Healthcare Professionals’ Perspectives of Nonsurgical Care of Older Inpatients with Class II or III Obesity and Comorbidities: A Qualitative Study

Introduction

Older people with Class II or III obesity (defined as body mass index (BMI) ≥35 kilogram divided by height in meters squared (kg/m²) or body mass index ≥40 kg/m², respectively) have age and weight related comorbidities needing complex care and frequent hospital admissions.^1–4 In 2017–18 Australian data reported 31% of adults were living with obesity (BMI ≥ 30 kg/m²).⁵ In 2019/20 the National Health Service in England reported a 17% increase in hospital admissions of patients with obesity compared to the 2018/19 period.⁶ Readmission to hospital is also higher for people with severe obesity. Fusco et al⁷ reported a 28-day readmission rate of 8.1% for those with severe obesity compared to 5.4% for people without obesity. With the increasing challenge of hospital admissions and readmission for older people with Class II or III obesity and comorbidities there is a need to understand health care professionals concerns around care delivery of this population.^1,8

In Australia, Class II and III obesity are classified as a chronic condition, however several organizations internationally classify this level of obesity as a chronic disease, resulting in variations in approaches to funding and treatments.^9–12 Internationally, policy documents and clinical guidelines recommend person-centred models of care (MOC) for effective prevention, assessment, and management of obesity.^11,13–16 To implement a person-centred model of care an understanding of factors influencing HCP and patient behaviour is required.¹⁷ The Theoretical Domains Framework (TDF) has 14 domains and has been successful in assisting researchers and quality improvement managers to understand factors influencing behaviours.¹⁸ Using these factors in conjunction with other frameworks like co-design,¹⁹ or the behavior change wheel,²⁰ successful strategies for MOC and improving patient care have been developed.^{17,18,21–23}

Little is known about factors influencing care of people with obesity in the non-surgical inpatient setting. Qvist et al²⁴ identified a gap in the literature on the experiences and perceptions of HCPs delivering inpatient care to people living with obesity (PwO) however, their study explored the experiences and perceptions of clinical leaders and managers rather than front line HCPs. Gunasekaran et al²⁵ also reported the same gap in the literature as Qvist et al, stating HCP perspectives on stigma and recovery in mental health settings “may provide important insights towards stigma that are otherwise unattainable from caregivers and consumers”. We therefore sought to understand the experiences and perspectives of healthcare professionals delivering non-surgical care to people with Classes II or III obesity admitted to a tertiary care hospital.

Materials and Methods

Study Design

This qualitative study used a hybrid method of thematic analysis of HCP interviews, incorporating inductive and deductive analysis. Approval for the study was granted by the Hunter New England Human Research Ethics Committee (NSW REGIS 2018/ETH00601). The Consolidated Criteria for Reporting Qualitative Research (COREQ)²⁶ guided reporting (Supplementary Box 1).

Setting, Participants, and Recruitment

This study was conducted within a tertiary referral hospital in regional Australia. Participants were eligible for this study if they were HCP providing non-surgical care to inpatients with Class II or III obesity. The patient group they were providing care for was people over the age of 50 years for non-Indigenous people and over 45 years for Indigenous people. The age ranges for this study were defined after considering the years of life lost for people with obesity (13 years), as reported by Fontaine et al,²⁷ and by examining the 28-day readmission rate for patients with a BMI ≥35 kg/m² within the district health service where the study was conducted. The district health service data reported a 28-day readmission rate of 37% for non-Indigenous patients ≥55 years of age and 40% for Indigenous patients ≥45 years of age (unpublished data). Invitations to participate were extended to HCPs by nurse unit managers, staff meeting chairpersons, and through study flyers displayed in staff tearooms. Table 1 details the inclusion and exclusion criteria. The first author obtained informed consent from all participants. The participant information sheet and the consent form both informed participants of the possibility of publication of anonymized quotes. All data were deidentified before analysis.

