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Australian bariatric nurses: What do they do and what do they need?
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Australian bariatric nurses: What do they do and what do they need? Marina Bogiatzis∗ , Kristin Wicking, Melanie Birks College of Healthcare Sciences, James Cook University, Townsville, Australia
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Article history: Received 24 February 2019 Received in revised form 5 August 2019 Accepted 24 November 2019 Available online xxx Keywords: Bariatric surgery Continuing education Nurses Nurse specialists Metabolic surgery Obesity
a b s t r a c t Background: Metabolic/bariatric surgery is the surgical treatment of obesity and obesity-related comorbidities. As one of the most obese nations in the world, the demand for continuing professional development (CPD) in this specialty is growing, however, it is unknown what form and content of education this group of specialist nurses need. Aim: This quantitative descriptive study sought to define metabolic/bariatric nursing practice in Australia and to identify the professional development needs of metabolic/bariatric nurses in Australia. Methods: A total of 37 metabolic/bariatric nurses from across Australia responded to an online survey. Data gathered enabled researchers to describe the demographics of the nurses, daily tasks in their nursing role, current education needs, their previous education, and their current learning needs. Findings: This study confirmed there is a gap in available education for metabolic/bariatric nurses in Australia. A third (n = 10, 32 %) of metabolic/bariatric nurses did not attend any relevant Continuing Professional Development in the last 12 months. All 34 were requesting more postgraduate education opportunities. Conclusion: Australian Metabolic/bariatric nurses are asking for more education to achieve the Continuing Professional Development required for nursing registration, so they may provide the specialised evidence-based care that metabolic/bariatric patients require. This study provides a list of favoured education topics and preferred modes of education delivery. The results from this study may be used to: assist in the development of education for metabolic/bariatric nurses at the workplace, conference and university level; and supports research on the specialised practice of metabolic/bariatric nursing. © 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction Obesity is a major public health concern (Australian Institute of Health & Welfare, 2017b) and currently, the most effective treatment for obesity is metabolic/bariatric surgery (Buchwald & Oien, 2013). With increasingly high numbers of metabolic/bariatric surgeries being performed globally, a new specialty area is developing. Metabolic/bariatric nursing is defined in this study as the nursing care of patients who are preparing to undergo or have undergone metabolic/bariatric surgery. The metabolic/bariatric nurse assists in all stages of the surgical pathway such as initial consultation, diagnosis, treatment, recovery and follow-up care, and is responsible for the coordination of care and the education of the multidisciplinary team (Johnson, Dohlin, & Severson, 2009). A metabolic/bariatric nurse is expected
∗ Corresponding author at: Nursing and Midwifery Building 25, Angus Smith Drive, Douglas, QLD, 4811, Australia. E-mail address: [email protected] (M. Bogiatzis).
to provide sensitive, compassionate, experienced, evidence-based care to patients in their care (Neil & Roberson, 2015) and must be able to educate the patient in all aspects of health that relate to metabolic/bariatric surgery. Metabolic/bariatric nurses are valued by healthcare facilities as they offer highly specialised care to patients undergoing surgery for obesity and obesity-related comorbidities, improve patient care, and improve hospital efficiency (McGinley, 2008). Nurses in the United States of America (USA) have shown an interest in metabolic/bariatric certification since the 1990s which led to the introduction of Certified Bariatric Nurses (CBNs) in 2007 (Berger et al., 2010). Metabolic/bariatric nurse coordinator roles have since been implemented in healthcare settings around the world (Sonoda, Seki, Kasama, Kikkawa, & Yotsuya, 2015; Thomas & Rickabaugh, 2008). However, Australia is yet to provide the same level of national education and certification to their metabolic/bariatric nurses, as there are no formal postgraduate courses specific to metabolic/bariatric nursing in Australia. In addition, even for short informal education seminars, there is a very limited range of continuing professional development
https://doi.org/10.1016/j.colegn.2019.11.011 1322-7696/© 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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Summary of Relevance Problem Metabolic/bariatric nursing practice is currently undefined in Australia and there is a limited amount of education available for nurses working in this specialty. What is already known Despite the advances in metabolic/bariatric nursing education and specialisation around the world, Australia is yet to provide the same level of national education and certification to their metabolic/bariatric nurses. What this paper adds This paper defines metabolic/bariatric nursing practice in Australia and provides a list of favoured continuing education topics and preferred modes of education delivery to assist in the development of future education that is relevant and accessible.
