Primary care nurses’ perceptions and experiences of patients being overweight or obese as well as visions and attitudes about working with lifestyle issues: a qualitative interview study

In 2016, overweight and obesity worldwide was high and obesity rates are expected to increase further until at least 2030 [ 1 , 2 ]. In Sweden, 51 % of adults were overweight or obese in 2018 [ 3 ]. Overweight and obesity contribute to a large proportion of lifestyle-related diseases and increase the burden on the health care system [ 4 ]. The obesity “pandemic” in almost all countries seems to be driven by changes in the food system, which is producing more processed, affordable food than ever before [ 5 ]. The urban environment has many physical features that reduce the need for physical activity, such as elevators, escalators and other labour-saving devices, along with passive entertainment such as video games and TV watching [ 6 ]. This sedentary behaviour has caused what is called a sitting disease (defined as metabolic syndrome and other ill-effects) and is a greater threat to public health and mortality than smoking [ 7 ], according to a large cohort study, maintaining physical activity from adolescence into later adulthood was associated with an up to 36 % lower risk for all-cause mortality [ 8 ]. In the Ottawa Charter, health care was emphasized to be of particular importance as an arena for health promotion because of a range of contact with the overall population [ 9 ], but it seems to be difficult to reorient health care towards health promotion [ 10 ]. However, primary care (PC) is the first point of contact for all patients and is thus viewed as the ideal place to address overweight, obesity and lifestyle issues [ 11 ]. There are therapeutic recommendations regarding how to treat overweight and obesity in PC [ 12 , 13 ], nevertheless, it seems challenging for health care professionals to face obesity; according to one study, they are experiencing this dilemma because the patient is recognized as central in disease management but is also unwilling to change, which is a major potential barrier to treatment [ 14 ]. In a Swedish study, 73 % of all health professionals in PC would like to work more to support the promotion of healthy lifestyles among their patients, and nurses were most favourable towards this work [ 15 ]. Nurses in a primary health care centre (PHCC) have two key roles in obesity management. First, they work with overweight patients with comorbidities; second, they work with healthy overweight patients [ 16 ]. PHCCs has guidelines to follow by the National Board of Health and Welfare for lifestyle counselling focusing on alcohol, smoking, unhealthy eating habits and inadequate physical activity for patients at risk (e.g., overweight, diabetes and high blood pressure) [ 17 ]. According to a two-year study of health care professionals about their use of practical guidelines, nurses were the professionals who had increased their lifestyle counseling most, however, there was room for improvement concerning methods for reducing alcohol consumption and unhealthy eating habits [ 15 ]. Overweight is a sensitive topic, and patients who are overweight often experience stigmatization and discrimination [ 18 ]. It is also known that there could be a weight bias in the interaction between healthcare professionals and the patients [ 19 ], therefore, it is important to create a climate with empathy and compassion where the patients feel seen and listened to [ 20 ]. A recommended method for lifestyle conversations is motivational interviewing (MI) [ 21 ]. The method seemed especially suitable for patients who have self-reported that they are motivated and aware of their role in making lifestyle changes. MI can enable patient self-determination and create a sense of well-being [ 22 ]. However, there are obstacles to overcome to address obesity in PC. A review of studies about physician and nurses’ approach to overweight and obese patients showed that health advice is more likely to be given when Body mass index BMI increases and can be of poor quality due to educational barriers and availability of resources [ 23 , 24 ]. These aspects require ongoing education for nurses and other practitioners about raising the topic with patients in a non-stigmatizing and non-harmful way [ 25 , 26 ]. Most nurses in PC are receptive to and play a key role in health promotion work and are well suited to work with this patient group. It should be clarified how this work can be better organized for the future from the nurse’s point of view to be able to slow down the development of obesity and metabolic diseases as well as improve public health. To describe primary care nurses’ experiences of patients being overweight or obese, as well as primary care nurses’ perceptions of overweight problems in society and visions working with lifestyle issues. The study had a descriptive design with a qualitative method and an inductive approach. Semi-structured face-to-face interviews were conducted with thirteen practice nurses in the southwest of Sweden. The inclusion criteria were nurses in PHCC with experience of working with overweight patients. The exclusion criteria were to understand the language in speech or writing. The participants in the study were nurses in a PHCC (registered nurses, health nurses or diabetic nurses). A strategic selection was used regarding age, work experience, gender and private or public workplace. Twelve of them were women aged 27–61 years, and one was a 62-year-old man; the median age was 51 years. Their working experience varied from 2 to 40 years with a