Communication is a procedure that is basically concerned with the transmission and acceptance of messages which may either change people’s perception or not (Tones and Green, 2005). This delivery of information and counsel is fundamental to strategies in a well being programme development (Naidoo and Wills, 2009, p.185). This procedure and the result of its accessibility, presents impulsive responses that affect the attitudes and opinions of many people.

Therefore, communication strategy means the use of conventional media support to pass across important information to the populace so as to enhance a change in people’s way of life (Naidoo and Wills, 2009, p.185). The communication strategy for this assignment will focus on the issue of obesity among college students in Newtownabbey area of Northern Ireland, how to raise awareness about its risk, and how to combat it through informed knowledge by reducing the havoc it can cause later in life to young adults if proper strategies are not put in place.

Rationale

In the western world most especially in the UK and the USA an outbreak of diet associated ailment is affecting the general public, which had led to an exceptional increase in the occurrence of obesity and its related ailment, that have led to imperative intervention for its eradication (Department of Health, Chief Medical Officer, 2003). It was also estimated by the (World Health Organisation [WHO], 2002) that roughly 58% of type 2 diabetes, 21% of CVD and 42% of some kind of cancers are ascribed to surplus adiposity in the body. This data was supported by a report written by the National Audit Office (2001) stating that over 9000 premature mortality is recorded each year in England due to obesity related disease, which causes a reduction in life anticipation by about 9 years.

The consequences of obesity can have a serious impact on people’s health and wellbeing especially teenagers by affecting them socially, psychologically and physically. This impact of obesity was summarised by (DHSSPS, 2002; Fit-future, 2006) as

Socially causing a reduction of life expectancy by roughly nine years.

Physically causing a major increase in the risk of Northern Ireland leading destructive ailment like cardiovascular diseases, diabetes and cancer.

Psychologically causing a major impact on teenagers’ self-esteem and emotional well being.

Physically predisposing overweight children to becoming obese adults in future.

In Northern Ireland it was reported that obesity was said to be causing 450 deaths every year which is equal to more than 4000 years of misplaced life (DHSSPS, 2002). Also it was gathered that this pandemic always lead to a 260 000 wasted productive years, which is equivalent to around £500 million economic lost (Fit-future, 2006).

Background

Obesity in children has drastically increased in England from 11% in 1995 to 19% in 2004 among boys of ages between 2-15 years old while the same trend also affected girls of the same age range by a radical increase from 12% in 1995 to 18% in 2004 (Department of health [DH], 2005). Fit-future (2006) also reported that the level of obesity in children in Northern Ireland is increasing every year resulting in about 20% of boys and 25% of girls being overweight or obese in primary one. This has resulted into more than a quarter increment in overweight and obesity in the last 10 years among 12 and 15 years old teenagers residing in Northern Ireland (Watkins and Murray, 2005).

This is why this communication strategy intervention needs to be promulgated to ensure that young citizens are fully aware of the consequences of obesity and its predisposing factor.

Management and Theoretical Opinions

People’s way of life in relation to their health has been regarded as the origin of several current diseases, which can be controlled by exploring many models in health that recognizes the reasons for behavioural transformation (Naidoo and Wills, 2009). Kobetz et al. (2005) claimed that a well constructed and strategic propagation of a theory based health communication and identifying the relevance of the theory is a major input to achieving a successful communication.

In order to have a valuable communication strategy that is well managed to combat the pandemic of obesity in childhood, the health promoter has sourced the help of a model called the Health Belief Model (HBM) (Becker, 1974). Janz and Becker (1984) declared that this model was previously developed to envisage precautionary health behaviours. The model looks at how beliefs impact on behaviour (Abraham and Sheeran, 2005), .i.e. what a person put into practice depends on how defenceless they recognize themselves to be to the ailment, their idea about susceptibility to the ailment (obesity) and its predisposing factor, the anticipated severity of that incidence, the advantage of implementing self-protection, and the barrier to its implementation. Where such health beliefs are understood from health education or perceived symptoms, it can help in stimulating healthy behavioural change (Naidoo and Wills, 2009). This is why a college is chosen to propagate and increase the awareness of obesity pandemic among children and to suggest a solution that could be of help to teenagers.