Box 1: The four domains of metabolic/bariatric nursing practice. The four domains of clinical practice (Berger et al., 2010, p. 403) Clinical management: provide and document direct and indirect clinical care and education to morbidly obese and bariatric surgery patients/family/support persons.Multidisciplinary team collaboration: communicate and educate to facilitate continuity of care among multidisciplinary teams for optimal patient outcomes, and to improve the quality of care for morbidly obese and bariatric surgery patients.Outreach: provide advocacy, support, and education to individuals, support groups, community groups and healthcare professionals related to morbidly obese and bariatric surgery patients.Program administration: provide leadership and a framework to coordinate services for optimal outcomes, and to improve the quality of care for morbidly obese and bariatric surgery patients.
opportunities for nurses working with metabolic/bariatric patients. To meet registration standards, nurses in Australia are required to achieve a minimum of 20 hours of continuing professional development. “Continuing professional development (CPD) is how nurses and midwives maintain, improve and broaden their knowledge, expertise and competence, and develop the personal and professional qualities required throughout their professional lives” (Nursing & Midwifery Board of Australia, 2016b, p. 4). Examples of CPD include in-service education, attending conferences and seminars or publishing a peer-reviewed journal article (Nursing & Midwifery Board of Australia, 2016a). The NMBA’s ‘Guidelines for Continuing Professional Development’ state that all CPD activities “must be relevant to each nurse’s area of professional practice” (2016a, p. 2). This was the first study to survey Australian metabolic/bariatric nurses on their professional development needs and sought to answer the following questions: 1 What is metabolic/bariatric nursing practice in Australia? 2 What are the professional development needs metabolic/bariatric nurses in Australia?
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2. Literature review Since the first metabolic/bariatric surgery in the USA in 1954, nurses have been involved in: educating patients prior to surgery; coordinating patient care; caring for the patients in surgical theatres, on the wards and at follow-up appointments through surgical practices, hospitals and community health services around the world. Articles on the role and importance of metabolic/bariatric nursing have been found from Japan to the USA, exemplifying how other countries have addressed a growing need in their health services and how a new specialty of nursing has arisen (Sonoda et al., 2015; Thomas & Rickabaugh, 2008). In 2007 the first metabolic/bariatric nursing certification was held in the USA and following its success, a research paper outlining how the certification was developed was published. The US study leading to the introduction of CBNs was produced by Berger et al. (2010) and was the first practice analysis study of bariatric nurses, which officially defined and documented the role of the bariatric nurse for the first time. The study collected 504 surveys from nurses working with bariatric patients across the US. The various positions of nurses included bariatric nurse coordinators 33 %, bariatric program coordinators 28 %, hospital floor nurses 24 % and ‘other’ roles 15 % such as operating room nurses, nurse practitioners and nurses in an office setting (Berger et al., 2010). This practice analysis study by Berger et al. (2010) was able to define the practice of bariatric nursing in terms of four domains of clinical
practice, which included 45 tasks and 54 knowledge areas. (See Box 1). This practice analysis described the tasks and knowledge areas that metabolic/bariatric nurses would need in order to become a Certified Bariatric Nurse. This work became a foundation for the development of a formal certification examination for eligible nurses who had two or more years of experience in bariatric nursing to become a Certified Bariatric Nurse (CBN) and thus be recognised a nurse to have advanced knowledge in bariatrics. There are now over 2000 CBNs in the USA (personal communication, Dr. Narelle Storey, Certified Bariatric Nurse Committee Member). In 2008, while American nurses were starting to become Certified Bariatric Nurses (CBNs), another article from the US by Thomas and Rickabaugh described a new position for nurse coordinators in the metabolic/bariatric acute care setting. Thomas and Rickabaugh (2008, p. 63) stated: “a bariatric nurse coordinator is an emerging role requiring a nurse with specialised, competent knowledge in bariatric patient care who has the visionary and management skills to coordinate patient care throughout a healthcare system”. Educating nurses about the reasons patients seek metabolic/bariatric surgery, including sensitivity training as well as physical nursing management, has been documented as beneficial to the patient through more informative, compassionate and unbiased patient care (Neil & Roberson, 2015). In 2009, a Minnesota hospital in the USA also described the introduction of a new position of a bariatric program coordinator (Johnson et al., 2009) and demonstrated multiple benefits not just to patients, but also to the nurses and hospital. Patient care improved with the education of nurses on topics surrounding pre-surgery and post-surgery metabolic/bariatric nursing and the patient’s length of stay was shortened reducing costs for both the patient and hospital. As the role of metabolic/bariatric nurses continued to prove beneficial in the USA, other countries, such as Japan, documented their experience of introducing the role of a Bariatric Nurse Coordinator. A Japanese observational study by Sonoda et al. (2015) examined the introduction of the role by comparing the patient’s transition through surgery with the nurse, to their transition with a physician. After observing 337 patients receiving metabolic/bariatric surgery, the average number of days from the initial consultation to the operative date was 67.9 days under physician supervision and 43.1 days with nursing intervention (Sonoda et al., 2015). This showed a substantially shortened pre-operative process leading to practice that was more efficient when a metabolic/bariatric nurse was involved. Metabolics/bariatrics is a highly challenging and complex specialty as obese patients are at risk of developing many comorbidities at an earlier age leading to premature mortality (National Health & Medical Research Council (NHMRC), 2013), including elevated
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blood pressure, high cholesterol, insulin resistance, coronary heart disease, ischaemic stroke, Type 2 diabetes and a range cancers that also increase steadily with increasing BMI (Australian Institute of Health & Welfare, 2017a). Given the increased risk of operating on, and caring for, metabolic/bariatric patients, there is now international recognition that a multidisciplinary team specifically designed to cater for the complex needs of metabolic/bariatric patients is beneficial. As a result, metabolics/bariatrics is quickly becoming an area of nursing specialisation around the world. If metabolic/bariatric nursing is to be a nursing specialty in Australia, then specialist education will be required. This quantitative descriptive study sought to define metabolic/bariatric nursing practice in Australia and to identify the professional development needs of metabolic/bariatric nurses in Australia.
