Art & science |
The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
OPPORTUNISTIC HEALTH PROMOTION AMONG OVERWEIGHT CHILDREN Study finds it is not appropriate to offer advice on admission to acute care, but it can be beneficial to do so at follow up, say Nicola Greenwood and Kiara Lewis Correspondence [email protected] Nicola Greenwood, sister (paediatrics), Calderdale and Huddersfield NHS Trust Kiara Lewis, head of the division of health and wellbeing, department of health sciences, University of Huddersfield Date of submission July 4 2014 Date of acceptance December 4 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ncyp-authorguidelines
Abstract Aim To explore children’s nurses’ attitudes to providing health promotion advice to overweight children and their families during hospital admissions.
of the topic; long-term benefits; parents – a barrier; need for training; and need for institutional support.
Methods Individual semi-structured interviews were conducted in a private room in the ward setting. Interviews were recorded and transcribed, and thematic analysis of the transcripts was undertaken.
Conclusion Further research with acute care children’s nurses in the UK is required to validate the study findings. More work is also needed to explore the ethics of health promotion in the acute care setting.
Findings The six themes generated from responses were: responsibility for health promotion; sensitivity
Keywords Acute care, child health, children’s nurses, health promotion, obesity, overweight
CHILDHOOD OBESITY is a national and global issue in public health (World Health Organization (WHO) 2012) and continues to be a priority for the Department of Health (DH) (2013). In England, around one in five four to five year olds and one in three ten to 11 year olds are classified as overweight or obese (Public Health England 2014). The figures are similar in Scotland (British Medical Association Scotland 2012) and are higher among four to five year olds in Wales where one in three are classified as overweight or obese (Wales Centre for Health 2013). Childhood obesity poses short and long-term risks to psychological and physical health (WHO 2012). Overweight children are at greater risk of developing obesity-related illnesses, such as sleep apnoea, hypertension and asthma, and chronic illnesses, such as heart disease; in adulthood, they have a greater risk of diabetes (Laing 2002, Camden 2009). Obesity can also have negative psychosocial effects (Camden 2009).
16 April 2015 | Volume 27 | Number 3
The consequences of obesity can put significant pressure on patients’ families, society and the NHS, and estimates have put the cost at more than £50 billion by 2050 (DH 2012). As a result, the UK government wants to ‘reverse the rising tide of obesity and overweight in the population by ensuring that all individuals are able to maintain a healthy weight’ (DH and Department of Children, Schools and Families 2008). As overweight children become overweight adults (WHO 2012), work needs to be done to prevent and reverse childhood obesity. The NHS Future Forum (2012) sets out a vision for all healthcare professionals (HCPs) to ‘make every contact count’ by delivering health promotion strategies. However, it has been suggested that intervention by healthcare services only occurs once the medical complications of obesity are apparent (Royal College of Physicians 2010). NURSING CHILDREN AND YOUNG PEOPLE
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Neil Webb
The issue of childhood obesity is one that cannot be avoided, in particular by those who have a responsibility to provide health care.
