The role of the professional nurse

This essay will explore the role of the professional nurse in relation to the public health issue: Obesity. Public Health is a government system concerned with managing the health of the nation through statistics, health promotion and education and also by influencing government policy. Its aim is to protect and improve the health of the public by tackling public health issues: problems that pose a threat to the health of the nation and may become an epidemic or a drain on NHS services and public finances.

The World Health Organisation (2006) defines obesity as ‘...abnormal or excessive fat accumulation that may impair health', and normally relates to people with a Body Mass Index of 30 and over, calculated as Weight (kg)/Height (m²). In 1992, obesity was already identified as ‘one of the most important preventable causes of ill health in the UK today' (Kent & Bowyer, 1992, cited in West, 1994, p.5). Statistics showed that between 1993-2007 the number of obese adults in England rose from 15-23% (NHS, 2009). Further speculation by Foresight (2007) claimed that ‘by 2050, 60% of men; 50% of women and 25% of children would be obese.' Obesity is, in itself, a disease but it also causes or exacerbates other conditions, for example, Gall Bladder Disease, Cancer, Respiratory Illness, Non-insulin dependent Diabetes and Coronary Heart Disease. The predicted cost of Obesity to the NHS by 2025 is £5.3billion (NHS, 2009, p.156). As such, obesity is not just viewed as a modern day affliction of the developed world but is cause for major economic concern, particularly to western governments.

Nursing is now seen as a profession. Once qualified, a Nurse is added to ‘The Register' and is expected to adhere to ‘The Code of Professional Conduct', becoming regulated by the Nursing and Midwifery Council. This is to ensure best practice; at the same time affording protection for the patient, the public, the NHS and the nurse alike. If a nurse is deemed to have broken the rules as stated in The Code then she may be struck off the register and prevented from practising again. To remain on the nursing register ‘...all nurses must re-register every three years and have completed at least 35 hours of continuing professional development' (Kozier et al., 2008, p.32). This will ensure currency of knowledge.

In Primary Care, the patient may present with symptoms relating to a condition associated with their obesity and yet is unaware of the connection. This patient may not realise their excess weight is, in itself, a risk to his health, particularly if they are from a country where excess weight reflects status and wealth. Others may decide for themselves that they are carrying too much weight and attend the local practice for help and advice. Caring nurses will be non-judgemental, refraining from stereotyping the patient as being idle and greedy, as they will know that several factors may be responsible for the obesity, including hormonal (Hypothyroidism); psychological (depression); genetic (Prader-Willi Syndrome) and sociological (culture and/or poverty). These issues may become clearer once the nurse has made an initial assessment of the patient, to include their ‘Activities of daily living', making use of an appropriate Nursing Model such as Roper, Logan & Tierney (Aggleton & Chalmers, 2000); a framework that helps nursing staff to fully assess an individual, holistically, and therefore enable them to produce a uniquely tailored care-plan. It can also serve as a checklist with which to monitor the patient's progress throughout their treatment and reassess the care plan as part of the nursing process, amending it if necessary.

The Nursing Process is a four stage ongoing cycle of Assessment; Planning; Implementation and Evaluation. A consequence of not doing this may mean that information important to the patient's recovery may be overlooked (Aggleton & Chalmers, 2000). For example, on assessing an obese female, the nurse may discover that she is a single mother of three young children, existing on benefits. It would not then be appropriate to advise her to join a gym, as realistically, she would be unable to afford this and may not have anyone to provide childcare. Instead, the nurse may start by encouraging her to begin walking daily. It may also become apparent that she is suffering from depression which requires referral to a psychologist.

Making good use of the Nursing Models and Nursing Process can help to prevent further ill-health and reverse the disease process as the root causes of the obesity are discovered and dealt with. The nurse as educator would seek to help the patient understand which foods would be better to avoid and explain the link between overeating, lack of exercise, obesity and other related health problems. Their knowledge will come from reliable scientific sources. It would not be professional, for example, for the nurse to endorse the Atkins Diet even though it may have been used successfully by many people to achieve quick and dramatic loss of weight. This is because the diet has not received official scientific accreditation and therefore cannot be guaranteed safe for use by everyone. The Care plan which is communicated to the patient is then recorded. Accurate, clear and consistent record-keeping is vital to continuity of care: ensuring that other members of the multi-disciplinary team involved in the patient's care have detailed knowledge regarding their condition and treatment received, including medication, personal wishes, allergies, consent given or refused etc. Nurses should take care not to include abbreviations which may be misconstrued by the patient should they wish to view their own records which is their legal entitlement. Nurses may also have to rely on the content of these records in the event of any subsequent court case that they may be expected to attend as witnesses. It is widely understood in the nursing profession that if something is not recorded then it did not happen (NMC, 2008). This can have damaging consequences for both the nurse and the NHS alike. Ideally, every conversation of importance with patients, family or other health professionals should be recorded. This will include clearly documenting, for example, that an obese lady is trying to get pregnant despite having been advised by the nurse that it will be detrimental to her current state of health to do so. This will also serve as future indication to another professional not to prescribe the obesity drug Rimonabant as there are clear contra-indications by the manufacturer not to prescribe this appetite suppressant to pregnant women (BNF, 2009).