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experts who trialled the survey for face validity. Based on feedback received, the survey was revised and a final version produced. 3.5. Data collection Data collection commenced following approval from the James Cook University Human Research Ethics Committee. The survey was open for two weeks from the first invitations distributed by ANZMOSS in December 2017. After this time, a reminder email from the organisation (ANZMOSS) was sent and an additional week was allocated for any remaining survey entries. A total of 37 eligible metabolic/bariatric nurses from across Australia completed the online survey (See Fig. 1). 3.6. Data analysis
3. Methods 3.1. Study design A quantitative, descriptive, cross-sectional survey was used in this study. The survey was cross-sectional as it provided data that represented the professional development needs of metabolic/bariatric nurses in Australia at one point in time. A national sample was collected to represent the diversity in metabolic/bariatric nursing in Australia and the different roles that make up the area of practice. A representation of nurses from around Australia gives a wider indication of current sources of metabolic/bariatric nursing knowledge and the gap in available education for nurses working in this sector. Using an anonymous survey method gave a voice to the nurses so they could openly express their views while allowing the researcher to remain objective. 3.2. Eligibility criteria and setting Participants included in the study were persons consenting to participate in the study and were currently employed as registered nurses in Australia who work specifically with patients who have had or are having metabolic/bariatric surgery. This study excluded registered metabolic/bariatric nurses from outside of Australia. 3.3. Recruitment The survey was disseminated via the professional organisation ANZMOSS (Australian and New Zealand Metabolic Obesity Surgery Society). An email containing a brief explanation of the study and a link to the survey was sent from ANZMOSS to the nursing membership and their networks to facilitate snowballing recruitment. To prevent any non-metabolic/bariatric nurses responding, the initial questions of the survey reaffirmed the inclusion criteria and nonsuitable applicants were exited from the survey. No identifying data was collected. Participants’ email addresses were accessed by the ANZMOSS organisation to ensure privacy, anonymity and remove any suggestion of coercion by the researchers. 3.4. Survey development Online databases and published literature were searched for validated survey tools that could be modified to address the aims of this study. No validated surveys could be found that obtained information from metabolic/bariatric nurses about their professional development needs. Similarly there were none from other nursing specialties that could be easily adapted. For this reason, a new survey had to be developed and validated. The survey tool was developed by the primary researcher and two research advisors in Qualtrics Online. The survey tool was validated by lay people and
Numerical data has been described using participant numbers, percentages and mean and standard deviation (SD) values to show distribution. Categorical data has been described using participant numbers and percentages. Statistical analysis was conducted using the computer software Microsoft Excel 2016 and the online survey platform Qualtrics. All textual data was analysed using colour-coding and framework analysis (Ritchie & Spencer, 1994). In this study, framework analysis has been used to compare the metabolic/bariatric nursing practice in Australia to that in the US based on the four domains of clinical practice as defined by Berger et al. (2010). Participant answers were exported from Qualtrics to Microsoft Excel 2016 to enable the nurses’ daily tasks to be broken down into single lines, that is, one nursing task per line. This allowed nursing tasks to be calculated and analysed for sorting into the four domains of practice. Identifying details were changed to avoid recognition of an individual nurse’s circumstances. 4. Results 4.1. Sample Of the 40 participants who gave consent and commenced the survey, 95 % (n = 38) were living in Australia and 5 % were not (n = 2). The two participants who did not live in Australia were not able to progress with the survey and were excluded from the study as they did not meet the inclusion criteria. 4.1.1. Geographic distribution There was representation from five of the eight states/territories of Australia: NSW 56.8 % (n = 21), QLD 29.7 % (n = 11), VIC 8.1 % (n = 3), SA 2.7 % (1), WA 2.7 % (n = 1), NT 0 %, ACT 0 % and TAS 0 %. One participant who did not select their state/territory of residence also did not progress with the survey. This left 37 surveys for analysis. 4.1.2. Gender and age Females represented 97 % of the participants (n = 36) and 3 % were male (n = 1). The most common age bracket of the 37 participants was the under 30 yrs with 27 % (n = 10), 31-40yrs with 24 % (n = 9), 41–50 with 24 % (n = 9), 51-60 yrs with 22 % (n = 8) and the over 60 yrs with 3 % (n = 1). 4.1.3. Years of experience in nursing All 37 participants confirmed they were registered nurses (RNs) and were registered between the years of 1976 and 2017. The years of nursing experience ranged from 0 years to 42 years. RNs who claimed 0 years’ experience were most likely new graduate nurses in their first year of nursing, however, had not completed one full year of experience. Years of nursing experience averaged 16 years (SD +/- 11).