Prochaska et al. (1992) also brought the idea of another model that suggests that individuals change their actions at some specific stages in life rather than making a single revolution. This model identifies that an individual move through several ladder to attain a healthy living only if they are aware of the necessity to make corrections.

Empowerment as related by (Tones and Tilford, 2001) was pointed out to be the major goal of health message propagation, because it help to develop individual autonomy and ensure they gain more power over their daily lives. It focuses on a “bottom-up” programme development technique (Laverack, 2005), because it tends to appraise peoples necessities before a strategy that will suit their condition is planned. An empowered and independent individual who recognizes that being obese can results into a lot of life threatening diseases later in life, which could make life miserable would tend to be cautious about the kind of lifestyle they adopt. This empowerment approach is viewed from the micro and macro perspectives, which are the self-empowerment and the community development approach (Naidoo and Wills, 2009). The former shows the extent at which individuals have authorities over their relationship with the society (Berry, 2007), while the latter encourage groups in the community to collectively discover their needs. Therefore, an approach that empowers, inform and enhance change in conduct is required for an effective health campaign.

In planning a health communication programme whose overall goal is to increase the awareness of obesity, it is very crucial that the establishment work collectively together and coordinate themselves in the same direction. This combined work is evaluated by using the idea of the SWOT analysis which considers the interior and the exterior component of an environment as a very important part of the premeditated planning process (Jackson et al., 2003). This assesses the “strengths, weaknesses, opportunities and threats” involved in planning the strategy. This assessment includes:

Strength: The help of some of the staff of the institution will be requested for volunteering role to reduce the finances of the plan, and to make student have a sense of belonging, since some of their tutors will be involved in impacting the messages.

Weaknesses: Problems might arise from encouraging food vendors to change the kind of food they prepare , because they might be reluctant in making changes due to an anticipated reduction in their sales and profit.

A conflict problem might also arise when trying to create partnership among the department that would be involved.

Funding of the strategy might also create a hindrance.

Opportunities: This strategy might help to reduce students thought of choosing to eat food that are life threatening.

Threats: This can lead to reduction of student’s purchasing power on foods that are high in cholesterol, which could affect the shops that need to make profit.

All effective organisation routine relies on the triumphant management of the prospects, challenges and the risks presented by the outside atmosphere. A well recognized technique for analysing the general environment is the PEST analysis .i.e. the Political, Economic, Socio-cultural and Technological influences (Harvard Business School Press, 2006). The key issues pertaining to the current strategy are explained below:

Political: The existing nation policies will be sourced to ensure the effectiveness of the new strategy by checking whether there are surviving political issues on obesity, and to exercise how this new intervention will add more to the knowledge of the public.

Economic: An approximate idea of the student finances will be identified, to assess if they will be able to afford the healthy food, so as to ensure compliance.

Socio-cultural: Student belief about the kind of food they eat their environmental and peer group influence on the choice of food they purchase will be examined.

Technological: Effort to provide weighing machines for Body Mass Index (BMI) check on campus and in the hall of residence and also provision of healthy food transaction machines.

In an organizational system it is of utmost significance that the manager and the leaders in charge of the success of an organization are well equipped with the traditions and personality of the people they work with. An effective leader and manager must ensure that they play a dynamic role, designate people and resources to the right avenue, and promote success all the time (Young and Dulewicz, 2009). A manager duty was summarized by (Stewart, 1999) as someone that makes a decision on how an establishment should be run by laying good examples in practice, cultivating the act of motivating the staff, encouraging good interpersonal interaction and communication, as well as ensuring improvement of staff skills and knowledge through different improvement programmes. It was also stated by Hargie and Dickson (2004, p.8) that managers at all levels must engage in four major activities to ensure the success of an organisation, this includes: planning, organising, leading and evaluating.

