Obesity is one of the major health problems in this society and is associated with a variety of health problems including hypertension, cardiovascular disease, diabetes, and other associated health risks (Cowley & Springen, 1995; Manson et al., 1995; Olefsky, 1994; ?-Sunyer, 1993; St. Jeor, 1993; Vickere, 1993). In the United States, the prevalence of obesity has increased in the past few decades. Obesity, denned as weighing 20% more than ideal body weight, is found in 20% to 30% of adult men and 30% to 40% of adult -women, with the highest rates among the poor and minority groups (Olefsky, 1994).
The health risks associated with obesity represent only one area of concern for overweight adults. Another area of concern deals with the negative attitudes of health professionals (including nurses) toward obese people and the management of their care when they are ill (Bagley, Conklin, Isherwood, Peehiulis, &. Watson, 1989; Brink, 1992; Maroney & Golub, 1992; Vickers, 1993). Many health professionals view obese individuals negatively (Bagley et al., 1989; Brink, 1992; Petemelj-Taylor, 1989; Vickere, 1993) and believe obese adults are responsible for their own weight control (Boyd, 1989; Carryer, 1991; Katz, 1981).
There IB a lack of information published on attitudes of nurses enrolled in a master's or a RN-to-BSN nursing program toward obese adult patients. Nurses who seek further education are likely to have had experience caring for obese patients and, thua, have had time to form attitudes and perceptions beyond that of entering students. Their attitudes and experiences may affect the management and quality of care offered to obese individuals and even may influence whether or not obese individuals seek needed health care (Carryer, 1991; McBride, 1988; Packer, 1991).
Miller (1992) argued that society stereotypes obese individuals as nonproductive, slow paced, easygoing, jolly, and obsessed with oral gratification and added that the American culture characterizes obese people as immature, passive, dependent, and having low self-esteem. Goffman (1963) pointed out that attributing negative characteristics or capabilities to numerous individuals in a given social (or health carel category stigmatizes the individuals. Wooley and Wooley (19831 reported that, with the exception of skin color, body weight was the most stigmatized physical Feature. Schwartz (1993) suggested cultural bias against obese women plays a major role in the origin of their low self-esteem, depression, weight loss, binge eating, and weight gain.
Many professional caregivers have adopted societal attitudes regarding obese individuals. Bagley et al. (1989) studied Canadian nurses' attitudes toward obese patients and found 42% agreed with the statement, "If given a choice, most nurses would prefer not to care for an obese patient" (.p. 5). Maroney and Golub U992) expanded on Bagley et al.'s study by comparing the attitudes of nurses in the United States with the attitudes of nurses in Canada. Almost 48% of the United States nurses agreed with feeling uncomfortable when caring for obese adult patients. More than 62% of United States nurses agreed that obesity in adults can be prevented by self-control, and more than 43% agreed that weight loss is only a matter of changing one's lifestyle.
For this study, the research questions included:
* What are the attitudes of RN students toward personalities and lifestyles and management of nursing care of obese adult patients?
* Are there effects of RN students' demographic variables on their attitudes toward the personalities and lifestyles of obese adult patients and attitudes toward management of their nursing care?
* Is there a relationship between RN students' attitudes toward personalities and lifestyles of obese adult patients and attitudes toward the management of their nursing care?
Sample and Design
A descriptive, correlational survey design was used to collect data from a selfselected, convenience sample of 73 RN students. Of the 73 nurses, 33 were RN-toBSN students attending a class in Professional Nursing I, and 40 were master's level students attending a class in Advanced Interpersonal Dimensions of Nursing Agency and Adult Health. All RNs were enrolled in a large midwestern school of nursing.
The demographic data indicates the participants' ages ranged from 20 to 53 (mean = 35.9). The majority of participants were female (n = 66, 90.4%) and in the MSN program (» = 40, 54.8%). Thirtysix individuals (49.3%) had completed an ADN program, 18 (24.7%) a diploma program, 14 119.2%) a baccalaureate program, and 5 (6.8%) an LPN program. The largest number of participants (n - 28, 38.4%) had worked as an RN for 6 to 15 years, were currently employed in a hospital (n = 42, 66.6%), were employed as staff nurses In = 41,65.1%), were White (n = 66, 90.4%), and perceived they needed to lose 10 lbs (n. = 44, 60.3%).