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Fig. 1. Participant flow chart.
Legend: Australian and New Zealand Metabolic Obesity Surgery Society (ANZMOSS).
4.1.4. Years of experience in metabolic/bariatric nursing The first RN from this study to commence work with metabolic/bariatric patients did so in 1983. The total years of experience in metabolic/bariatric nursing varied between the individual RNs (n = 37) from 0 to 26 years of experience. The average years of experience in metabolic/bariatric nursing was 7.5years (SD +/- 6). 4.1.5. Formal post-graduate education Of the 35 RNs who responded to this item, 13 had formal postgraduate qualifications (37 %) and 22 did not (63 %). The most common postgraduate courses were graduate certificates and diplomas in acute care nursing or critical care nursing, graduate certificate of stomal therapy, masters in surgical nursing and a graduate diploma of health management. One nurse had completed a graduate certificate in chronic disease nursing. 4.2. What is metabolic/bariatric nursing practice in Australia? 4.2.1. Current role All 37 participants worked in metabolic/bariatric areas or with metabolic/bariatric patients at the time of the survey. There were six nursing roles within metabolic/bariatric nursing identified by the survey including ward nursing 48 % (n = 20), practice nursing 24 % (n = 10), theatre nursing 12 % (n = 5), nursing management 7 % (3), research nurse 7 % (n = 3) and nurse academic 2 % (n = 1). The total number of responses is equal to 42, as some nurses indicated they had multiple roles. 4.2.2. Percentage of hours spent working in the metabolic/bariatric specialty According to the 37 participants, the average percentage of time worked in the metabolic/bariatric specialty varied across roles. Practice nurses spent most of their time in the specialty (82 %) followed by theatre nurses (80 %), ward nurses (68 %), research nurses (67 %), nurse managers (57 %) and nurse academics (10 %). 4.2.3. The daily nursing tasks Daily tasks of the 36 RNs who responded to this question were exported to Excel and categorised according to the domains of practice for metabolic/bariatric nurses identified in the practice analysis study by Berger et al. (2010). Nurses in the academic and research roles did not list any clinical tasks in their daily roles, however the ward nurses, theatre nurses, nurse managers and practice nurses listed daily tasks that represented all four domains of practice.
The analysis of categorical and ordinal data revealed that the role of the metabolic/bariatric nurse in Australia was very similar in daily task descriptions to that of metabolic/bariatric nurses in the US. The following daily nursing tasks have been further described and segmented using the four domains of practice as described in the US study by Berger et al. (2010). This is an appropriate framework for analysis as this is the only country that has been known to produce a practice analysis report of metabolic/bariatric nurses. 4.2.3.1. Domain 1: clinical management. Berger et al. (2010, p. 403) define clinical management tasks as “providing and documenting direct and indirect clinical care and education to morbidly obese and bariatric surgery patients/family/support persons”. In the survey, metabolic/bariatric nurses in Australia listed 44 daily tasks that fit within this definition of clinical management duties. The most frequently occurring tasks listed were: pre-operative and post-operative education, monitoring health status of the patient, wound and pain management, monitoring fluid intake, dietary advice, recognising and alerting the surgeon to potential complications and being the main point of contact for staff and patients, offering reassurance and support. The diversity of tasks across different nursing roles was apparent with such an extensive list of tasks performed on a daily basis. A third of all nursing tasks in clinical management can be attributed to the pre-operative phase and sometimes this could involve the care of patients from rural/remote areas via phone consultations or Skype. As one of the few nursing specialities that requires the nurse to care for patients at times without face-to-face consultation, it is apparent that a metabolic/bariatric nurse requires the skills to develop rapport, educate and offer support, not only face-to-face, but also through other modes of communication (e.g. phone consultation, videoconferencing, email). 4.2.3.2. Domain 2: multidisciplinary team collaboration. Berger et al. (2010, p. 403) define multidisciplinary team (MDT) collaboration as providing “communication and education to facilitate continuity of care among multidisciplinary teams for optimal patient outcomes, and to improve the quality of care for morbidly obese and bariatric surgery patients”. Metabolic/bariatric nurses in Australia listed nine daily tasks that involved the collaboration of the MDT. For example, participants made reference to: “Working as part of a team with the receptionist, practice manager, dietitian, psychologist, meditation support nurse, doctors and surgeons”.