There are different management theories that can be used in planning this strategy, but the contingency theory is the best (Donaldson, 2001). It was claimed by (Vecchio, 2000) that the technique and systems of running an organization bulge down to the incentive given to the staff and the dedication of the staff to the company.

Leadership was also described by (Mullins, 2002) as the value that can be introduced into a profession which is not designated to a particular person but comes as an impulsive reaction.

In achieving an effective management technique, maintaining a conflict free team work must be the ultimate duty of a leader as well as a good manager. A management skill that will ensure acknowledging the ideas of all team members must be established to avoid conflict, because a victorious team must have an apparent goal, good interpersonal relationship, excellent communication skills and must be up to the task. This idea was supported by Hargie and Dickson (2004) when they highlighted the four major skills that must be exercised to shun conflict.

Martins and Rogers (2004) stated that to properly deal with a team conflict, a manager must adopt the ability to negotiate and bargain, which is very important in tackling a team problem. This help to create a rapport among the team members which will ensure reaching a compromise by finding solution to the conflict. Martin and Rogers (2004) also suggested that for a manager to be in full control, he must be calm, logical in his thoughts and be able to control his emotions.

To meet the overall aims of this strategy, Martin and Rodgers (2004) pointed out that it will be important to adopt a coordinated partnership approach. This will involve statutory sectors, particularly health and education, local, voluntary and community sectors such as Health and Social Trust, as well as Healthy Living Centre. Such organisations could be involved in supporting and providing information to increase awareness.

Communication Strategy

The chosen venue for the proposed communication strategy is the Northern Regional College (NRC) in Newtownabbey area of Northern Ireland, since early years of children and teenagers has been described as a period when they tend to acquire long term behaviours and attitudes (Naidoo and Wills ,2009, p.206).The NRC is an educational and learning institution where skills can be impacted in a secure and compassionate environment ,which made it a perfect place for propagating a health message ( Xiangyang et al., 2003). In view of the fact that teenage years are characterized by peer group influence, the school surroundings provides a chance to communicate with adolescent and provides learning opportunities and a secure environment to perform latest skills (Naidoo and Wills, 2009, P.207).

This strategy will focus on young children of both sexes in a college setting of age range 14-16 years old through the adoption of a classroom-based method of delivering lecture that will enlighten the students on the proper dietary habit and the kind of healthy food they can lay their hands on. This educational intervention will comprise of about five lectures, which will be accomplished in a week. Different materials like visual aids, slides and transparency that have been pre-tested in the pilot study will be used by the volunteers and the health promoter involved in propagating the messages. The visual aid will contain important information on diet and health, many food deficiency disorders, and importance of physical activity and the various kinds that will suit the student daily life. Interpersonal interactions, small group discourse and group work, as well as workshops that will comprise of the use of the slides to convey healthy eating messages to increase the awareness of obesity, that is tips that will assist them to eat well will also be show cased to augment the stuff of the message being delivered (Parrot, 2004). A follow up pamphlet containing all the messages delivered will be provided for the college students to upgrade the information they have heard during the intervention. Posters displayed at every corner of the school will also be involved to ensure students are well informed.

Overall Goal

The overall aim of this communication strategy is to inform and raise the intensity of consciousness among college students about the risk of obesity.

Objective

The purpose of this proposed strategy will centre on enlightening student by creating alertness, which will result in healthy way of life from the scrash by catching them in their juvenile years. The objective is adapting the term (SMART), which means the aim must be “Specific for the programme, Measurable, Achievable in its totality, and Realistic to the target group as well as Time conscious” (Mullins, 2002). The learning objectives are

To create awareness about the kind of healthy food that can promotes healthy living among teenagers.