median of 28 years. They were recruited from seven primary health care centres (PHCCs) located in the southwest of Sweden. Some PHCCs had more patients with foreign backgrounds and lower socioeconomic situations. The PHCC’s also differed in size and whether they were located on the countryside or in the city. Each head manager of the PHCC received an e-mail with an information letter about the study, and they were asked if they were interested in participating in the study. They were also asked to forward the e-mail to those nurses who worked with lifestyle issues with a focus on overweight. A reminder was sent out after ten days if no one had responded. Thirty-five PHCCs in southwest of Sweden received an e-mail. When the nurses agreed to participate, we conducted an interview at their workplace. One nurse was interviewed in her home. They received both verbal and written information about the study and a consent form to read and sign when we met before the interview. Data were collected using an open qualitative interview [ 27 ] in the form of a dialogue. The recruitment occurred between October 2019 and February 2020. A semi-structured interview guide developed by the authors was used with open questions, and the interviewer also had the opportunity to ask probing questions. The first interview was carried out as a pilot, and then included in the study. The topics were nurses’ thoughts about overweight in general and in society, why overweight has increased, what experiences they had working with patients with overweight and lifestyle difficulties, how they worked with lifestyle issues and if overweight was prioritized in PHCCs. Furthermore, there were questions regarding if they received support from the manager, if there were ethical dilemmas, what results they obtained and if they had any dream scenarios of how they would like to work with obesity and lifestyle issues. The interviews lasted from 22 to 45 min and were digitally recorded and transcribed verbatim. Notes was also taken during the interviews. Data saturation was achieved when no new data occurred in the interviews. Qualitative content analysis was conducted based on the steps described by Graneheim & Lundman [ 28 ]. The analysis began by reading the transcriptions several times to obtain an overall sense of the data. Sentences and phrases corresponding to the aim of the study, referred to as meaning units, were highlighted. The meaning units were abstracted, coded and subsequently sorted into subcategories and categories based on similar content of the analysis, an example can be seen from table 1 (below). The subcategories and categories were discussed in a cross-professional group with four people (two nurses, one physiotherapist and one physician). Throughout data analysis, several meetings of this cross-professional group occurred. All members in the group had read the interviews and discussed the codes, subcategories and categories until a consensus was met. They all had long experience of working with lifestyle issues and of the analysis method. The translation into the English language occurred after the data analysis. The analysis of the interviews resulted in three categories and nine subcategories. Examples of the analytic process in the categories, Primary care nurses wish to promote health and prevent illness, Arenas for health promotion in society and support patients to change their behaviour, follows in Table 1 . The analysis of the interviews resulted in three categories and nine subcategories which is presented in Table 2 . This category consisted of three subcategories: School’s and media’s impact on lifestyle , Regulation of the food market and Health promotion outside of the health care mission The nurses found it important to inform parents, children and teenagers early about what is a healthy lifestyle. School was considered an important platform, and the school nurse had a task to begin early when informing children and young people of what a healthy diet is in order to establish a normal eating behaviour. Schools should teach students to think critically about what to listen to and how to screen information from Instagram and Facebook. The nurses experienced that adolescents were adversely affected by images of a perfect body that led to eating disorders such as bulimia and anorexia. There was also experiences that the school should work more on encouraging more daily exercise and preferably encouraging gymnastics between lessons so that the students could develop a healthier lifestyle, prevent overweight and perform better in school. Information on healthy diets and exercise was considered important to disseminate. A nurse said the following: “School is a place for information and thoughts on what is normal diet and exercise…. a little more wellness at school does not hurt.” (Nurse 11). The nurses felt that the media such as TV, magazines and social media had an increasing impact on our lifestyle and our eating habits and that different messages in newspapers and magazines about what is a healthy diet and lifestyle became confusing. The influence of the media on our lifestyle, especially our eating habits, was something that was reflected around, and many felt that there was far too large a selection of different food programmes on TV with “delicious” food and far too few educational and informative programmes about what is a healthy diet and how to cook it. According to a All food programmes on It is is on should programmes about what a normal like of (Nurse It was also that for and food was far too often and had a impact to unhealthy food and too especially if