Table 1 Inclusion/Exclusion Criteria

Data Collection

Semi-structured interviews were conducted within the privacy of staff offices or hospital meeting rooms between August and December 2019 using an interview guide developed by the research team (Supplementary Table 1). Interviews were ceased at data saturation, this was the point where no new themes, ideas or information were evident during the interviews.²⁸ The guide was consumer tested with a patient hospitalized with Class III obesity and comorbidities at the time of development. Interviews were audio-recorded and transcribed using an external encrypted transcription service. Transcriptions were checked against the audio-recordings by one member of the research team (the first author) and emailed to the participants for verification. Transcriptions with participant corrections (n=3) replaced the original transcriptions in the analysis.

Data Analysis

The NVIVO 12 Pro software program (QSR International, Melbourne, Australia) was used to assist with data organization. The interview raw data were analysed using inductive thematic analysis as described by Nowell et al.²⁹ Deductive thematic analysis mapped the themes to the domains of the TDF version 2 to identify factors influencing HCP behaviors.¹⁸

Initially 10% of the transcripts were coded by one member of the research team (the first author), and these codes were discussed with the other members of the research team. To ensure rigor a second member of the research team (the third author) independently coded 10% of the interviews and interrater reliability was assessed resulting in a Kappa coefficient of 0.85, indicating almost perfect agreement across subthemes and themes. These two research team members then defined the codes and developed a coding tree. The first author then coded the remaining 90% (totaling 100%) while the third author independently coded a total of 50% of the interviews for comparison. Coding comparison at completion of all coding achieved a Kappa coefficient of 0.75, indicating substantial agreement across domains.³⁰ Disagreements were resolved through discussion and data checking for accuracy. Broad themes were extracted from the codes and discussed and confirmed with all authors.¹⁸

Results

Participants

The disciplines of the 24 HCPs who completed the study were doctors (n=4), nurses (n=6), dietitians (n=2), physiotherapists (n=5), pharmacists (n=2), occupational therapists (n=3), and social workers (n=2). Seven participants were previously known to the interviewer. Rigor was strengthened by following COREQ guidelines. Validation strategies were also used, these included the interviewing researcher’s reflective diary, having participants confirm their interview transcripts, co-coding of the transcripts, and discussion of the data and codes amongst the research team.^26,28

To ensure anonymity participants’ data were pooled into Medical/Nursing and Allied Health. HCPs years of experience ranged from 1.5 to 43.0 years [median = 11.5, (7.5, 20.0)], 66% of participants were female, and 63% worked in the acute care sector. Demographics and characteristics of participants are summarized in Table 2.

Table 2 Demographic and Professional Characteristics of the Participants

Interviews totaled 633 minutes of audio-recording, with interviews ranging from 18 minutes to 41 minutes [mean = 26.5 minutes (SD = 7.2)].

Inductive and Deductive Themes

Inductive analysis identified four major themes (Barriers, Facilitators, Current Practice, and Recommendations) and 11 subthemes. Deductive analysis matched these themes to nine of the 14 domains within the TDF (Figure 1).^18,22,31

Figure 1 Themes and subthemes mapped to the Theoretical Domain Framework.

Criteria used for mapping the themes to the TDF domains included the frequency of belief statements across the domains,³² presence and prevalent beliefs,¹ and evidence of strong belief influencing behaviour.¹⁸ The relevant domains from the TDF included memory, attention, and decision process; knowledge; social influences; environmental context and resources; beliefs about consequences; skills; social/professional role and identity; beliefs about capabilities; and goals. Themes and subthemes mapped to the TDF domains are supported by participant quotes in Table 3.

Table 3 Themes and Subthemes Mapped to Theoretical Domains

Theme 1 Barriers

This theme identified three subthemes. The HCP described barriers to provision of optimal care due to perceived patient related factors, health system issues, and provider issues.

