The WHO (2021) reports that in 2016, 1.9 billion adults were overweight, with 650 million adults classed as obese worldwide. In the UK, 64.2% of adults are overweight, with 28% of these classed as obese (Baker, 2022). Locally, the population statistics are lower than that of the UK, with the amount of overweight or obese adults being 61.1% (Isle of Man Director of Public Health, 2017). Yet, this remains a high percentage given that excess weight is a major risk factor for diseases such as type 2 diabetes, cardiovascular disease and cancer (Department of Health (DoH), 2011), as well as increasing a person's mortality risk from COVID-19 by 33% (Public Health England (PHE), 2020).
Various organisations including PHE (2017), National Institute for Health and Care Excellence (NICE) (2015) and the Department of Health and Social Care (2020) highlight the importance of preventing and reducing excess weight. Other sources such as the National Obesity Forum (2005), the Nursing and Midwifery Council (NMC) (2018) and the Royal College of Nursing (RCN) (2012) recognise the importance of community nurses providing public health advice to patients.
Community nurses often visit patients numerous times, providing plentiful opportunities to discuss and utilise weight management interventions. Yet, evidence suggests that nursing staff often find the topic of weight difficult to address, citing barriers such as time constraints, lack of knowledge and the sensitive nature of the subject (Brown et al, 2007).
Weight Management Pathways
NICE (2014) recommend the use of tiered pathways within their weight management guidelines, with various pathways being utilised across the UK (Supplementary Information 1). Locally, however, we have no pathway or tool to support an individual to manage their weight and promote a healthy lifestyle.
Locally, we currently use the Malnutrition Universal Screening Tool (MUST) to measure a patient's weight at every initial assessment. Yet, the tool only recommends actions if someone is underweight (British Association for Parenteral and Enteral Nutrition (BAPEN), 2018).
After searching and reviewing Weight Management Pathways (WMPs) from areas across the UK with a similar demographic and rural population, five pathways were chosen to inform the development of a local WMP (Figure 1). These also reflected NICE guidelines and NHS weight management tiers (Reddy, 2006; McFarlane, 2008; Corrigan, 2016; Hampshire County Council, 2018; East and North Hertfordshire CCG (ENHCCG), 2019).
Aim
The aim of this research was to understand community nurses' views on weight management within their practice and the potential implementation of a WMP. Their views could then bridge the gaps identified within the literature and empower staff to give their opinions. This can reduce potential implementation barriers, while also providing local healthcare services with information to encourage and facilitate the introduction of this pathway.
Methods
An interpretative, phenomenological approach, consistent within qualitative enquiry was utilised to allow the researchers' professional experience to inform the study (Holloway and Galvin, 2007). Purposive homogenous sampling was utilised to recruit participants to ensure a focused enquiry. Hence. participants with prior subject knowledge were recruited (Remanyi, 2013). Focus groups were used to collect rich, in-depth data, while thematic analysis was used alongside the Theoretical Domains Framework (TDF) to analyse the data. The TDF is a validated framework with 11 domains that is often utilised in implementation research to identify influences on healthcare professionals' (HCPs) behaviours and the factors that affect them, such as individual motivation and the dissemination of guidelines. This can highlight potential implementation barriers and inform the design of future interventions. The TDF was used within this research to identify such barriers to the implementation of a WMP (Cane et al, 2012; Atkins et al, 2017).
All local community nursing staff were invited to participate, with six staff being recruited for the focus groups. This consisted of three qualified District Nurses (DNs) (one x Band 7 and two x Band 6) and three Band 5 registered nurses. Considering that the local community nursing service has around 45 staff, this is a representative sample based on the current hierarchical structure and experience. Participants were sent an information letter regarding the study and a consent form to sign and return to the researcher. The focus group took around 40 minutes, which was led by the lead researcher using a moderator aide memoir and an interview schedule of six questions that related to the identified domains within the TDF. These questions are:
- What role do you as community nursing staff currently have in weight management?
- How do you currently assess and treat patients' weight?
- This is a draft WMP and is based on similar ones utilised within primary care in the UK. Do you think this WMP would be useful in the local community nursing service to aid in the management of overweight and obesity?
- What would aid and encourage you to utilise a WMP within your role?
- What would you foresee as potential barriers when implementing a WMP within the local community nursing service?
- Have you ever tried to encourage weight loss with a patient and if so what were your experiences of it?
Seven TDF domains were identified as codes due to their relevance to the research subject based on the literature review and professional experience. The focus group was audio-recorded and transcribed verbatim using the MAXQDA Analytics Pro 2020 (Supplementary information 2).
The transcript was anonymised using participants' initials and sent back to them for validation of their responses. Once validated, the responses were coded into one of the seven identified TDF domains.
Results
Overall, 10 themes emerged across the seven domains (Table 1). Findings are discussed by domain, including quotes from participants to further illustrate the identified themes. Participants discussed their current practice relating to weight management. They were also shown the designed WMP so as to gain their views and how it could be used.