they were and were more Some of the nurses felt that such as the food and food it difficult for to what a and diet It is often the of the to at the The nurses were by several patients that it was a to when they were and and it was then difficult to unhealthy The availability of food and the that the were open the were considered problems that it difficult for to the A nurse out the following: is to because the food food with too and and it difficult to what a healthy diet is a of on (Nurse The nurses described that the should greater and not at the because it became a major for to be to that were were people with a foreign and those with poor who often two large of of one because it was as being The nurses that should more to public health in school and promote and consumption of in the to the most They described that society should the of a and the of healthy A nurse said the following: A would have but then should lower the of healthy like and (Nurse The nurses agreed that private were to improve and public health. children and young people was as those who work for children and young health who are also in the school. The most and for diet were Some nurses patients to with the diet with the of a where they could and support that the nurses not have the opportunity to The nurses’ experienced that all patients were at different and were using and it was to follow up with them they the nurse’s support and to and at the Some of the nurses described that it was important not to but also to patients to One of the nurses had a group for the patients outside the PHCC at a and several patients A nurse said the following: in not but also on we at the in the can have a the years have patients to develop a new lifestyle with (Nurse a a with had by the health centre by a of patients who to be of a but the because there was about whether it was or A nurse described it as was not that A public health centre that patients to a private what about all the other there were about (Nurse In with a socioeconomic the nurses felt that a barrier for patients to the The nurses felt that it would be for people to out and by but the nurses described that people to work out on their with the of on TV or the This category has four subcategories: A patient for lifestyle of about how to use guidelines, ethical and problems the nurse’s role and as a point for patients. A with the patient was important for the nurses in a It was as a for the patient to with weight and a change in lifestyle. The nurses described that the care had and in ten years, the contact had and the work The nurses experienced that work not was prioritized and that the was and but in the the nurses that it would be more for PHCCs if the and work is not given more According to a be to have more nurse need to the development in the early the patients because we have to work more on this as (Nurse Most nurses would have more for this work because there was a to and the was not the first there could be that affected the such as work and These experiences behaviour, and the nurses felt similar to A nurse described it as first need to be to many have a lifestyle that are like a (Nurse The nurses said that the of with the patients an important role in about a it was a and they could feel it was important not to use The nurses described that they used a of motivational conversations with open questions but not use the to the and to have more Some nurses described that a in the work was that at the patients were well and They had read on the and they what was and there was about different diets that the nurse the A nurse out the following: are many many are well and not to listen to a nurse who them what to and what not to (Nurse The nurses felt that the to and and care were important to a A nurse said the following: and too with then from the and have to a The and a all the (Nurse nurses described that they to nurses in order to more or but it has not as as they The nurses described that they to inform as early as care and were care was a opportunity to the development of overweight in They felt that there were guidelines for different during lifestyle conversations and for overweight, but it was how to it they felt that worked on The nurses had the experience that at several there were no and they felt that for more difficult patients they more education about A nurse out the following: a in this work would have (Nurse They their for in and to different of patients in order to and obtain better They felt that they had to read on their and and ask A nurse described it as would to on a diet and to read a of would have to (Nurse nurse described it as is that there are no guidelines for health conversations in health so we the at all health to it how many at what (Nurse The patient used in the work were often the and the Swedish The nurses described ethical and that they had to with in their work with overweight patients. One nurse had preferably recommended diet that in and felt it was difficult for her not to about it. nurses experienced that there were many different diets and of advice in but agreed that it was important that the PHCC work be The nurses described that PHCCs should be able to more for those who it. The nurses felt that it could be a with especially for women from a where it was considered to be overweight and that it was associated with It was challenging for the nurses to Some described that it was not to inform the patient because they to that being overweight is a health A nurse said the following: not think should be to the patient that in order to well in the weight before the it is a of and (Nurse 