Perceived Patient Related Factors

This subtheme related to the TDF domains of social influences, knowledge, and memory, attention, and decision process. Patient motivation, and HCP knowledge and attitudes highlighted a disconnect between the HCPs and patients. The social influence domain related to patient visitors bringing in food not recommended in the patient care plan and was viewed by HCP as detrimental to the patient’s recovery and health. The HCPs perceived the reasons for these family interactions to be a lack of education (mapping to the knowledge domain). The memory, attention, and decision process domain related to HCPs’ perception that patients lack motivation to change. HCPs saw patients’ decisions and behaviours contrary to HCPs recommendations as patient barriers to care.

Health System Issues

The TDF environmental context and resources domain mapped to this subtheme exposed the HCP perceptions relating to a lack of community support services, staffing, and physical resources. Additionally, HCPs stated that inpatient systems for patient assessment and management, and access to equipment and resources were not fully implemented and/or did not meet the patients’ care needs, emphasizing the gaps in both the HCP and patients’ ability to assess and manage obesity related health according to best practice recommendations.

In the acute sector obesity related health is expected to be managed within the community setting unless it directly hinders the resolution of the patient’s acute health issue and/or delaying discharge. However, the HCPs stated this was a lost opportunity for patient education and appropriate intervention while identifying the inability of patients to access community care because of the lack of services, and/or financial and physical access issues.

Providers Issues

Lack of teamwork, a prevailing culture of blaming the patient, and a gap in HCP education, knowledge and training was evident within this subtheme. The social/professional role and identity TDF domain related to teamwork. A collaborative team approach depended on the context of the HCP workplace. While subacute HCPs and the HCPs of one acute ward identified collaborative multidisciplinary teams working well together, HCPs working within other areas of the acute sector experienced less cohesion and lack of accessible multidisciplinary team members. HCPs identified that care within the acute care sector was often siloed to admission diagnosis where the patients’ care was solely around their acute illness without a holistic overview. Although some HCPs discussed improvement in staff attitudes and a reduction in stigmatization, many gave recent examples of inappropriate hospital staff behaviour, highlighting the domains of social influences and beliefs about consequences.

This subtheme also mapped to the knowledge domain with formal education and knowledge of Class II or III obesity (including pathophysiology), limited to a minority of the HCPs interviewed. There was a gap in the comprehensive holistic knowledge of the pathophysiology of obesity, assessment, and management, and associated available services and resources within the current system. Knowledge was discipline specific; medical officers had the most comprehensive knowledge. Within nursing and with allied health there were gaps in knowledge resulting in their failure to use available health service systems for the assessment and management of inpatients with obesity. For example, some participants stated they were aware of a Bariatric Assessment and Management Plan form, however, they had never completed one, while others stated they were unaware of how to access bariatric equipment and were unable to do so after hours because they usually referred this to the nursing or allied health managers for actioning. Most HCPs reported that obesity related in-service training was limited to manual handling, or assessment, prescription and/or use of equipment. Several HCPs discussed their self-directed learning and educational sources while a minority stated they had not received any education or training related to care of PwO, relying on experiential learning from their professional colleagues. Mapping to the TDF social influences domain several HCPs highlighted the difficulty in changing some staff behaviours. They gave examples of some HCPs’ incorrect perceptions that PwO require larger doses of medication than patients without obesity and incidents where PwO are not given adequate recovery time to return to their baseline function, resulting in PwO not receiving the same opportunities as patients without obesity.

Theme 2 Facilitators

Within Theme 2, HCPs discussed elements that enhanced the healthcare of this patient group. The subthemes of patient centred approach, knowledge, and resources in the non-acute setting mapped to the domains of beliefs about consequences; skills; social/professional role and identity; knowledge, and environmental context and resources.

Patient Centred Approach

The beliefs about consequences domain related to the mental health issues, past trauma, and/or difficulties in patients’ history identified as a significant issue by most of the HCPs. When discussing the elements of successful patient care, collaborative teamwork, building a strong rapport, and a non-judgmental attitude within a patient-centred approach that is individualized to each patient, (mapped to the skills, and social/professional role identity domains), were strongly emphasized by the HCPs.