Table 1. Domains, domain focus and themes
| Domains | Domain focus | Themes |
|---|---|---|
| Environment context and resources | How the environment and resources impact a healthcare professionals (HCPs) skills and behaviours |
|
| Knowledge | Identifies what HCPs know about the topic or behaviour | Health promotion and advice |
| Skills | Focuses on skills staff do or do not possess and how they utilise them |
|
| Social or professional role and identity | How a person views their professional role and personal identity in relation to the behaviour |
|
| Beliefs about capabilities | HCPs awareness of their competence and confidence when carrying out certain behaviours |
|
| Beliefs about consequences | How HCPs view the outcome and reason of doing or not doing the behaviour |
|
| Social influences | Social aspects of what may cause a HCP to carry out a behaviour, ie. social pressure or organisational culture |
|
Environment, context and resources
Participants identified the use of the MUST tool during their assessments in relation to individuals who are underweight and so, they are more likely to refer these patients to other services (Supplementary information 2;1):
‘It's focused on being underweight and losing weight unintentionally rather than managing anybody that's overweight and it's not interested if anybody is overweight because they score zero.’
The need for a tool to guide and support HCPs with assessment and interventions was also recognised by participants. The draft WMP was shown to participants who were asked if they thought it could be useful:
‘I think it would be beneficial for patients and as a professional, it gives you that guidance to follow.’
Another theme within this domain was the resources required to implement a WMP, including staffing, cost and time. Participants were aware of the current vacancies within the local service and the increased workload that implementing and utilising a WMP could have:
‘And the time issue as well isn't it, because when you get into that conversation about weight, diet and everything. It can take a long time can't it.’
Knowledge
Participants discussed the health advice they provide to patients, which included nutrition advice relating to chronic conditions such as diabetes and wound management, as well as exercise, foot care, smoking and mental wellbeing (Supplementary information 2;7). One participant specified when they would provide diet advice:
‘I think if you've got somebody with a wound or health issues you'd encourage them on what to eat.’
Participants acknowledged that they did not possess enough knowledge to be able to provide effective weight management advice.
Skills
Participants recognised that training would be required for all staff to ensure that the advice and interventions they were giving were both effective and standardised (Supplementary information 2;12):
‘If there was training around it then professionals would be giving equitable advice to each patient.’
Another skill that participants identified as crucial in training was motivational interviewing (MI). One participant felt that their lack of MI technique impacted upon the advice they provided to patients:
‘I'm very good at saying you shouldn't be doing this, there's a leaflet, rather than understanding how to motivate somebody and understand why they aren't motivated.’
Social influences
One participant's response was exclusive to this domain while discussing when they would refer patients regarding their weight (Supplementary information 2;19):
‘I think we're more likely to refer them if they're underweight, not necessarily ignore, but don't really address it as much if they're overweight, do we?’
All participants agreed with this statement indicating a culture within the service. This could be due to a lack of knowledge or a lack of pathways and referral process to follow.
Social or professional role and identity
Participants acknowledged that the sensitive subject matter and lack of confidence in the subject sometimes prevented them from discussing weight with patients (Supplementary information 2;22):
‘I think we're a bit embarrassed to mention it aren't we? We're quite happy to mention they're underweight but to say to somebody we need to do something because you’re overweight it's a different kettle of fish, it's a very sensitive subject.’
One participant felt that their appearance may impact the weight management advice they give:
‘I think it depends on who's delivering the care as well because I mean I'm not thin by any means so if I was telling someone that's a similar weight to me to lose weight it might be quite awkward.’
The importance of staff engagement across the health service was identified in relation to all staff in the local health service using the WMP and that there may be some resistance to change.
Beliefs about capabilities
Only one participant's response coded to just this domain and it related to confidence when carrying out weight management interventions specifically to housebound patients (Supplementary information 2;27):
‘It's because of the criteria of people we see. It's different with the treatment room patients, but the ones at home that's a very difficult group to help change their habits.’
Beliefs about consequences
Participants also considered the consequences of patients successfully engaging in lifestyle and weight management advice; this included discussions around patient compliance. A participant who had previously worked as a practice nurse discussed previous experiences (Supplementary information 2;31):
‘People didn't want to change or they didn't think they had an issue or they didn't understand so it's a really, really hard thing to help.’
Other potential consequences of the implementation of a WMP related to communication, particularly with general practitioners (GPs). Participants voiced concerns that GPs may refer patients to the community nursing service for weight management interventions once a WMP was in place. Systems were also identified as a communication barrier as there are currently various systems in use across the healthcare service, these were in relation to both previous encounters with HCPs and referrals to other professionals:
‘Maybe the fact that we don't have one communication system between professionals could be a barrier because it's not always easy to refer to dietitians and GPs and that technology barrier.’