Two questionnaires were administered. A researcher-designed personal data questionnaire, consisting of nine items, was used to gather demographic data. A second questionnaire, Nurses' Attitudes Toward Obese Adult Patients by Bagley et al. (1989), was used with permission to measure RNs' attitudes toward the personalities and lifestyles of obese patients and the management of their care.
The Nurses' Attitudes questionnaire is a 28-item Likert-type questionnaire divided into two subscales. One subscale of 13 questions addresses the personalities and lifestyles of obese adults, and the second subscale of 15 questions addresses the management of care of obese adults. Internal reliability for the total scale was .92. Subscale internal reliability was not tested. Content validity was established by using independent nurse experta to provide the stimulus around which the items were constructed. Construct validity was estimated by the strong correlation of scores from a Likert-type attitude questionnaire with those of the SemanticDifferential Profiles of Obesity questionnaire administered concurrently (Bagley et al., 1989).
Packets containing an invitation-top artici paté cover letter, the Nurses' Attitudes Toward Obese Adult Patients questionnaire, a personal data questionnaire, and a computer scan sheet were distributed to all students in designated classes. Participant consent was implied by the completion of both questionnaires, which required approximately 15 minutes to complete. No codes or names were solicited which insured anonymity for the participants, and they were assured that all information gathered would be reported only as group data.
Attitudes Toward Personalities and Lifestyles of Obese Adults. Of the 73 participants, more than half of the RN students felt obese adults have poor food selection (70%i, can lose weight if they change their eating habits (50%), and lack self-confidence (54%). Seventy- three percent disagreed with the statement that most obese adults are lazy, and 92% disagreed that most obese adults are pushy and aggressive.
At test revealed there were no statistically significant differences between nurses in the RN-to-BSN program or in the master's program, those employed or unemployed, or those needing or not needing to lose 10 lbs and their attitudes toward personalities and lifestyles of obese patients.
A one-way ANOVA indicated a statistically significant difference between nurses' years of practice and their attitudes toward personalities and lifestyles of obese adults (F = .0092, ? = < .05). Registered nurse students who had worked fewer than 6 years had significantly higher mean scores (mean = 3.05, SZJ = .5833) or more negative attitudes toward obese adult patients than those who had worked 6 to 15 years (mean - 2.66, SD = .5483). The age of the nurse was negatively correlated with attitudes toward the personalities and lifestyles of obese patients (r = -.3152, ? = .009) indicating that as age increased, negative attitudes decreased.
Attitudes Toward Management of Care. Data indicate that of the 73 respondents, more than half (58%) agreed caring for an obese adult was physically exhausting, 38.3% often felt uncomfortable when caring for obese adult patients, and if given the choice, 28.8 % would prefer not to care for an obese adult patient. Ninetyfive percent disagreed with the statement that they "would rather not touch an obese adult," and 84.7% disagreed that "it does not hurt to apply scare tactics to obtain the compliance of the obese patient."
At test and a one-way ANOVA determined there were no statistically significant differences of nurses' attitudes toward management of obese patients related to the demographic data or between groups of RNs (BSN mean = 2.48, SD = .484; MSN mean = 2.29, SD = .619). As noted in the Table, the correlation coefficient r = -.3523, p = .003) revealed age had a moderately negative correlation with attitudes toward management of obese patients.
When comparing the relationship between the attitudes of respondents toward the personalities and lifestyles of obese adults and their attitudes toward managing the care of this population, there was a high positive relationship (r = .7213,P = .000) (Table).
Correlation Matrix of Nurses' Age, Attitudes Toward Managing the Care of Obese Adult Patients and Toward Personalities and Lifestyles of Obese Adult Patients
Attitudes Toward Personalities and Lifestyles of Obeee Adults. Results of this study suggest attitudes of RN student nurse participants toward the personalities and lifestyles of obese patients were negative. Tbe majority of RN student nurses agreed obese adults:
* Have poor food selection.
* Could prevent obesity through using eelf-control.
* Could lose weight if they changed their eating habite.