Knowledge

The domains of social/professional role and identity, skills, and knowledge related to this subtheme. The level of knowledge within all disciplines except for medical officers depended on years of experience, area of clinical practice, and individual self-generated enquiry. HCPs level of knowledge and skills were limited to their social/professional role and identity. Staff were aware of knowledge gaps with patient care challenges prompting several HCPs to discuss their self-directed education and the experiential learning strategies used to improve knowledge and clinical practice.

Resources in Sub-Acute Setting

Within the environmental context and resources domain HCPs from the subacute setting identified facilitators that they believed were less available in the acute setting, which lead to rehabilitation staff having extra support when caring for PwO. These related to the rehabilitation MOC and timely booked admission, which limited the number of patients with Class II or III obesity to two on the ward at a time, patient goal setting, multidisciplinary collaborative management plans, reduced staff turnover, and longer length of stay were advantages leading to better experiences for the HCPs caring for this inpatient group compared to those in the acute sector.

Theme 3 Current Practice

Theme 3 included one subtheme of exploring factors influencing clinical management. This mapped to eight domains of social/professional role and identity; beliefs about capabilities; social influences; knowledge; skills; goals; environmental context and resources; and memory, attention, and decision process.

Exploring Factors Influencing Clinical Management

Within the Current Practice theme, patient and HCP factors influenced clinical management. Patients’ psycho-social well-being, complexity of comorbidities, cognitive status, physical status, and mobility, reflected in their decision making, recovery outcomes and level of engagement with staff and mapped to the domains of beliefs about capabilities, memory, attentions, and decision process, and skills, and goals domains. The HCP emphasized the importance of psychological support and an understanding of the patient’s history. For the HCPs their individual social context and personal beliefs, education/knowledge of obesity and its management, access to resources, and the inability to ensure optimal continuum of care when discharging patients was reflected in their experiences of caring for this patient cohort, and mapped to domains of social influences, knowledge, environmental context and resources, and social/professional role and identity. Mobility assessments and lack of access to resources and services causing difficulties in maintaining continuum of care and best practice discharge processes, were the most frequent experiences expressed by the HCPs.

Theme 4 Recommendations

HCP recommendations for strategies to address the gaps in care included internal and external approaches, some of which are beyond the scope of the health service and require collaborations with higher level government, social policy changes, and health planning. Internal recommendations included engaging patients in their care, improving the quality of current care, increasing access to education, support, equipment, resources, and services. These mapped to the domains of beliefs about consequences, skills, knowledge, and environmental context and resources, respectively. Recommendations requiring external collaboration and resources include increased services and resources, strategies targeting societal stigma and discrimination towards PwO, and classification of Class II and III obesity as a chronic disease. These recommendations mapped to the domains of environmental context and resources, and social influences – political domains.

Engaging Patients

While all participants identified the importance of building a therapeutic relationship with patients, some disciplines experienced better patient engagement than others. This related to the domains of beliefs about consequences, skill, and knowledge. Patient knowledge and understanding of HCP roles assisted with engagement. Pharmacists reported time pressures and patients not understanding their role, which affected their capacity to establish rapport with some patients. While physiotherapists believed patients were accepting of their role, even if the patients did not fully participate within their goal orientated care plan.

Access to Quality Care

The dominant domain for this subtheme was environmental context and resources. All HCPs described frustrating experiences and difficulty in accessing timely services and resources, hindering their ability to deliver best practice and dignified care. Their recommendations included increased accessibility to appropriate equipment with accompanying storage areas, access to a broader variety of accessible quality fresh food, adequate HCP staffing within all specialties, specialized pharmacy resources (mapped to the environmental context and resources domain) and education for HCPs, all hospital staff, and patients (mapped to the knowledge domain).