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Art & science | qualitative research Literature review Despite calls for nurses to provide health-promoting advice, the research available suggests that this is a neglected area (DiNapoli et al 2011, Ashby et al 2012, Lee et al 2012, Keleher and Parker 2013, Robinson et al 2013, Elwell et al 2014). Surveys conducted in the United States and Australia, with the participation of children’s primary care nurses and school nurses, have highlighted common obstacles to raising the issue of childhood obesity. These include time barriers, lack of knowledge and confidence to raise the topic, concerns about damaging the relationship with the child and parents, and questions about whether it was part of their job (Small et al 2009, DiNapoli et al 2011, Hessler and Seigrist 2011, Ashby et al 2012). A few qualitative studies with school nurses and primary care nurses have also been conducted that provide more detail on staff concerns. Nurses are uncomfortable about raising body weight concerns with a child’s family, particularly if they feel the child is not motivated to lose weight and if one or both parents are also overweight (Edvardsson et al 2009, Steele and Jensen 2011, Robinson et al 2013). This is compounded when the nurses themselves think they have problems controlling their own weight (Steele and Jensen 2011). Obesity is a condition about which nurses may think they cannot provide adequate advice or treatment, so raising the issue becomes futile (Hessler and Seigrist 2011). Jacobson and Gance-Cleveland (2010) suggest that healthcare professionals (HCPs) will only engage with childhood obesity if there is a ‘paradigm change which acknowledges that paediatric obesity is a chronic condition that can be prevented and managed’. Robinson et al (2013) observe that nurses who experience more autonomy in their role and increased support in their practice could overcome some of these barriers. In the limited research in the acute children’s setting, only one qualitative study has been identified: Elwell et al (2014) were interested in the barriers to ‘making every contact count’ in a children’s hospital in the UK. Their interviews revealed that many HCPs were concerned about the following: ■ When is the right time to intervene with health promotion? ■ If I do intervene, will it have any effect? ■ How long will it take? As the number of children admitted to hospital with overweight or obesity as a compounding (or causal factor) will be at least as high as those in the ‘normal’ population, and in reality higher, it was thought that this was an important setting in 18 April 2015 | Volume 27 | Number 3
which to gather information. The issue of childhood obesity cannot be avoided, in particular by those with a responsibility to provide health care.
Aims The purpose of this investigation was to explore the attitudes of children’s nurses to delivering health promotion to overweight children and their families during acute hospital admission of the child.
Methods This qualitative study was conducted by one of the authors (NG) in the children’s ward of an NHS district hospital. Six nurses were purposively sampled to ensure the inclusion of nurses across the hierarchy of the ward team and with varying lengths of experience, also ensuring that data was manageable within the time constraints of the study. All six participants received written information and gave written consent to participate. Individual semistructured interviews were conducted in January and February 2013 in a private room on the ward. A pilot interview was conducted, and minor adjustments made to the interview schedule to clarify the questions (Box 1). Interviews were recorded and transcribed, and transcripts anonymised. Thematic analysis was performed and the themes validated by returning them to participants to confirm that analysis reflected their contributions, a process known as participant validation (Parahoo 2006). Ethical considerations Ethical approval for the study was granted by the university school research ethics panel, and permission was given in writing by the NHS trust’s research and development department and by ward managers.
Findings The study highlighted some differences in attitudes between the respondents, but neither length of experience nor training seemed to have any impact on opinions. Six themes emerged from the data, which will be discussed in relation to previous research. Responsibility for delivering health promotion All participants agreed they had a responsibility to promote the health of children and young people: ‘I think you do… [have a role in health promotion], they come in, they’re under your care and you’ve got a duty of care as a whole, the whole person, not just a set of symptoms, so I do think we have a role in a way’ (participant 2). Despite this, when probed further, the participants debated whether it was part of their role as acute care nurses. They named several primary NURSING CHILDREN AND YOUNG PEOPLE
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Box 1 Interview schedule ■ Do you have a role in health promotion, specifically for overweight children, as a nurse working in an acute care unit? ■ Do you have any skills, knowledge or training to enable you to promote healthy eating and exercise? ■ Do you perceive there to be any benefits to you discussing diet and exercise with overweight children and their families? ■ Do you perceive there to be any barriers to you raising the issue with families? ■ Do you have any personal experience of speaking to families of overweight children? care professionals, including GPs, health visitors and school nurses, as holding the overall responsibility for health promotion. Sensitivity of the issue Participants said the acute care setting might not be an appropriate place to discuss long-term health and health promotion in relation to a child’s weight: ‘…it can be discussed but you’ve got to get the child right and back out in their own environment… And then revisit it in a calmer situation. Parents come into hospital… and they’re in a strange environment, they might feel alienated, they’re scared, if their child’s ill… whether you’re fat or thin, if you’re