Part of integrated course Stand-alone course Not taught Total Pedagogies used Lecture or slide presentation Reading assignment Interviews with obese patients Class discussion Clinical mentorship Other Total (multiple answers allowed) Instructor attitude about obese patients Are usually noncompliant and will not follow through with diet and exercise regimens Can achieve normal weight or BMI through healthy eating Should be able to sustain a weight loss of 5–10% of starting weight to improve health May be healthy without losing weight Are usually unable to control their weight Total
Number
Percentage
42 75 24 4 4 149
28.2 50.3 16.1 2.7 2.7 100
81 66 2 149
54.4 44.3 1.3 100
140 0 8 148
94.6 0 5.4 100
119
81.5
104 16
71.2 11.0
120 52 22 433
82.2 35.6 15.1
1
0.7
33
23.1
81
56.6
25
17.5
3
2.1
143
100
to the attitude the teachers attempted to convey to their students about obesity. Faculty expect students to be able to use adult and pediatric BMI criteria (98.6% and 71.5%, respectively) to assess obesity, and to use standard scales (84.7%). Assessment by waist–hip circumference, skinfold calipers, and bioimpedance monitors are taught less frequently.
4
The survey provided a baseline for what content faculty emphasize in their courses when teaching about obesity. The relative importance of obesity topics are summarized in Table 3. Content topics faculty rated as receiving moderate or high emphasis in their teaching about obesity were: (a) the role of economic disparities in controlling obesity, (b) obesity comorbidities, (c) the benefits of physical activity, (d) behavioral and psychosocial influences on obesity, (e) the importance of a 5–10% weight loss to reduce health risks, and (f) the role of overeating and portion size control in obesity and its management. Topics receiving low emphasis were (a) genetics of obesity; (b) hypothalamic regulation of hunger, satiety, and weight; (c) indications for bariatric surgery consultation; (d) nondietary stimuli for adipogenesis; (e) characteristics of commercial weight loss programs; (f) common complications of bariatric surgery; and (g) assessing clinical facilities for barriers to care. Respondents did differ in the emphasis they placed on obesity content topics when compared by their predominant teaching major, as shown in Table 3. Participants teaching in Pediatric NP or multiple majors were more likely to place moderate or high emphasis on the role of the hypothalamus in regulating hunger, satiety, and weight than the faculty teaching in Acute Care, Adult, Family, Neonatal, or Women’s Health majors (p < .05). Faculty teaching in Family NP and Women’s Health majors were more likely than teachers in other majors to place moderate or high emphasis on teaching about the characteristics of commercial weight loss programs (p < .05). Faculty with teaching responsibilities primarily in Acute Care, Family, Pediatric, and Women’s Health majors were more likely to report moderate or high emphasis on teaching about the complications of bariatric surgery than faculty teaching in Adult, Gerontological, Neonatal, or multiple NP majors (p < .001). Faculty also differed slightly in their content emphasis when compared by whether or not they engage in clinical practice (Table 3). Those who maintain a practice were more likely to give moderate or high emphasis to teaching about (a) the metabolic effects of weight loss (p < .05); (b) comorbidities associated with obesity (p < .001); (c) beneficial effects of exercise (p < .01); (d) behavioral, emotional, cultural, and family influences (p < .001); and (e) risks and benefits of pharmacological therapy (p < .05) than subjects who do not engage in clinical practice. Subjects who had personal experience with obesity showed no differences in their content emphasis when compared to faculty who did not have personal obesity experience.
Obesity education for nurse practitioners
M. M. Rogge & E. Merrill
Table 3 Obesity content emphasis Emphasis by teaching major, clinical practice, and personal experience with obesity (Pearson’s chi square)
Overall emphasis on topic Obesity topic Topic
Not taught (1)
Low (2)
Moderate (3)
High (4)
Total
Rating average
Teaching major
Clinical practice
Personal experience
Genetics and the role of common polymorphisms in obesity Role of economic disparities in accessing healthy foods or safe exercise in controlling obesity Metabolic effects of weight loss Comorbidities associated with obesity Beneficial effects of physical activity Behavioral, emotional, cultural, and family influences on obesity Importance of a 5–10% weight loss to lower health risks Assessing patients’ readiness to change behaviors Effects of mild, moderate, and vigorous activity on energy expenditure in obesity Likelihood and processes of weight recovery after weight loss Benefits and risks associated with pharmacological interventions for obesity Hypothalamic regulation of hunger, satiety, and weight Role of overeating and portion size control in obesity When to make a referral for bariatric surgery consultation Characteristics of commercial weight loss programs (Weight Watchers, Jenny Craig, NutriSystem, etc.) Assessing health care facility to barriers to care for obese patients Nondietary stimuli for adipogenesis Common complications of bariatric surgery and how to manage them Effects of healthcare provider attitudes
38 (26.4%)
50 (34.7%)
49 (34.0%)
7 (4.9%)
144
2.17
26.85
2.85
4.44
6 (4.2%)
24 (16.8%)
74 (51.7%)
39 (27.3%)
143
3.02
15.95
0.77
2.97
7 (4.9%) 2 (1.5%) 4 (2.8%) 1 (0.7%)
34 (23.9%) 3 (2.1%) 2 (1.4%) 19 (13.3%)
60 (42.3%) 36 (24.8%) 53 (36.8%) 68 (47.6%)
41 (28.9%) 104 (71.7) 85 (59.0) 55 (38.5%)
142 145 144 143
2.95 3.67 3.52 3.24
28.04 22.57 15.71 18.35
8.75∗ 17.62∗∗∗ 10.82∗∗ 13.49∗∗
3.01 0.63 3.29 0.87
7 (4.9%)
14 (9.8%)
60 (42.0%)
62 (43.4)
143
3.24
18.85
8.91∗
2.27
5 (3.5%)
18 (12.7%)
62 (43.7%)
57 (40.1%)
141
3.20
10.90
3.86
2.29
6 (4.2%)
38 (26.6%)
64 (44.8%)
35 (24.5%)
143
2.90
23.39
1.46
1.59
19 (13.3%)
53 (37.1%)
56 (39.2%)
15 (10.5%)
143
2.47
18.05
3.09
2.18
18 (12.6%)
49 (34.3%)
56 (39.2%)
20 (14%)
143
2.55
15.54
8.58∗
4.26
24 (17.1%)
69 (49.3%)
40 (28.6%)
7 (5.0%)
140
2.21
33.78∗
2.96
2.43
6 (4.3%)
23 (16.3%)
65 (46.1%)
47 (33.3%)
141
3.09
21.07
5.66
3.13
42 (29.6%)
55 (38.7%)
40 (28.2%)
5 (3.5%)
142
2.06
31.30
1.73
1.40
43 (30.3%)
62 (43.7%)
33 (23.2%)
4 (2.8%)
142
1.99
32.48∗
1.89
0.85
34 (24.5%)
55 (39.6%)
43 (30.9%)
7 (5.0%)
139
2.17
10.96
1.06
0.32
52 (37.4%) 54 (38.0%)
62 (44.6%) 58 (40.8%)
20 (14.4%) 28 (19.7%)
5 (3.6%) 2 (1.4%)
139 142
1.84 1.85
31.09 47.74∗∗∗
5.27 3.66
0.80 1.49
16 (11.3%)
39 (27.5%)
55 (38.7%)
32 (22.5%)
142
2.73
24.76
2.16
1.47
∗
p