To guarantee teenagers disseminate the message received from school to other members of the families for optimum health.

To enlighten students about the kind of lifestyle they need to instill to avoid the risk of having the ailment.

To establish whether student have a prior knowledge of the ailment and its consequences.

To prevent obesity and overweight by promoting attitudes, knowledge and communication skills that makes healthy eating practices realisable.

Time Frame

The anticipated time for the programme would be within a three months period. Which means the strategic planning should start roughly in May 2010 and execution of the plan should begin in June and end in July 2010.

During this period the pilot study that is incorporated into the plan will be undertaken, to provide an opportunity to appraise and monitor the effectiveness of the strategy, so as to make amendment where necessary.

Implementation of the Strategy

To achieve a success in carrying out this strategy an ethical issue must be considered, since the target group are among the vulnerable groups of the society. This view was declared by (Beauchamp and Childress, 2001) where they highlighted the four famous ethical principles that need to be put in place when organising any health promotion campaign. This include respecting peoples autonomy and confidentiality, being beneficence, causing no destruction to people, and making good justice as at when necessary. Considering all this ethics the message to be delivered must be free of ambiguities, threat free, and must also be from an authentic source to avoid misinformation.

Evaluation The appraisal for this strategy must be in line with measuring the goal set down during the planning of the strategy. Since evaluation is done mainly to assess the development and the usefulness of a programme, it is fundamental to gather information during the commencement and closing of an intervention program (Naidoo and Wills 2009, p.296). The type of data considered necessary for this anticipated strategy will involve the use of the two means of gathering information .i.e. the qualitative and the quantitative method of data collection (Parry-Langdon et al., 2003). An impact assessment method of evaluation will be incorporated into the sessions by distributing questionnaires to the college students to fill in furtively before each session and instantly after the session to assess their knowledge about obesity ailment and its risk before and to measure the impact of the strategy on the college students after the intervention. A focus group dialogue will also be held among students and their tutors to establish if the modus operandi used for the programme execution was a good idea. This is needed to prove the quality of the future programme that will be executed (Nutbeam, 1998).

Conclusion

Obesity is regarded as one of the key health predicament facing both the developed and developing society today, and it is fundamental that society are provided with all the essential information and support required to improve and sustain high-quality health. The role of communication in enabling and empowering the populace to make intelligent decisions about life is vital to changing behaviour, and the approach in which knowledge is assimilated goes a long way in effecting change.

The effectiveness of communication depends on the authenticity of people’s daily lives and their present practices, as well as their perception towards existence.

To attain prolong success in health promotion; it is very crucial that work is motivated by using the bottom up approach (Naidoo and Wills, 2009), and to ensure all management issues are taken into consideration.

Abstract

Obesity is rapidly becoming the world’s largest health issue with no sign’s of moderating (National Health Service (NHS), 2007). Not only does obesity have significant human cost in relation to the onset of disease and early mortality but also constitutes a severe financial burden to the NHS. The cost of obesity to the United Kingdom (UK) NHS was estimated to be approximately £1 billion a year with an additional £2.3- £2.6 billion a year to the economy as a whole (Department of Health (DOH), 2007). Overall hospital admissions for obesity as has bariatric surgery with 2724 operations carried out between 2007 and 2008.

Attitudes to obesity are generally negative in the published literature but one study highlighted that nurses, in particular, hold negative attitudes towards this client group. This study will focus on obese patients’ perceptions of nurses’ attitudes towards them. A quantitative paradigm incorporating a descriptive survey design will be selected as the most appropriate approach. The sample will comprise members of the British Obesity Surgery Patient Association (BOSPA) who will be invited to complete, a structured online questionnaire on a protected part of the website. The sampling technique used will be purposive and a convenience sampling and data will be analysed statistically.

Introduction/ Background.

The focus of this study will be the obese patients’ perception of the attitudes of the nurses towards them. To gain an insight into and an understanding of this area of practice, the literature relating to obesity and bariatric surgery, the patient experience and nurses’ attitudes will be critically appraised.