Record-keeping is an example of nurses being accountable. Accountability can also be demonstrated by checking the patient's records against any prescribed medication on the British National Formulary and ensuring that the correct drug/amount is administered. Any discrepancy must be queried with the prescribing Doctor and a refusal to administer the prescription must be documented, to explain and justify the nurse's actions, otherwise harm may be done to the patient and could result in the nurse being sued for negligence even though it was the doctor's mistake. Nurses are accountable for all their actions and omissions. (NMC, 2009)

Consent must be obtained for every procedure. The obese patient on a hospital ward will be asked for their consent to be moved with the hoist and this would usually be sought verbally or through implied consent with a nod of the head. This may be an embarrassing situation for the patient, so if consent is obtained, the patient's dignity could be preserved by drawing the curtains before the hoist is fitted. The nurse will, of course, already have explained the procedure to the patient and informed them of why the procedure is necessary. A sensitive nurse may also casually advise that it is now hospital policy that manual handling of anyone other than a small child requires the use of the hoist or other moving aids. Despite this, the patient may still be deeply humiliated and may well feel that his human rights have been violated by contradicting Article 3 of the Human Rights Act 1998; retrospectively trying to sue the nurse and the hospital trust. According to Dimond (2008), recording consent can prevent negative consequences. Written consent must be obtained for all surgical procedures. The patient with mental capacity reserves the right to refuse any treatment and if nurses choose to ignore this, they leave themselves vulnerable to prosecution for assault/battery. Consent may be more likely to be obtained when the nurse demonstrates respect for the patient and is honest. Any risks with any procedure must also be carefully explained. Patient autonomy means that the patient has the right to self-determination. Autonomy is paramount and should the obese patient refuse to diet, then that refusal should be respected. If, however, surgery is dependent on the patient losing some weight beforehand, the nurse may wish to explain this to the patient and also assure them that any weighing procedure will be carried out discreetly. Patient choice must be respected even if it leads to their death. (NMC, 2009)

Confidentiality is of upmost importance and the nurse will never openly discuss, for instance, the weight of an obese patient with other team members where the conversation may be overheard by others. This can cause hurt and embarrassment to the patient and there is also a legal, moral and contractual (of employment) obligation to observe confidentiality rules. To maintain confidentiality, anything that the patient discloses to the nurse in confidence must remain so except, for example, in the case of the obese threatening suicide, where the appropriate third parties should be informed. If the disclosure is of a personal nature, e.g. that the patient intends to leave his wife when his desired weight loss has been achieved, or has a sexually transmitted infection, then that information must remain firmly between the patient and the nurse. (REF)

Nurses owe a duty of care to all their patients and this means that they will ‘respond to all patient needs' (Kozier, 2008 p.34). This should be undertaken willingly and without prejudice. Non-maleficence means to do no harm; Obese patients are likely to have already experienced discrimination and a nurse must never tease them as this will inevitably cause psychological damage. Nurses have a duty of beneficence towards patients, meaning ‘to do good' and this could include encouraging an obese Muslim female to attend female-only swim sessions. On assessment it should be noted whether an interpreter may be required if the patient's English is limited. This will enable them to make informed choices about treatment options and will avoid an obvious barrier to communication. Providing an Interpreter demonstrates that the nurse is engaged in their Duty of Care towards the patient. Nurses should be careful, however, to use professional translators, as according to Mayberry & Mayberry (2003) using friends or family may void any consent given.

Non-verbal communication such as body language, can be interpreted in different ways and nurses must ensure that they respect their patient's personal space and use appropriate eye contact, depending on the patient's culture. Folding arms or yawning are indications of disinterest and boredom and will quickly lead to lack of trust or co-operation. Nurses need to involve the patients in their own treatment plan and poor body language can have the opposite effect.

Other examples of barriers to communication with patients could involve psychological reasons, for instance, a patient refusing to acknowledge that his obesity is a health issue may not listen to advice, or co-operate. Another may feel ashamed of their size and may not be truthful with the nurse when discussing their lifestyle. The compassionate nurse listens, motivates and educates patients; empowering them. This will help them to take control and make the best decisions. Patient autonomy is promoted and their confidence will grow as a result. Other communication barriers may arise because of physical disability such as deafness whereby nurses could provide leaflets and seek the help of a fluent signer. For others who are not mentally competent, communication may be very difficult and the nurses should act as advocate, perhaps enlisting the help of the carer or other health professional who can advise on the best methods. Nurse advocacy (ref) is especially important with vulnerable patients who may not be, or feel capable of, speaking up for themselves.

Barriers can exist between the nurse and other health care professionals when hierarchy is an issue (REF). A doctor may feel superior to a nurse and therefore may not wish to listen to the nurse's recommendations. Barriers to communication with a patient's family may stem from the family's own prejudices against the nurse's colour, race, or other status. Likewise, the nurse must ensure that her own prejudices do not impede her professionalism and she must treat all patients with the same high standard of care; therefore observing and respecting equality and diversity.

To summarise, obesity affects people from all backgrounds. It is a serious public health issue. A professional nurse applies their up-to-date knowledge to the quality care of the obese patient, educating and motivating them towards a healthier lifestyle. They will not discriminate against nor pre-judge any patient and will value patients' opinions; respecting their dignity and autonomy throughout treatment.


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