having an asthma attack, it’s scary, so perhaps that moment is not the right time, but then I do think it should be revisited more calmly’ (participant 3). It was also suggested that discussing long-term issues might make parents think that the acute problem is not being addressed. Participants proposed that there were exceptions when children presented with a diet- or weight-related condition. Although they did not think health promotion should be delivered during admission, they did suggest that follow up would be appropriate. Benefits Nurses reported that they could see the long-term health benefits from delivering effective health promotion strategies. The positive effects of weight reduction on the incidence of chronic illness and psychological wellbeing were also referred to. However, none of the participants mentioned the effect of obesity on acute illness; this may be a significant contributing factor in the low prioritisation of health promotion activities in acute care. Parents Overall, nurses viewed parents as a barrier to the delivery of health promotion. Three respondents expressed concern that a parent would be offended if their child were to receive health promotion about NURSING CHILDREN AND YOUNG PEOPLE
their weight. Parental attitudes were recognised as a significant factor and it was suggested that parents would not be receptive to health promotion: ‘People would assume that parents won’t take any notice of you, and that it’ll be in vain… that you’ll give them this information but they won’t do anything… because, if it’s a lifestyle choice, they’ll continue to do that’ (participant 1). This perception among nurses appears to affect their willingness to deliver health promotion. Skills Participants reported that they required communication skills and knowledge of what constitutes a healthy diet and exercise to help deliver health promotion. Although it was emphasised that some skills are generic and transferable, only participant 6 reported having specific training about nutritional assessment. This confirms the results of previous studies that have consistently reported lack of training on health promotion for nurses (DiNapoli et al 2011, Ashby et al 2012). Institutional support and resources Nurses responded that, although there was little provision of information or resources in the ward environment, they would be confident in obtaining guidance using the internet. They also referred to the dietetic service as a supportive resource offering expert knowledge. Lack of time for health promotion on the ward was reported but not as emphatically as anticipated. It was suggested that in the workload of an acute care setting, health promotion did not have high priority: ‘…there’s other things that will take priority… we might discuss asthma, diabetes… but I don’t think obesity is something that has a big enough catch on the ward that we’d talk about it’ (participant 3).
Discussion Nurses suggested that the responsibility for delivering health promotion lies with primary care practitioners such as school nurses, health visitors and GPs. Studies exploring health promotion in primary care have recorded professional opinions similar to those in this study. In research undertaken by Walker et al (2007), GPs responded that they did not consider it their duty to address the issue of childhood obesity and suggested that social care services were responsible, whereas nurses reported that lack of training, time, resources and parental motivation prevented them delivering health promotion (DiNapoli et al 2011). The research suggests that HCPs are falling short of the NHS vision to ‘make every contact count’. Participants also raised concerns about the sensitivity of the issue and the appropriateness of the April 2015 | Volume 27 | Number 3 19
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Art & science | qualitative research hospital setting for the delivery of health promotion about obesity. These concerns have also been documented in previous studies. Steele and Jensen (2011) and Edvardsson et al (2009) describe the concerns of HCPs in the community about upsetting the child and their family by discussing weight. Further to this, Penn and Kerr (2014) find that children’s nurses face an ethical dilemma in meeting the needs of overweight children, with a conflict between the duty of the government and HCPs to promote health versus the child’s and parents’ right to choose unhealthy lifestyles. Elwell et al (2014) reiterate nurses’ concerns about raising lifestyle-related issues during hospital admissions when families are already under stress. In contrast, Elwell et al (2014) also comment that some professionals considered that the hospital setting offers an ideal opportunity to reach children and young people who might otherwise have little contact with HCPs. This needs further exploration to clarify whether the acute care setting should be used for health promotion. If it is the best place, further training and institutional support are required to enable nurses to undertake the role, as shown in this and previous studies (DiNapoli et al 2011, Ashby et al 2012, Elwell et al 2014). This study has highlighted that, in acute care settings, children’s nurses report that health promotion strategies are not prioritised in the workload and therefore time is not dedicated to them. This finding is reiterated by Elwell et al (2014) in a study of 33 HCPs who stated that they feared opening discussions on lifestyle behaviour change because it could take a large and unpredictable amount of time. Despite this, the effects of obesity on acute
and chronic illness are well documented (Laing 2002, Camden 2009) and it has been said by participants in these studies that benefits can be derived from any health promotion, for the NHS and its organisations as well as for service users (Elwell et al 2014). Limitations The sample size was small and the population had similar characteristics. Larger scale research with children’s nurses across the UK is required to validate the findings. More work is also needed to explore the ethics of health promotion in the acute care setting. This study was undertaken within the constraints of a master’s dissertation.