Obesity is defined as an excessive fat accumulation that is a risk to health. This is identified according to international guidelines by a body mass index (BMI), where a person’s weight is divided by the square of their height. A person having a BMI of 30 or more is classed as obese.

Being obese is a major risk factor for a number of chronic diseases, including diabetes, strokes, hypertension, cardiovascular disease, musculoskeletal disorders like osteoarthritis, and some cancers (World Health Organisation (WHO), 2009). These conditions cause premature death and significant disability (WHO, 2006).

In England the prevalence of obesity has almost trebled in the last two decades, with nearly one in five adults currently classified as obese, (National Audit Office (NAO), 2001). Obesity is rapidly becoming the world’s largest health issue (NHS, 2007); it is on an upward trend with no signs of moderating. By 1998 the incidence of obesity had almost trebled, at present almost half of women and two thirds of men are either overweight or obese, meaning one in five adults in the UK are obese (NAO, 2001). Not only does obesity have significant human costs, contributing to the onset of disease and early mortality, but also has severe financial burdens on the NHS. It has been estimated that the cost of obesity to the UK NHS is approximately £1billion a year, with an additional £2.3billion-£2.6billion a year to the economy as a whole. If the current trend is not halted, it is estimated that by 2010 the cost to the economy alone could be £3.6billion a year (DOH, 2007).

Overall hospital admissions for obesity have increased, reaching 5,018 in 2007/08, a 30% rise in one year and almost a sevenfold increase in a decade. Increasing numbers of drugs are being prescribed by doctors for obesity with the number of items rising 16% in one year to reach 1.23 million in England in 2007 (Telegraph, 2009).

It is now said that Britain is facing an ‘obesity time bomb’ as the number of middle aged people dying as a result of being overweight has doubled in less than a decade (Telegraph, 2010). The statistics show that more than 190 under 65 year olds died as a direct result of their obesity last year compared to just 88 in 2000; deaths among those aged between 46 and 55 almost tripled. Obesity was a contributing factor in a further 757 deaths last year compared to just 358 in 2000. These death rates are said to continue to increase rapidly through the decades as the overweight youngsters of today become middle aged (Telegraph, 2010). IS THE TELEGRAPH A RELIABLE SOURCE? WHAT IS IT REPORTING FROM, A RESEARCH STUDY, GOVERNMENT FIGURES??

The government is committed to tackling the rising trend of obesity in the UK; in 2008 the DOH set out a strategy to enable everyone in society to maintain a healthy weight. The strategy focuses on five main areas the healthy growth and development of children, promoting healthier food choices, building physical activity into our lives, creating incentives for better health and personalised advice and support. In spite of these national efforts and incentives to support a reduction in problems associated with obesity, such as lifestyle, diet and exercise, bariatric surgery has become more common.

Weight loss surgery is available for people with a BMI of 40 or more (the morbidly obese) and could be an option for people with a BMI of 35 to 40, who have life threatening cardiopulmonary problems, obesity related heart disease or diabetes (NHS, 2007). Weight loss surgery is usually only available on the NHS where there is a clear clinical need for surgery, and other treatment options have been tried but failed (NHS, 2007).

The three most widely uses techniques in weight loss surgery are gastric band surgery, gastric bypass surgery and intra-gastric balloon. Gastric band surgery involves a surgical procedure to fit a band around the upper part of the stomach to limit the amount of food a person eats. Each operation costs between £8,000 and £10,000. Gastric bypass surgery is a similar procedure which uses a band to decrease the stomach pouch, but differs to the gastric band surgery as the smaller stomach is re-routed to the small intestine, bypassing the rest of the stomach. It costs in the region of £10,000 to £12,000 (NHS, 2007). Finally, intra-gastric balloon surgery comprises implantation of a soft silicone balloon into the stomach, which aids weight loss as it takes less food to stop a person feeling hungry and costs between £3,500 and £4,500 (NHS, 2007).