These attitudes are consistent with the negative attitudes Katz (1981) found in individuals who believed obese adults can control their weight. Likewise, the majority of RN student nurse participante responded that they felt obese adults lacked confidence and were not pushy or aggressive. These findings coincide with those of Miller (1992) who reported the American culture characterizes obese individúale as dependent, passive, depressed, and having low eelf-esteem.
While it would appear educational level may affect the attitudes of RN students regarding obese patients' personalities and lifestyles, this study found that the "more educated" MSN studente did not have significantly different attitudes toward obese patients than did students from the RN-to-BSN program. This finding is similar to that found by Bagley et al. (1989) who reported that attitudes of RN participants toward personalities and lifestyles of obese patients were not significantly different according to level of education. It suggests amount of education is not solely responsible for attitudes and values in such areas as obesity, but attitudes also are dependent on areas other than education (e.g., socioeconomic status, cultural experiences) (Katz, 1981).
Are obese individuals more critical of others who are obese? Bagley et al. (1989) found this to be true in their study. They found RN participants who recognized their own weight problems tended to be more negative toward obese adults. This was not true in the present study which found that overweight participants who recognized their own weight problems were not more negative toward obese individuals than RN student nurses of normal weight.
The RNs who had worked fewer than 6 years had more negative attitudes toward the personalities and lifestyles of obese adult patients than those who had worked more than 6 years. Likewise, respondents indicated that as they became older, thenstigma regarding obesity decreased. Both of these factors may be clinically relevant in that more experienced RNs or older RN students have had more opportunities to change their ideas regarding obesity and the meaning it has for them. Additionally, there was a high positive correlation of RN students' attitudes toward personalities and lifestyles of obese patients and their attitudes toward management of their care, suggesting that the older, more experienced RN students may provide better care.
Attitudes Toward Management of Care. Questions may arise during an obese patient's hospitalization regarding whether or not they should be placed on a reducing diet when they are hospitalized for problems unrelated to obesity. Only one fourth of the respondents in this study felt obese patients should be placed on a reducing diet. This differs from Bagley et al. (1989) and Maroney and Golub's (1992) findings in which the majority indicated that an appropriate intervention was a reducing diet. Participants in the present study may adhere to the current belief that interventions for obesity need to be holistic and more individualized because reducing diets are not likely to work (Popkess-Vawter, 1993; Schwarte, 1993).
Caring for obese patients can be exhausting and uncomfortable, and when given a choice, RN students agreed they and their colleagues would prefer not to care for these patients. However, as the age of the RN students increased, they tended to have less negative attitudes or stigma toward managing the care of obese adults.
This study demonstrates that a stigma exists toward thinking about and caring for obese adult patients. More than half of the RN students believed obese adults could lose weight if the; changed their eating habits and disagreed with putting obese patients on diets while hospitalized. Also, the RN students indicated they bad differing ideas on how the care of obese patients should be managed. Therefore, in planning care, RN students should collaborate on the best interventions to ensure continuity of care and establishment of sound rapport with obese patients. If RN students hold unwarranted prejudice ß regarding obesity, they must identify and work through these prejudices before beginning care. If this does not occur, the negative attitudes of RN students are likely to become apparent to obese patients, and then they may feel rejected, diminished, and become uncooperative (Lambert & Lambert, 1985).
The findings of this study indicate the need for nurse educators to assess their curricula to determine whether lifestyle and personalities and management of care of obese adulte is presented in a positive manner. Nurse educators at both the undergraduate and graduate levels bear a responsibility to influence students' attitudes toward obese individuals and to teach students sensitivity and caring. Influence of attitudes could occur in classrooms or in clinical or continuing education settings. Regardless of the setting, nurse educators should share current research on the causes, health risks, and nursing interventions associated with obesity to reduce etigmatization of obese adults (Maroney & Golub, 1992).
Conclusions from this study are not generalizable because of the small sample size and the possibility that responses from the convenience sample of RN students were in accordance with how the participants thought they should respond. Nevertheless, the results provide a basis for further exploration and analysis of RN students' attitudes toward the personalities, lifestyles, and care of obese adults and provide evidence to nurse educators that gaps exist in students' attitudes and willingness to care for obese patients.
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Correlation Matrix of Nurses' Age, Attitudes Toward Managing the Care of Obese Adult Patients and Toward Personalities and Lifestyles of Obese Adult Patients