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“Work with the surgeon and anaesthetist to provide optimal recovery of the patients”. Both of these participant responses exemplify the number of professional relationships that the metabolic/bariatric nurse is required to maintain in order to provide optimal and holistic care. For metabolic/bariatric surgery, patients could be required to meet with a dietician, psychologist, gastroenterologist, metabolic/bariatric nurse, metabolic/bariatric surgeon, anaesthetist, sleep study technician, exercise physiologist and any specialist the patient is already seeing, such as a cardiologist. All members of the MDT influence the decision of whether a patient is an eligible candidate for surgery. Coordinating the care of the patient was a common task listed in this domain of practice, particularly gathering the reports from all MDT members and presenting them to the surgeon for confirmation of surgery. MDT collaboration commences prior to surgery and continues throughout the follow-up phase of patient care. 4.2.3.3. Domain 3: outreach. The third domain, Outreach, is defined as “providing advocacy, support, and education to individuals, support groups, community groups, and healthcare professionals related to morbidly obese and bariatric surgery patients” (Berger et al., 2010, p. 403). It is primarily focussed on the education of staff and the community in relation to morbid obesity to help people understand the life-threatening disease, how it affects the patient’s physical and mental health, the process of undergoing metabolic/bariatric surgery and what this means for the patient’s future health. The nurses listed 13 daily tasks that supported outreach, mostly through education and research. Examples of the listed tasks that fall into this domain are: Educating nurses on the ward or in the hospital, educating undergraduate nursing students during their practical experience on the wards, collaborating with the US on metabolic/bariatric research and developing educational seminars for nurses. Three nurses specifically mentioned the daily task of collecting data to contribute to the Bariatric Surgery Registry (BSR), which collates data on all metabolic/bariatric surgery performed in Australia. 4.2.3.4. Domain 4: program administration. The fourth domain of practice for metabolic/bariatric nurses is to “provide leadership and a framework to coordinate services for optimal outcomes and to improve the quality of care for morbidly obese and bariatric surgery patients” (Berger et al., 2010, p. 403). There were thirteen daily tasks listed within this domain of program administration. Ward nurses, practice nurses, theatre nurses, research nurses and academic nurses were all represented in this domain. Some of the daily tasks of nurses practising in this domain were: coordination of theatre bookings and operating lists for all surgeons, coordination of application to become a Centre of Excellence in Metabolic and Bariatric Surgery, managing a GIT bariatric ward, advocating for patient safety and education, and managing clinical research trials. 4.3. What are the professional development needs of metabolic/bariatric nurses in Australia? 4.3.1. Professional development over the last 12 months Participants were asked to list all forms of continuing professional development (CPD) they had attended over the previous 12 months. Of the 32 RNs who responded, 16 (50 %) attended metabolic/bariatric conferences/meetings, 7 (22 %) attended metabolic/bariatric seminars, 6 (19 %) provided metabolic/bariatric education to colleagues and the multidisciplinary team, 4 (13 %) attended metabolic/bariatric education in their workplace, 1 (3 %)
Fig. 2. Nursing resources for metabolic/bariatric patient care information. Legend: Multi-Disciplinary Team (MDT).
Fig. 3. Postgraduate education opportunities for metabolic/bariatric nurses. Legend: Continuing Professional Development (CPD).
attended the US certification of bariatric nursing examination, 1 (3 %) took part in a journal club and 10 (31 %) did not attend any education specific to metabolic/bariatric nursing in the preceding 12 months. 4.3.2. Accessing further information When looking for advice or more information, participants accessed a variety of resources. (See Fig. 2). Of the 35 nurses who answered this question, 30 (86 %) said they would ask the metabolic/bariatric surgeon for advice regarding the care of a patient if they needed more information. The next most frequently reported source of additional information was fellow nurses, with 17 of the 35 (49 %) approaching fellow nurses for advice regarding patient care. 4.3.3. Preferred future postgraduate education The majority (63 %) of the 34 respondents who answered this question believed that a formal graduate certificate in metabolic/bariatric nursing should be available for RNs in Australian universities. Three-day workshops and one-day seminars were also highly valued. (See Fig. 3). 4.3.4. Desired topics for further education Of the 26 who responded, 22 metabolic/bariatric nurses listed 41 topics on which they would like to have more education. These are presented in Table 1. Four nurses answered that they did not require any further education at the time. The education topics have been listed using terminology as close to the participants’ requests as possible, while also allowing similar statements to be grouped together where necessary. While all requested topics may be beneficial to all nursing roles, the topics have also been listed with nominal data to show which nursing role was requesting each topic. This can be viewed in Supplementary Material.