As bariatric surgery is classed as major abdominal surgery, post-operative care is of high importance. Management of patients following surgery includes oxygenation, pain management, mobilisation, wound care, nutrition therapy, education and emotional support (Harrington, 2006). The major topics highlighted in bariatric postoperative treatment plans include; pulmonary, cardiovascular, fluid and electrolytes, pain and discomfort, activity/ambulation, skin and wound, gastrointestinal, psychosocial and safety (Harrington, 2006).

In 2007/8 there were 2,724 finished treatments categorised as bariatric surgery the majority in women, compared with 1,951 the previous year, (Telegraph, 2009). Pressure is mounting on the NHS to increase its capacity to handle weight loss surgeries, but it currently does just 46% of the desired obesity surgeries (BOSPA, 2009). As a result a number of people from the UK go abroad for weight loss surgery.

An attitude is an abstraction or theoretical construct used to indicate and summarise psychological tendencies (Brown, 2005). They are one way of describing differences between people with regards to their differing likes and dislikes. Attitudes are enduring thoughts, beliefs and feelings that people have about an issue, people or events (Cormack, 2000).  Attitudes consist of three aspects; an emotional or evaluative component, a belief or cognitive component and an action or behavioural component. The emphasis based placed on all three components varies greatly on in both attitude theory and research (Cormack, 2000). A belief is the thoughts and cognitions that people hold, they show a general correspondence to whether something is positively or negatively evaluated (Cormack, 2000).

Nurses are required to adhere to the standards set by the Nursing and Midwifery Council code which states that they must not discriminate in any way against those in their care and that people must be treated kindly and considerately (NMC, 2009).

Many studies that have focused upon attitudes of nurses towards obesity in the literature found that there is a negative attitude towards the obese patient and obesity as a whole, examples include ‘Management of obesity in primary care; nurses’ practices, beliefs and attitudes’ (Brown, Stride, Psarou, Brewins & Thompson, 2007), ‘Female nurses’ perceptions of acceptable body size’ (Wright, 1997), and ‘Challenges in caring for the morbidly obese: differences by practice setting’ (Drake et al, 2008).

A study also found that nurses feel uneasy about assessing and talking about weight management (Wright, 1997). Only one study out of the six explored in the literature review rejects the view that nurses have negative attitudes towards obesity and the obese patient (Zuzelo & Seminara, 2006).

Lansing, McGuire, Palmersheim, Baird and Twedell (2009) propose in their piece of research that bariatric patients often encounter challenging physical environments and sometimes encounter negative attitudes from health professionals when seeking care. Equipment, environment, education and resources are important to providing sensitive, respectful, safe and high quality patient care. According to the National Association of Bariatric Nurses (NABN), the nurse-patient relationship is of great importance and attitudes, emotions and moods can affect this relationship.

The DOH developed a patient experience definition after a great deal of research; the outcome was that an ideal NHS should meet both physical and emotional needs of patients, which means getting good treatment in a comfortable, caring and safe environment which is delivered in a calm and reassuring way. People must be given information so they are able to make choices, and feel confident and in control; they should be talked to and listened to as an equal and should be treated with honesty, respect and dignity (DOH, 2007).

Action has been taken to listen to the ‘patient’s opinion’ through the Patient Opinion website where relevant information can be found and shared. Patients can read about others’ experiences, what they think of local hospitals, hospices and mental health services and share ideas on how services can improve. The Patient Opinion website was founded by a general practitioner (GP), Paul Hodgkin, who wanted to establish a way of making the wisdom of patients available to the NHS (Patient Opinion, 2010).

Therefore a review of the literature was conducted with the aim of examining nurses’ attitudes towards obesity and the obese patient and to analyse the available evidence base on nursing attitudes to obesity to improve the understanding of patients’ experience

Literature review.