11). The nurses felt that it was to address the overweight if the patient had high blood because then could the and focusing on other such as and to into diet and overweight at a later A nurse was that the patient would it difficult that was a normal weight and had no experience of being was to A nurse described it as is important to so that not the patient and what is and not use Overweight is and (Nurse Some nurses about the experience of patients who should weight before an obesity and who they met far later when they had weight but had not as they It was difficult to how to support A nurse described what a patient her regarding thoughts about the have on but have to and (Nurse One nurse described that their PHCC had as a healthy PHCC and on that health is not something can for but it a of work to health. The nurses had and visions on how to up work with overweight and lifestyle to improve and obtain better They felt that they had a working with the but most a and more with more professionals such as a especially for patients with health problems with a they were experienced as difficult patients. The nurses that the patients could whether they or group there would be a greater selection of than to The nurses described that in most there were no overweight at but this was something that several nurses to A nurse described it as among and is if have a patients can other and (Nurse There was a for more support and resources for this work to be able to on to a greater The nurses to especially for with to prevent the development of A lifestyle with as a point for patients with a that was more and on this were A nurse described it as would like a lifestyle where could them on have motivational conversations and follow up more There is of to as well as and we can patients be (Nurse The nurses described to have availability during the for a health school with with for those who had during the A nurse described that her PHCC to video meetings to the patients and also to increase the availability of lifestyle nurse would like to up in her way and a school where the patients can how to cook a healthy Health were described by nurses as to PHCCs and were to be a way to prevent but were at private PHCCs. The nurses that PHCCs should to out to the population more with health information before too The nurses described that they also a to and similar experiences among diabetes They to have education and information on the about obesity and lifestyle from such as studies and from all Sweden. A nurse out the following: have known that we need to more about to feel in so that can to this patient about it to from and not the but also in Sweden to have more in what we (Nurse 11). they worked more with for physical activity on to the patients to them with and in there was the of to that in people with physical activity at a to the Most nurses felt that it was a that could be used it was more for to This category has two subcategories: The the and the has to a healthy lifestyle. The of the patients varied on their and a major role in the results The nurses described that several patients and had not but at the Some were more motivated when they had high blood or and were The nurses found it difficult to when to up and when to the patients to change their lifestyles could be and a often experienced from the patient to change and because the up and no one and it was not to when to the A nurse is difficult to all when they are not motivated and them It is a when to up and when to (Nurse The nurses also experienced the work as and especially when the patients had results and felt Some patients had several poor habits, and if they could of at least one of they often felt and then their According to a patient for to understand that to a and and not (Nurse nurse can be difficult to However, it is when to a on the and they have in weight and to can be a but can be of (Nurse The nurses described that as the patients had their health but that they have different on their and health. They described that we have more sedentary in of and that this early in The nurses felt that should greater and not with their A nurse described it as have a in raising they the children but they have to that the children to (Nurse The nurses described that as a one be a role in of exercise and social media and as one A nurse is important to children and early in so that they develop habits for (Nurse One that the nurses was that there was information and it could be difficult to screen for what is or they felt that PHCC has a to work with information and what is The nurses felt that the were by about of and such as being in a when and not being able to read on the and education also major and in foreign to a of a it was not to in the for nurses food is and patients on how to cook and healthy food and think that should (Nurse to people to with food and food like and and cook those who they at it is no use because it is have (Nurse The nurses that the to other They felt that the patients had their for their but the nurses felt that they had a mission to the patients to for their lifestyles both in and They also that the had a to when the problems became too large and affected the quality of nurses described it as has the to out the about what is and and when or the or because of being overweight. The has to when or is in or her and (Nurse important task is to patients to focus on their lifestyle and not their to feel (Nurse The nurses described that when patients felt that they were better about their lifestyle change, it was for them to up and to to their

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