Discussion
The NMC (2018) and Queen's Nursing Institute (QNI) (2016) recognise the importance of nurses' roles in health promotion. It is vital that HCPs possess good knowledge and understanding so that advice and interventions are effective (Kardakis et al, 2014; Pearce et al, 2019). Participants in this study accepted that their lack of knowledge and confidence around this subject often prevented them from addressing weight management with patients. Studies by Chan et al (2013) and Blackburn et al (2015) have shown an increase in staff confidence following training, with some staff reporting more effective patient outcomes. Participants discussed the need for training in how to utilise a WMP, specifically in relation to MI.
Evidence recognises MI as a proven behaviour change tool. It encourages individuals to take responsibility for their own health whilst understanding the need for change (NICE, 2014; Sellwood, 2014). Participants discussed their concern regarding patient engagement with weight management interventions. This is echoed in studies within the literature which found that HCPs were less likely to attempt lifestyle interventions with patients if they lacked motivation to change.
Participants highlighted the need for a WMP or tool to assist and support staff with the assessment and treatment of a patient's weight and thought that the one shown to them would be useful. NICE guidelines and other research advocates the use of a WMP or tool for HCPs to use, providing effective weight management interventions. Blackburn et al (2015) and Hansson et al (2011) reported the need for guidelines and a standardised approach to weight management to enable consistent high quality care and advice for patients. Implementing a WMP within the local service could standardise care and ensure patients receive the correct health advice whether they are under or overweight. As staff currently use the MUST assessment tool during initial assessment, a WMP could be implemented and used alongside it. This would prevent a significant workload increase for staff, which participants identified as a potential barrier.
Laidlaw et al (2019) analysed previous research and found that professionals did not discuss patients' weight due to a fear of upsetting them. This theme was also identified within the literature review and the findings of this research. Participants recognised that they don't broach the subject of weight management as they feel embarrassed and don't want to offend patients. Some participants also reported that they may not raise the subject due to their own appearance as, if they are overweight, the patient may not take them seriously. Brewah et al (2018) recognised that there are a proportion of overweight and obese nurses within the NHS; therefore, if these nurses felt the same, they may not be raising the subject with patients and care would not be standardised. Having a WMP in place to initiate a conversation on weight management as part of the assessment process can help normalise the topic for both nurses and patients without fear of embarrassment or offence. Staff awareness of their lack of interaction with patients regarding weight management and the advice they do give would indicate that they are already engaging in some form of health advice. This could mean less resistance to change if a WMP was to be implemented.
Following discussion of interventions relating to the WMP, one of the DNs mentioned the possibility of nurse prescribers being able to prescribe interventions such as Weight Watchers and exercise on prescription as opposed to referring on to GPs and practice nurses. This is not a recognised step on any of the UK pathways that were reviewed. However, Lundberg et al (2020) report that DNs in Sweden are able to prescribe exercise to play a key role in promoting healthier lifestyles. This is an intervention that could be considered locally to decrease onward referrals and could also improve patient engagement if it is prescribed by a professional who has built a rapport with the patient.
Participants noted the cost of the implementation, staff training and intervention resources as well as the use of different electronic record systems, as barriers. Participants also recognised that separate record systems could mean a lack of communication and not being able to access relevant patient records regarding previous weight management discussions and interventions. Background literature did not identify these findings as barriers, possibly because previous research has not focused specifically on the implementation of a WMP.
Limitations identified within this study included the lead researcher's status as a novice researcher, which could affect the reliability of the data. This was mitigated by the researcher's leadership experience, use of checklists and aide memoirs, as well as validation of participant responses. Secondly, a local rise in COVID-19 cases during the time of data collection caused a marginal impact on participant numbers. A study from the literature review employed a similar number of participants from a larger sample population (Holmgren et al, 2019), implying sufficiency of sample within this qualitative study.
Conclusion
The purpose of this research set out to gain community nurses' views on a WMP, identify potential barriers to its implementation and provide information on the need for a WMP locally. The research methodology aided in the fulfilment of the research. The findings of this research not only reflected background literature but also identified new findings and potential barriers to change, which can be used to inform the development and implementation of a local WMP. This research has been presented to senior community nurses as well as the local Minister for Health and Social Care. Further development of the WMP would be beneficial alongside research into other professional's views of a WMP.
Key points
- Despite 61.1% of the local population being overweight or obese there is currently no tool or pathway to aid weight management
- National Institute for Health and Care Excellence weight management guidelines recommend the use of tiered pathways to support individuals
- Local community nursing staff participated in a focus group to gain their views on the implementation of a weight management pathway (WMP)
- Community nurses are well placed to provide weight management support for patients
- Perceiving weight management as a sensitive topic, the lack of a WMP, time constraints and resources can be barriers to initiating weight management conversations
- Staff would require training in the use of a WMP, as well as the use of MI as a behaviour change technique
CPD reflective questions
- Have you ever not discussed weight with a patient due to you viewing it as a sensitive subject?
- What pathway or tool, if any, do you use in your workplace to address weight management and is it effective?
- What else could we do as nurses to ensure weight management becomes a routine part of our assessments?