Education Support

The knowledge domain related to education gaps identified by most HCPs. Lack of implementation of current systems supporting this patient group within the health service was demonstrated by some HCPs within the acute sector. HCPs discussed how they were aware of bariatric assessment care plans but had never commenced one or received education on their use. They were also unaware of available resources or how to access resources. Incomplete assessment on referral and admission (such as weighing patients) was also discussed by several HCPs. HCP suggested health service education sessions, and the development of specialist HCP roles, similar to current specialized diabetes and respiratory roles. The environmental context and resources and social influences domains were mapped to one HCP discussing the need for a broader public health approach to obesity related health and prevention strategies at a society level rather than the individual level, questioning the effectiveness of current multimessage campaigns.

Obesity as a Chronic Disease

This subtheme related to the beliefs about consequences and social influences–political domains with many of the HCPs identifying the chronic nature and/or mental health factors associated with obesity. Some HCPs believed a reclassification of obesity as a chronic disease would reduce patient blame and stigmatization and increase funding, research, resources, and services. Others considered this classification as detrimental to the patients’ well-being.

Discussion

The current study explored HCPs perceptions in delivering non-surgical care to older inpatients with Class II or III obesity and comorbidities. Findings identified the absence of a holistic MOC for this patient group. Currently siloed care addresses patient comorbidities (eg, respiratory or endocrine) which do not incorporate obesity management, unless it is impeding recovery from their admission diagnosis. HCPs experienced an inability to achieve patient-centred dignified multidisciplinary best practice care due to some staff practices stigmatizing patients, inadequate environments (room size, doorway width and storage space), a lack of HCP and patient education/knowledge of bariatric assessment and management, staffing (both levels and timely availability), resources (bariatric equipment and education), and services. The HCP interviews highlighted key major themes of Barriers, Facilitators, Current Practice and Recommendations, with subthemes including factors to improve the care for this patient group. Deeper understanding of these themes was achieved by mapping to the nine TDF domains. Condensing the five most frequent TDF domains into three key groups of 1) knowledge and skills; 2) environment and resources; and 3) social/professional role and identity and beliefs about consequences can inform development of strategies for the implementation of a holistic obesity MOC.

HCPs develop their knowledge and skills from formal and in-service education programs, policies, clinical guidelines, and mentor/experiential training. Research, obesity clinical guidelines, and policy documents within Australia and internationally, clearly map evidence-based requirements for the prevention, assessment, and management of Class II and III obesity across all areas of the healthcare system.^{13–15,32,33} Most HCPs, however, reported little to no formal education on the pathophysiology or a holistic view of the causes of obesity or patient-first evidence-based care for this inpatient group. This is consistent with the Snodgrass et al³⁴ survey of 296 allied health professionals and nurses.

HCPs reported that local guidelines focused on manual handling, access to equipment, and some patient assessments, indicating a lack of an overarching MOC (like other chronic disease MOC) for this patient group. A lack of knowledge and/or implementation of admission procedures including weighing patients on admission, use of bariatric care plans, and/or accessing and use of appropriate equipment and services was evident as some HCPs were unaware of, and/or had not fully implemented existing clinical guidelines and processes that were available to support their practice. Failure to record patient’s weight on admission resulted in HCP not recognizing patients as Class II or III obesity or considering them of lower weight status. This aligns with the evidence of an assessment gap,^1,35,36 and guideline implementation failure at inpatient level reported in the United Kingdom and Canada.^13,33,37

The HCP obesity knowledge and skills gaps found in this study were previously identified within this district health service in 2015, 2016, and 2019.^2,34,38 Results from a scoping review by Ewens et al aligns with the results described in this study that HCPs experience a lack of education and access to equipment and resources.¹ This knowledge/skills gap is common within health services in Australia and internationally.^34,38,39

The Australian, Canadian, and United Kingdom policies and guidelines all recommend further HCP education and training,^13–15 with obesity education programs shown to improve care for patients with obesity.^4,40 A Norwegian qualitative study found an educational program linking general practitioners, physicians, and staff at three hospitals treating large numbers of patients with obesity over an extended training period resulted in primary and secondary integrated care, and improvements in professional relationships, knowledge, competence, and service delivery.⁴ Sanchez-Ramirez et al⁴⁰ found a 1-day education program improved HCP skills and attitudes when caring for patients with obesity.