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Ward (n = 11)
Practice (n = 7)
9
5
4
5 4 3 3 3
1 1 1 1 1
2 3 1 1
3 2 2 2 2 2 2
1 1 1 1 1
1 1 2
Manager (n = 2)
Research (n = 2)
Academic (n = 1)
1
1
1 1
1
1
1
1
1
1 1 1 2 1 1
1 1 1 1 1
1 1 1 1
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2 1 1
1 1 1 1 1
Theatre (n = 3)
1 1 1 1 1 1
1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1
1 1 1 71
1
1 1 1
1 23
1 32
5
2
5
4
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Total Requests
Regular ongoing education to update staff on new surgeries, procedure changes or policy changes Accessing and keeping up to date with metabolic/bariatric nursing research Endoscopic sleeve surgery How to manage post-operative complications The benefits of metabolic/bariatric surgery How to adopt and ensure evidence-based practice in the metabolic/bariatric setting Strengthening the role of metabolic/bariatric nursing in Australia Anatomy and physiology of the metabolic processes and digestive system How to give advice on health and nutrition Post-operative malnutrition issues, vitamin deficiencies What happens after a patient leaves hospital-the recovery process Signs and symptoms of deterioration after surgery Psychological health of metabolic/bariatric patients and how to address concerns Intragastric balloon procedure Education and support for patients with eating disorders Education, dietary advice and support for managing weight regain at follow-up appointments Dietary advice for increasing protein in the first few months post-operatively How to manage hypoglycemia perioperatively and long term. How to manage nausea and vomiting post-operatively- short and long term How to access lap band ports and make adjustments How bariatric surgery physically and mechanically changes the digestive process The different metabolic/bariatric surgeries performed in Australia Watch a metabolic/bariatric surgery being performed Dumping syndrome Post-operative care of the metabolic/bariatric patient Discharge advice regarding patient’s post-operative diet and symptoms of potential complications Developing a hospital menu for post-bariatric surgery patients Role of the practice nurse Management of a bariatric clinic Educating new graduate nurses or nurses new to metabolic/bariatric surgery Sensitivity training-encouraging compassionate nursing through knowledge of the patient’s experience Treating the whole metabolic disease. Resolving comorbidities before and after surgery The process of psychological review before and after surgery Attending metabolic/bariatric conferences-national and international Developing clinical pathways for metabolic/bariatric patients post-operatively How to address poor attendance to follow-up appointments What does the dietician and physiotherapist tell the patient? Education of patients at the pre-surgery appointment to prepare them for the recovery phase in hospital Manual handling expectations Complications post-omega loop, roux en y bypass and duodenal switch Pharmaceutical options for weight loss Total requests per role
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Requested topics for further education
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Table 1 Requested topics for further education.
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The most requested topic was to have more ongoing or frequent education to update nursing staff on new surgeries, procedure changes or policy changes: “On-going education in all areas as this a growing industry. We need to be kept up-to-date with new procedures, endoscopic procedures in particular” (P7). “It would be nice if on-going education was an option regarding changes in bariatric surgery. As improvements or changes happen quite often, the VMO [Visiting Medical Officer] have the procedure done before liaising with nursing staff regarding post-op care. An example of this would be the endoscopic sleeve gastrectomy. . . .I find different VMO’s have different post-op preferences which often leads to confusion in patient care” (P22). 5. Discussion 5.1. What is metabolic/bariatric nursing practice in Australia? The analysis of data in this study revealed that the role of the metabolic/bariatric nurse in Australia was very similar in daily task descriptions to that of metabolic/bariatric nurses in the USA, the only country that has been known to produce a practice analysis report of metabolic/bariatric nurses. The daily tasks of metabolic/bariatric nurses in Australia were successfully categorised into Berger’s four domains of clinical management, MDT collaboration, outreach and program administration (2010), indicating that this study supports Berger’s Four Domains of Practice as a validated structure in defining the practice of metabolic/bariatric nursing in Australia. Defining the practice of any nursing specialty is an important step before being able to develop a set of population-specific clinical practice guidelines and clinical competencies to improve nursing practice. This was highlighted for another two specialty nurse roles (breast and colorectal cancer screening nurses) in Spain, where the identification of daily nursing activities allowed them to develop competencies, a necessity for evaluating nursing care (Benito et al., 2016). Implementing the competencies ensured the development of evidence-based practices, personalised care and quality healthcare practices for these two emerging specialty roles. Benito et al. (2016, pp. 356-357) also concluded “nurses should continually reassess their competencies and identify their needs for additional knowledge, skills, personal growth, and integrative learning experiences”. Implementation of specialised metabolic/bariatric coordinators and the provision of workplace education has been linked with improved hospital efficiency, decreased costs to patient and research informed nursing practice (McGinley, 2008). 5.2. What are the professional development needs of metabolic/bariatric nurses in Australia? Responses in this study clearly indicate that some hospitals are yet to develop clinical pathways for nursing care of metabolic/bariatric patients and associated nursing competencies. The nurses expressed concern that regular ongoing education in this specialty is lacking and this education gap often leaves them without the relevant knowledge on new procedures and policies. A one-day seminar for metabolic/bariatric nurses hosted annually by ANZMOSS was the only form of nationally available education mentioned in the survey responses. In-services or seminars held in practices or hospitals were the only forms of frequent specialty education reported by the nurses in this study. The nurses in this study reported that they relied on surgeons and fellow nurses for education and advice on patient care, however a third still felt their CPD had not been relevant enough for their practice development