Conclusion Acute care children’s nurses concur with the findings of other studies that the acute setting may not be an appropriate environment for the delivery of health promotion on child obesity, important though this may be. Further research is required to support the development of appropriate policies, training and protocols if health promotion is to be implemented opportunistically in the acute care setting.
Implications for practice ■ Guidelines emphasise the duty to deliver health promotion in children’s acute care. ■ Weight reduction in obese children is an important but sensitive topic, particularly with parents. ■ Training, dedicated time and support are required for staff providing health and lifestyle information. ■ Institutional policies should be adapted accordingly. ■ Further large-scale research is needed.
Conflict of interest None declared
Online archive For related information, visit our online archive and search using the keywords
References Ashby S et al (2012) Survey of Australian practitioners’ provision of healthy lifestyle advice to clients who are obese. Nursing and Health Sciences. 14, 2, 189-196.
Edvardsson K et al (2009) Raising issues about children’s overweight – maternal and child health nurses’ experiences. Journal of Advanced Nursing. 65, 12, 2542-2551.
British Medical Association Scotland (2012) Childhood Obesity. BMA Scotland, Edinburgh.
Elwell L et al (2014) Health professional perspective on lifestyle behaviour change in the paediatric hospital setting: a qualitative study. BMC Pediatrics. 14, 71-79.
Camden SG (2009) A captive condition: childhood obesity. Nursing Management. 40, 2, 25-32. Department of Health (2012) Obesity. DH, London. Department of Health (2013) Reducing Obesity and Improving Diet. DH, London. Department of Health and Department of Children, Schools and Families (2008) Healthy Weight, Healthy Lives: A CrossGovernment Strategy for England. DH, London. DiNapoli C et al (2011) Pediatric nurses’ perceptions, attitudes, and knowledge of childhood obesity at an academic medical centre. Bariatric Nursing and Surgical Patient Care. 6, 3, 125-131.
20 April 2015 | Volume 27 | Number 3
Hessler K, Seigrist M (2011) Nurse practitioners’ attitudes and treatment practices for childhood overweight: how rural and urban practitioners differ. Journal of the American Academy of Nurse Practitioners. 24, 2, 97-106. Jacobson D, Gance-Cleveland B (2010) A systematic review of public health care provider education and training using the chronic care model for childhood obesity. Obesity Reviews. 12, 5, e244-e255. Keleher H, Parker R (2013) Health promotion by primary care nurses in Australian general practice. Collegian. 20, 4, 215-221. Laing P (2002) Childhood obesity: a public health threat. Paediatric Nursing. 14, 10, 14-16.
Lee DJ et al (2012) Exploring the midwife’s role in health promotion practice. British Journal of Midwifery. 20, 3, 178-186. NHS Future Forum (2012) The NHS’s Role in the Public’s Health: A Report from the NHS Future Forum. Department of Health, London. Parahoo K (2006) Nursing Research: Principles, Process and Issues. Second edition. Palgrave Macmillan, Basingstoke. Penn S, Kerr J (2014) Childhood obesity: the challenges for nurses. Nursing Children and Young People. 26, 2, 16-21.