Staff identified their roles and were willing to deliver education and care to this patient group. However, they reported that without an obesity MOC they were unable to fulfil their professional roles adequately due to acute inpatient bed pressures, lack of trained staff, resources, and services across all continuums of care. In a qualitative study, Pearce et al⁴¹ interviewed 23 participants from upper/middle-level management and 23 clinical frontline staff. Their findings aligned with HCPs’ experiences in the current study, including a disconnect between aims at policy level and practical implementation with negative consequences for patients.

HCPs observed that the stigmatization of patients has reduced due to staff familiarity and experience caring for the increased numbers of admissions of patients with obesity. The HCPs reported that their experiences in the acute care environment was not conducive to caring for this inpatient group. Inadequate bariatric equipment storage, room access, acute care silos, lack of staffing, MOC, and ad hoc multidisciplinary teams affected their ability to deliver timely appropriate and dignified care. This interfered with their ability to build patient rapport and partnership, and increased patients’ embarrassment and stigma. Phelan et al⁴² reported the impact of HCP weight bias on patient care and its negative impacts on patient outcomes. The implication for patients is that they may perceive they are a burden within the system.

Inpatient and ongoing outpatient specialist services/MOC, were recommended by the HCP as strategies to improve care. A MOC is broadly defined by the NSW Agency for Clinical Innovation as “the way health services are delivered.” It outlines best practice care and services for a person, population group, or patient cohort as they progress through the stages of a condition, injury, or event.²³ Evidence of specialist obesity services, with policies, guidelines, and assessment tools are well documented in the literature, particularly from countries where Class II and III obesity are classified as a chronic disease.^{11,13–16,43} Countries that identify obesity as a chronic disease and are supported by health service funding have identified programs at clinical ward level with continuum of care follow-up.^44,45

Rees et al¹² scoping review reported on the variation of approaches to treatment for this inpatient group. In the current study, HCPs experiences aligned with many of the scoping review findings including knowledge gaps, practice implementation gaps, difficulty with lack of patient engagement, gaps between guideline best practice recommendations and frontline activity, lack of funding, services and resources, incomplete multidisciplinary teams, and lost opportunities for interventions. Cost-benefits from specialist MOC were demonstrated by Brain et al’s⁴³ analysis of chronic wound clinics and Mudd et al’s⁴⁶ analysis of a multidisciplinary aerodigestive service. With annual predicted direct costs of obesity for the study district health service of $A339,338,879 expected to increase by 3% annually further research into the cost-benefit of an appropriate MOC is urgently needed.²

Strengths and Limitations

As a single site study within one tertiary referral hospital in Australia the generalization of these results is limited to other similar service health care settings. With data collection completed just prior to the COVID-19 pandemic the HCP experiences post-COVID are unknown. As a long-standing staff member some of the HCPs interviewed were known to the interviewer, however rigor was strengthened by following COREQ guidelines. Strengths are the inductive thematic analysis as guided by Nowell et al,²⁹ and the deductive analysis using the TDF¹⁸ and the addition to the literature of frontline HCPs experiences and perceptions in delivering care to this inpatient cohort.

Conclusion

This paper builds on previous research highlighting the continuing gaps in HCPs knowledge, resources, services, and best practice MOC. There is a disconnect between the overarching policies, and available clinical guidelines which impacts frontline HCPs ability to deliver best practice care to this cohort.^13–15,47 By linking our key findings to TDF domains, barriers to best practice have been identified and solutions offered.¹⁸ Adopting a holistic multidisciplinary team MOC within a chronic disease framework could facilitate patient engagement and improvements in HCP practice and patient outcomes. Further research is required to implement strategies to overcome these barriers in the development of a non-surgical inpatient MOC. The authors recommend the development of strategies using the themes mapped to the TDF, to develop a patient-centred non-surgical MOC.