Nurses are obliged to follow the Nursing and Midwifery Council (NMC) Code which states that they must keep their skills and knowledge up to date and deliver care on the best available evidence or best practice (NMC, 2008).

A literature review was performed to identify and review published material relating to the patients’ experience and perception of nurses’ attitudes towards them after bariatric surgery as an area of interest to develop and research. Various databases including CINAHL plus with full text, Cochrane library, MEDLINE, Interscience and the Ibis library catalogue were searched. Even though there are many resources available for a literature review these resources were chosen for their suitability and ease of access.

The search was restricted to published resources in relation to health and social care and the selected literature restricted to nursing. The following key words and Boolean operators were used in the initial search; obesity, bariatric surgery, nursing, attitudes and post operative care. Relevant studies were selected, reviewed, analysed and summarised.

Critical analysis of literature found.

Brown (2006) conducted a literature review on nurses’ attitudes towards adult obese patients with the aim of gaining an understanding of the attitudes of nurses towards this client group and the methods by which they have been studied. The review highlighted eleven studies relevant to the aims of the study, the earliest being published in 1985. Eight of the studies used quantitative designs and three of the studies qualitative. The most common method used in the qualitative studies was semi-structured interviews with sample sizes of ten nurses, using purposive sampling technique which were analysed using thematic analysis. The main findings on attitudes were that nurses’ felt ambivalent and uneasy when working with obese patients.

The most common method in the quantitative studies was self-administered questionnaires using convenience sampling with a sample size of seventy people and above. The main findings on attitudes included obese patients were evaluated more negatively and that is was physically exhausting when caring for an obese patient.

The review concluded that there is relatively little research about the subject and further research is needed. Brown found that most of the studies reported weaknesses of sampling and measurement. For the qualitative studies, the theoretical basis, rather then simply convenience for the sampling was not clear and the lack of analytical or exploratory depth restricts the transferability of these studies. Also the quantitative studies had relatively small samples drawing on convenience samples making it difficult to generalise the findings.

An important and consistent finding was that a proportion of nurses have negative attitudes and beliefs reflecting stereotyping according to variables such as age, gender, experience and the weight of the nurse which influences their attitudes.

Brown, Stride, Psarou, Brewins and Thompson (2007) conducted a correlation study on the management of obesity in primary care in which nurses’ practices, beliefs and attitudes were analysed. Structured questionnaires were posted to 564 nurses and health visitors in primary care organisations in England. All nurses and health visitors working within the four primary care trusts in the North of England which were selected for their typicality with respect to initiatives to tackle obesity and levels of obesity were included in the study.

Of the 564 questionnaires posted, 544 were actually delivered and 398 completed and returned, resulting in a response rate of 72.3%. Data analysis was conducted by categorising the questions for example demographic and occupational characteristics, practice activity and beliefs and attitudes and then the means scores were calculated.

The selection of data collection tool successfully generated a high response rate however two of the attitudinal scales had low internal reliability. The findings highlighted the need for training and organisational support for obesity management by primary care nurses and, although outright stereotypes were rare, there was a range of potentially negative beliefs and attitudes relating to obesity and obese patients.

Wright (1997) investigated female nurses’ perceptions of acceptable female body size in a qualitative study using semi-structured interviews with a sample size of ten nurses recruited through convenience sampling. Convenience sampling was used because of time and financial restriction however this method decreases the representativeness of the sample and size of the sample being small means the findings cannot be generalised to the whole profession. The nurses were of a variety of ages with hospital-based nursing backgrounds however, none were directly involved in work with weight management.

A semi-structured format was used for the interviews so that it included clarification and discussion while ensuring that all areas were addressed. Interviews took place at a time and place convenient to participants and had no time restrictions. Analysis was carried out by examination of themes that emerged from interviews.