Small L et al (2009) Pediatric nurse practitioners’ assessment and management of childhood overweight/obesity: results from 1999 and 2005 cohort study. Journal of Pediatric Health Care. 23, 4, 231-241. Steele RG, Jensen CD (2011) School nurses’ perceived barriers to discussing weight with children and their families: a qualitative approach. Journal of School Health. 81, 3, 128-137. Walker O et al (2007) A qualitative study of primary care clinicians’ views of treating childhood obesity. BMC Family Practice. 8, 1, 50.
Public Health England (2014) PHE Obesity 2014. www.noo.org.uk (Last accessed: March 16 2015.) Robinson A et al (2013) Child obesity prevention in primary health care: investigating practice nurse roles, attitudes and current practices. Journal of Paediatrics and Child Health. 49, 4, e294-e299. Royal College of Physicians (2010) The Training of Health Professionals for the
Prevention and Treatment of Overweight and Obesity. RCP, London.
Wales Centre for Health (2013) Programme Highlights Levels of Child Obesity in Wales. tinyurl.com/m53zurd (Last accessed: March 16 2015.) World Health Organization (2012) Global Strategy on Diet, Physical Activity and Health: Childhood Overweight and Obesity. WHO, Geneva.
NURSING CHILDREN AND YOUNG PEOPLE
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The synthesis of art and science is lived by the nurse in the nursing act
JOSEPHINE G PATERSON
OPPORTUNISTIC HEALTH PROMOTION AMONG OVERWEIGHT CHILDREN Study finds it is not appropriate to offer advice on admission to acute care, but it can be beneficial to do so at follow up, say Nicola Greenwood and Kiara Lewis Correspondence [email protected] Nicola Greenwood, sister (paediatrics), Calderdale and Huddersfield NHS Trust Kiara Lewis, head of the division of health and wellbeing, department of health sciences, University of Huddersfield Date of submission July 4 2014 Date of acceptance December 4 2014 Peer review This article has been subject to open peer review and checked using antiplagiarism software Author guidelines journals.rcni.com/r/ncyp-authorguidelines
Abstract Aim To explore children’s nurses’ attitudes to providing health promotion advice to overweight children and their families during hospital admissions.
of the topic; long-term benefits; parents – a barrier; need for training; and need for institutional support.
Methods Individual semi-structured interviews were conducted in a private room in the ward setting. Interviews were recorded and transcribed, and thematic analysis of the transcripts was undertaken.
Conclusion Further research with acute care children’s nurses in the UK is required to validate the study findings. More work is also needed to explore the ethics of health promotion in the acute care setting.
Findings The six themes generated from responses were: responsibility for health promotion; sensitivity
Keywords Acute care, child health, children’s nurses, health promotion, obesity, overweight
CHILDHOOD OBESITY is a national and global issue in public health (World Health Organization (WHO) 2012) and continues to be a priority for the Department of Health (DH) (2013). In England, around one in five four to five year olds and one in three ten to 11 year olds are classified as overweight or obese (Public Health England 2014). The figures are similar in Scotland (British Medical Association Scotland 2012) and are higher among four to five year olds in Wales where one in three are classified as overweight or obese (Wales Centre for Health 2013). Childhood obesity poses short and long-term risks to psychological and physical health (WHO 2012). Overweight children are at greater risk of developing obesity-related illnesses, such as sleep apnoea, hypertension and asthma, and chronic illnesses, such as heart disease; in adulthood, they have a greater risk of diabetes (Laing 2002, Camden 2009). Obesity can also have negative psychosocial effects (Camden 2009).
16 April 2015 | Volume 27 | Number 3
The consequences of obesity can put significant pressure on patients’ families, society and the NHS, and estimates have put the cost at more than £50 billion by 2050 (DH 2012). As a result, the UK government wants to ‘reverse the rising tide of obesity and overweight in the population by ensuring that all individuals are able to maintain a healthy weight’ (DH and Department of Children, Schools and Families 2008). As overweight children become overweight adults (WHO 2012), work needs to be done to prevent and reverse childhood obesity. The NHS Future Forum (2012) sets out a vision for all healthcare professionals (HCPs) to ‘make every contact count’ by delivering health promotion strategies. However, it has been suggested that intervention by healthcare services only occurs once the medical complications of obesity are apparent (Royal College of Physicians 2010). NURSING CHILDREN AND YOUNG PEOPLE
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Neil Webb
The issue of childhood obesity is one that cannot be avoided, in particular by those who have a responsibility to provide health care.
Downloaded from RCNi.com by ${individualUser.displayName} on Dec 12, 2015. For personal use only. No other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science | qualitative research Literature review Despite calls for nurses to provide health-promoting advice, the research available suggests that this is a neglected area (DiNapoli et al 2011, Ashby et al 2012, Lee et al 2012, Keleher and Parker 2013, Robinson et al 2013, Elwell et al 2014). Surveys conducted in the United States and Australia, with the participation of children’s primary care nurses and school nurses, have highlighted common obstacles to raising the issue of childhood obesity. These include time barriers, lack of knowledge and confidence to raise the topic, concerns about damaging the relationship with the child and parents, and questions about whether it was part of their job (Small et al 2009, DiNapoli et al 2011, Hessler and Seigrist 2011, Ashby et al 2012). A few qualitative studies with school nurses and primary care nurses have also been conducted that provide more detail on staff concerns. Nurses are uncomfortable about raising body weight concerns with a child’s family, particularly if they feel the child is not motivated to lose weight and if one or both parents are also overweight (Edvardsson et al 2009, Steele and Jensen 2011, Robinson et al 2013). This is compounded when the nurses themselves think they have problems controlling their own weight (Steele and Jensen 2011). Obesity is a condition about which nurses may think they cannot provide adequate advice or treatment, so raising the issue becomes futile (Hessler and Seigrist 2011). Jacobson and Gance-Cleveland (2010) suggest that healthcare professionals (HCPs) will only engage with childhood obesity if there is a ‘paradigm change which acknowledges that paediatric obesity is a chronic condition that can be prevented and managed’. Robinson et al (2013) observe that nurses who experience more autonomy in their role and increased support in their practice could overcome some of these barriers. In the limited research in the acute children’s setting, only one qualitative study has been identified: Elwell et al (2014) were interested in the barriers to ‘making every contact count’ in a children’s hospital in the UK. Their interviews revealed that many HCPs were concerned about the following: ■ When is the right time to intervene with health promotion? ■ If I do intervene, will it have any effect? ■ How long will it take? As the number of children admitted to hospital with overweight or obesity as a compounding (or causal factor) will be at least as high as those in the ‘normal’ population, and in reality higher, it was thought that this was an important setting in 18 April 2015 | Volume 27 | Number 3
which to gather information. The issue of childhood obesity cannot be avoided, in particular by those with a responsibility to provide health care.
Aims The purpose of this investigation was to explore the attitudes of children’s nurses to delivering health promotion to overweight children and their families during acute hospital admission of the child.
Methods This qualitative study was conducted by one of the authors (NG) in the children’s ward of an NHS district hospital. Six nurses were purposively sampled to ensure the inclusion of nurses across the hierarchy of the ward team and with varying lengths of experience, also ensuring that data was manageable within the time constraints of the study. All six participants received written information and gave written consent to participate. Individual semistructured interviews were conducted in January and February 2013 in a private room on the ward. A pilot interview was conducted, and minor adjustments made to the interview schedule to clarify the questions (Box 1). Interviews were recorded and transcribed, and transcripts anonymised. Thematic analysis was performed and the themes validated by returning them to participants to confirm that analysis reflected their contributions, a process known as participant validation (Parahoo 2006). Ethical considerations Ethical approval for the study was granted by the university school research ethics panel, and permission was given in writing by the NHS trust’s research and development department and by ward managers.