After reviewing this study many interesting aspects were highlighted; for example, nurses feel uneasy about assessing and talking about weight management with patients, there was a view that overweight patients are seen in a negative light because of potential health risks and that strong evidence suggests that there is discriminatory practice towards overweight female patients by doctors.

A study by Drake et al. (2008) identified challenges in caring for the morbidly obese. A quantitative, descriptive, questionnaire survey design using a purposive sample of approximately four hundred nurses was used. Even though the sample was large there were only 109 usable surveys (27%) because all the questions had not been answered. Nurse’s names and e-mail addresses were generated from the membership list of the National Association of Bariatric Nurses. Statistical analyses were performed using the SPSS 13.0 software package.

The nurse’s attitude to obese patients was identified by the nurses themselves as a significant barrier to care. However, the study concluded that more research needs to be carried out to first understand what constitutes the ‘nurse’s attitude’ and then to understand how it relates to the proceeding variable. Several other factors were identified which included staffing adequacy, lack of specialised equipment, a belief that behavioural issues are a major contributor to morbid obesity and finally, a belief that it is the patient’s personality which is a major barrier in preventing the nurse from providing optimal care (Drake et al., 2008).

Research conducted by Zuzelo and Seminara (2006) rejects all the preceding assumptions of nurses holding negative attitude towards the client group. This study was non-experimental and designed to elicit a description of registered nurses (RN) attitudes toward obese adult patients using survey instrumentation. Full time RNs employed by a single health care network and practicing across three types of care settings within a medical centre, acute rehabilitation institution and skilled facility were encouraged to participate. RNs received the survey in their mailboxes, they replied during an eight week period with an overall response rate of 16.2%

The instrumentation scale consisted of twenty eight items developed to measure attitudes of RNs towards obese patients across three dimensions; nursing management, lifestyle and personality characteristics. Statements were rated along a 5-point Likert scale, 1 being strongly agree and 5 being strongly disagree.

Data analysis was conducted using the statistical package for social sciences (SPSS), version 11.5. The results revealed the RNs have positive attitudes towards obese adults and were keenly concerned with providing respectful patient care. However, the RNs did voice concerns about safety when mobilising patients and they were aware of increased amount of time required of nurses when providing care for this client group. Limitations of this study included a low response rate (16.2%) and a low alpha score of 56 which determines the internal consistency suggests the instrument was less consistent than anticipated for the sample.

Finally, Watson, Oberle and Deutscher (2008) conducted research on the development and psychometric testing of nurses’ attitudes towards obesity and obese patients (NATOOPS) scale. This study was designed to develop and test an instrument to measure nurses’ attitudes towards obese adult patients and obesity as a whole.

Attribution-value theory served as the conceptual framework for the study. Item development began with a careful review of the scale developed by Bagley et al (1989) which formed the basis for most of the item scales. Further scales were added in accordance with the theory and current understandings of obesity. Most items were phrased such that a higher score would indicate more negative attitude but to avoid response bias some items were phrased in the opposite direction. To ensure content validity, the questionnaire was submitted to a panel of experts consisting of 3 memebrs with expertise in questionnaire design and 2 nurses who work with obese patients. There was 100% agreement that the development items were appropriate.

The instrument was sent to 1,400 randomly selected Alberta registered nurses and achieved a response rate of 46.1%. Respondents were predominantly female (95.5%) and the average age of respondents was 42 years. A total of 71 scale items which reflected what the researchers believed to be a multidimensional concept of attitude toward obesity and obese patients were included. All scale items were framed as 100mm visual analogue scale (VAS) which allows seldom too often or agree to disagree on each end, depending on the item stem.

The sample size was sufficient to conduct factor analysis, as there were nearly 9 cases per item for the 71-item scale. This study had a relatively high response rate for a random sample and the sample was considered to be reasonably representative of Alberta nurses. The scale demonstrated very good internal consistency reliability. A limitation of this study is that a detailed analysis of relationships among those variables and scale responses was not performed.