Findings The study highlighted some differences in attitudes between the respondents, but neither length of experience nor training seemed to have any impact on opinions. Six themes emerged from the data, which will be discussed in relation to previous research. Responsibility for delivering health promotion All participants agreed they had a responsibility to promote the health of children and young people: ‘I think you do… [have a role in health promotion], they come in, they’re under your care and you’ve got a duty of care as a whole, the whole person, not just a set of symptoms, so I do think we have a role in a way’ (participant 2). Despite this, when probed further, the participants debated whether it was part of their role as acute care nurses. They named several primary NURSING CHILDREN AND YOUNG PEOPLE
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Box 1 Interview schedule ■ Do you have a role in health promotion, specifically for overweight children, as a nurse working in an acute care unit? ■ Do you have any skills, knowledge or training to enable you to promote healthy eating and exercise? ■ Do you perceive there to be any benefits to you discussing diet and exercise with overweight children and their families? ■ Do you perceive there to be any barriers to you raising the issue with families? ■ Do you have any personal experience of speaking to families of overweight children? care professionals, including GPs, health visitors and school nurses, as holding the overall responsibility for health promotion. Sensitivity of the issue Participants said the acute care setting might not be an appropriate place to discuss long-term health and health promotion in relation to a child’s weight: ‘…it can be discussed but you’ve got to get the child right and back out in their own environment… And then revisit it in a calmer situation. Parents come into hospital… and they’re in a strange environment, they might feel alienated, they’re scared, if their child’s ill… whether you’re fat or thin, if you’re having an asthma attack, it’s scary, so perhaps that moment is not the right time, but then I do think it should be revisited more calmly’ (participant 3). It was also suggested that discussing long-term issues might make parents think that the acute problem is not being addressed. Participants proposed that there were exceptions when children presented with a diet- or weight-related condition. Although they did not think health promotion should be delivered during admission, they did suggest that follow up would be appropriate. Benefits Nurses reported that they could see the long-term health benefits from delivering effective health promotion strategies. The positive effects of weight reduction on the incidence of chronic illness and psychological wellbeing were also referred to. However, none of the participants mentioned the effect of obesity on acute illness; this may be a significant contributing factor in the low prioritisation of health promotion activities in acute care. Parents Overall, nurses viewed parents as a barrier to the delivery of health promotion. Three respondents expressed concern that a parent would be offended if their child were to receive health promotion about NURSING CHILDREN AND YOUNG PEOPLE
their weight. Parental attitudes were recognised as a significant factor and it was suggested that parents would not be receptive to health promotion: ‘People would assume that parents won’t take any notice of you, and that it’ll be in vain… that you’ll give them this information but they won’t do anything… because, if it’s a lifestyle choice, they’ll continue to do that’ (participant 1). This perception among nurses appears to affect their willingness to deliver health promotion. Skills Participants reported that they required communication skills and knowledge of what constitutes a healthy diet and exercise to help deliver health promotion. Although it was emphasised that some skills are generic and transferable, only participant 6 reported having specific training about nutritional assessment. This confirms the results of previous studies that have consistently reported lack of training on health promotion for nurses (DiNapoli et al 2011, Ashby et al 2012). Institutional support and resources Nurses responded that, although there was little provision of information or resources in the ward environment, they would be confident in obtaining guidance using the internet. They also referred to the dietetic service as a supportive resource offering expert knowledge. Lack of time for health promotion on the ward was reported but not as emphatically as anticipated. It was suggested that in the workload of an acute care setting, health promotion did not have high priority: ‘…there’s other things that will take priority… we might discuss asthma, diabetes… but I don’t think obesity is something that has a big enough catch on the ward that we’d talk about it’ (participant 3).
Discussion Nurses suggested that the responsibility for delivering health promotion lies with primary care practitioners such as school nurses, health visitors and GPs. Studies exploring health promotion in primary care have recorded professional opinions similar to those in this study. In research undertaken by Walker et al (2007), GPs responded that they did not consider it their duty to address the issue of childhood obesity and suggested that social care services were responsible, whereas nurses reported that lack of training, time, resources and parental motivation prevented them delivering health promotion (DiNapoli et al 2011). The research suggests that HCPs are falling short of the NHS vision to ‘make every contact count’. Participants also raised concerns about the sensitivity of the issue and the appropriateness of the April 2015 | Volume 27 | Number 3 19
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Art & science | qualitative research hospital setting for the delivery of health promotion about obesity. These concerns have also been documented in previous studies. Steele and Jensen (2011) and Edvardsson et al (2009) describe the concerns of HCPs in the community about upsetting the child and their family by discussing weight. Further to this, Penn and Kerr (2014) find that children’s nurses face an ethical dilemma in meeting the needs of overweight children, with a conflict between the duty of the government and HCPs to promote health versus the child’s and parents’ right to choose unhealthy lifestyles. Elwell et al (2014) reiterate nurses’ concerns about raising lifestyle-related issues during hospital admissions when families are already under stress. In contrast, Elwell et al (2014) also comment that some professionals considered that the hospital setting offers an ideal opportunity to reach children and young people who might otherwise have little contact with HCPs. This needs further exploration to clarify whether the acute care setting should be used for health promotion. If it is the best place, further training and institutional support are required to enable nurses to undertake the role, as shown in this and previous studies (DiNapoli et al 2011, Ashby et al 2012, Elwell et al 2014). This study has highlighted that, in acute care settings, children’s nurses report that health promotion strategies are not prioritised in the workload and therefore time is not dedicated to them. This finding is reiterated by Elwell et al (2014) in a study of 33 HCPs who stated that they feared opening discussions on lifestyle behaviour change because it could take a large and unpredictable amount of time. Despite this, the effects of obesity on acute
and chronic illness are well documented (Laing 2002, Camden 2009) and it has been said by participants in these studies that benefits can be derived from any health promotion, for the NHS and its organisations as well as for service users (Elwell et al 2014). Limitations The sample size was small and the population had similar characteristics. Larger scale research with children’s nurses across the UK is required to validate the findings. More work is also needed to explore the ethics of health promotion in the acute care setting. This study was undertaken within the constraints of a master’s dissertation.
Conclusion Acute care children’s nurses concur with the findings of other studies that the acute setting may not be an appropriate environment for the delivery of health promotion on child obesity, important though this may be. Further research is required to support the development of appropriate policies, training and protocols if health promotion is to be implemented opportunistically in the acute care setting.
Implications for practice ■ Guidelines emphasise the duty to deliver health promotion in children’s acute care. ■ Weight reduction in obese children is an important but sensitive topic, particularly with parents. ■ Training, dedicated time and support are required for staff providing health and lifestyle information. ■ Institutional policies should be adapted accordingly. ■ Further large-scale research is needed.
Conflict of interest None declared
Online archive For related information, visit our online archive and search using the keywords
References Ashby S et al (2012) Survey of Australian practitioners’ provision of healthy lifestyle advice to clients who are obese. Nursing and Health Sciences. 14, 2, 189-196.
Edvardsson K et al (2009) Raising issues about children’s overweight – maternal and child health nurses’ experiences. Journal of Advanced Nursing. 65, 12, 2542-2551.
British Medical Association Scotland (2012) Childhood Obesity. BMA Scotland, Edinburgh.
Elwell L et al (2014) Health professional perspective on lifestyle behaviour change in the paediatric hospital setting: a qualitative study. BMC Pediatrics. 14, 71-79.
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Hessler K, Seigrist M (2011) Nurse practitioners’ attitudes and treatment practices for childhood overweight: how rural and urban practitioners differ. Journal of the American Academy of Nurse Practitioners. 24, 2, 97-106. Jacobson D, Gance-Cleveland B (2010) A systematic review of public health care provider education and training using the chronic care model for childhood obesity. Obesity Reviews. 12, 5, e244-e255. Keleher H, Parker R (2013) Health promotion by primary care nurses in Australian general practice. Collegian. 20, 4, 215-221. Laing P (2002) Childhood obesity: a public health threat. Paediatric Nursing. 14, 10, 14-16.
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