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needs. When looking to other members of the multidisciplinary team receiving education in this field, dietitians in Australia have already been completing metabolic/bariatric workshops that certify them to care for and offer dietary advice to metabolic/bariatric patients since 2017. The Australian Nursing and Midwifery Federation (ANMF) dictates that registered nurses require access to continuing professional development, should seek financial support from their employers for post-graduate courses, and that education facilities should aim to provide CPD courses to nurses and employers that reflect their learning needs (Australian Nursing & Midwifery Federation, 2016). 5.3. Implications 5.3.1. Education The results from this study may be used to assist in the development of education for metabolic/bariatric nurses at the workplace, conference and university level. By providing a list of the nurses’ requested education topics and a table of topics nurses found most important, education facilities have the data to inform their education content so it may be tailored to the metabolic/bariatric nursing field and the identified nursing roles within it. 5.3.2. Practice By highlighting the gap in the literature and available education resources, this study may indirectly improve the care of a high-risk group of patients by advocating for more education of metabolic/bariatric nurses in Australia. 5.3.3. Policy The results of this study have suggested multiple forms of education that would support education providers in the development of future CPD activities for metabolic/bariatric nurses. The findings from this study support ANMF policy on encouraging nurses to seek their required CPD and provides the impetus for healthcare facilities to provide ongoing evidence-based education to nursing staff through in-services, nursing grand rounds and scholarships. Addressing the learning needs of metabolic/bariatric nurses in Australia will allow nurses and employers to meet nursing policy requirements and will support the introduction of a new nursing role (a metabolic/bariatric nurse coordinator) within healthcare facilities. 5.3.4. Research This study has identified a gap in previous Australian research and has reinforced the international research on metabolic/bariatric nursing specialisation to date. Further research on this topic in varying contexts or countries will continue to strengthen the knowledge of metabolic/bariatric nursing practice internationally. 5.4. Strengths and limitations This was the first study to survey metabolic/bariatric nurses in Australia regarding their professional development needs. This gap in the literature lead to the development of a new survey that was rigorously tested by metabolic/bariatric health professionals, non-metabolic/bariatric health professionals and lay people. The survey was easily accessible for participants using the online survey platform Qualtrics. This allowed successful nation-wide delivery. Potential bias of this study would be the invitation of nurses primarily from a professional organisation for metabolic/bariatric surgery. The nurses in this organisation could potentially be more eager for education in this field than non-member nurses who still work with metabolic/bariatric patients.
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Due to the time restriction on this study, a limited period of three weeks was allowed for data collection. This time restriction may have contributed to the small sample size. Given the relatively small population of bariatric nurses in Australia however, this sample is considered adequately representative to support the conclusions drawn. Therefore the sample size and associated results may not be generalisable to the whole of the metabolic/bariatric nursing population in Australia. Inferences can, however, be drawn from the analysis that have implications for practice and future research. The structure of this survey may be used on a larger scale to further investigate the role of metabolic/bariatric nurses, their educational needs, how they currently receive education on an international scale. 6. Conclusion This quantitative descriptive study surveyed 37 RNs working with metabolic/bariatric patients from around Australia. The findings define the practice of metabolic/bariatric nursing in Australia and report the professional development needs of metabolic/bariatric nurses in this context. The results indicate metabolic/bariatric nurses are requesting more education across a variety of topics, in particular, they wish for more frequent education sessions to keep informed about this rapidly changing and growing specialty. The participants showed strong support for more CPD opportunities with post-graduate certificates and one-day seminars being highly rated as preferred methods of education delivery. The findings and recommendations from this study have the ability to improve metabolic/bariatric nursing practice and patient care across Australia. Author agreement The authors declare that this article is the authors original work. This article has not received prior publication and is not under consideration for publication elsewhere. All authors have seen and approved the manuscript being submitted. The authors abide by the copyright terms and conditions of Elsevier and the Australian College of Nursing. Ethical Approval Ethical approval was sought and obtained from the Human Research Ethics Committee on the 27th November, 2017. Ethics Approval Number: H7209.
Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.colegn.2019.11. 011. Declaration of Competing Interest The authors have no conflicts of interest to report. References Australian Institute of Health and Welfare. (2017a). Weight loss surgery in Australia 2014–15: Australian hospital statistics. Cat. No. HSE 186. Canberra: AIHW. Australian Institute of Health and Welfare. (2017b). Impact of overweight and obesity as a risk factor for chronic conditions: Australian Burden of Disease Study. Australian Burden of Disease Study series no.11. Cat. no. BOD 12. Canberra: AIHW. Australian Nursing and Midwifery Federation. (2016). Nursing education: Registered nurse Retrieved from. http://anmf.org.au/documents/policies/P Nursing education RN.pdf Benito, L., Binefa, G., Vidal, C., Lluch, M. T., Puig, M., Padrol, I., et al. (2016). Identifying nursing activities in population-based colorectal and breast cancer screening programs in Spain: A Delphi study. Collegian, http://dx.doi.org/10. 1016/j.colegn.2016.07.005 Berger, N. K., Carr, J. J., Erickson, J., Gourash, W. F., Muenzen, P., Smolenak, et al. (2010). Path to bariatric nurse certification: The practice analysis. Surgery for Obesity and Related Diseases, 6(4), 399–407. http://dx.doi.org/10.1016/j.soard. 2010.04.003 Buchwald, H., & Oien, D. M. (2013). Metabolic/bariatric surgery worldwide 2011. Obesity Surgery, 23(4), 427–436. http://dx.doi.org/10.1007/s11695-012-0864-0 Johnson, A., Dohlin, E., & Severson, K. (2009). The CNS role: Coordination of a bariatric surgery program across the continnum. Clinical Nurse Specialist, 23(4), 224. McGinley, L. D. (2008). The vital role of a clinical nurse specialist in a bariatric setting, Philadelphia. National Health and Medical Research Council (NHMRC). (2013). Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: National Health and Medical Research Council. Neil, J. A., & Roberson, D. W. (2015). Enhancing nursing care by understanding the bariatric patient’s journey. AORN Journal, 102(2), 132. http://dx.doi.org/10. 1016/j.aorn.2015.05.014 Nursing and Midwifery Board of Australia. (2016). Guidelines: Continuing professional development Retrieved from. http://www.nursingmidwiferyboard. gov.au/Codes-Guidelines-Statements/Codes-Guidelines/Guidelines-cpd.aspx Nursing and Midwifery Board of Australia. (2016). Registration standards: Continuing professional development Retrieved from. http://www. nursingmidwiferyboard.gov.au/Registration-Standards/Continuingprofessional-development.aspx Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman, & R. G. Burgess (Eds.), Analysing qualitative data (pp. 219–262). London: Routledge. Sonoda, K., Seki, Y., Kasama, K., Kikkawa, E., & Yotsuya, T. N. (2015). Role of the bariatric nurse/coordinator in bariatric surgery in Japan New York. Thomas, S. A., & Rickabaugh, B. (2008). Bariatric nurse coordinator: Carving out a new role in bariatrics. Bariatric Nursing and Surgical Patient Care, 3(1), 63–72. http://dx.doi.org/10.1089/bar.2008.9989
Funding This study received no funding.
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Australian bariatric nurses: What do they do and what do they need? Marina Bogiatzis∗ , Kristin Wicking, Melanie Birks College of Healthcare Sciences, James Cook University, Townsville, Australia
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Article history: Received 24 February 2019 Received in revised form 5 August 2019 Accepted 24 November 2019 Available online xxx Keywords: Bariatric surgery Continuing education Nurses Nurse specialists Metabolic surgery Obesity
a b s t r a c t Background: Metabolic/bariatric surgery is the surgical treatment of obesity and obesity-related comorbidities. As one of the most obese nations in the world, the demand for continuing professional development (CPD) in this specialty is growing, however, it is unknown what form and content of education this group of specialist nurses need. Aim: This quantitative descriptive study sought to define metabolic/bariatric nursing practice in Australia and to identify the professional development needs of metabolic/bariatric nurses in Australia. Methods: A total of 37 metabolic/bariatric nurses from across Australia responded to an online survey. Data gathered enabled researchers to describe the demographics of the nurses, daily tasks in their nursing role, current education needs, their previous education, and their current learning needs. Findings: This study confirmed there is a gap in available education for metabolic/bariatric nurses in Australia. A third (n = 10, 32 %) of metabolic/bariatric nurses did not attend any relevant Continuing Professional Development in the last 12 months. All 34 were requesting more postgraduate education opportunities. Conclusion: Australian Metabolic/bariatric nurses are asking for more education to achieve the Continuing Professional Development required for nursing registration, so they may provide the specialised evidence-based care that metabolic/bariatric patients require. This study provides a list of favoured education topics and preferred modes of education delivery. The results from this study may be used to: assist in the development of education for metabolic/bariatric nurses at the workplace, conference and university level; and supports research on the specialised practice of metabolic/bariatric nursing. © 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
1. Introduction Obesity is a major public health concern (Australian Institute of Health & Welfare, 2017b) and currently, the most effective treatment for obesity is metabolic/bariatric surgery (Buchwald & Oien, 2013). With increasingly high numbers of metabolic/bariatric surgeries being performed globally, a new specialty area is developing. Metabolic/bariatric nursing is defined in this study as the nursing care of patients who are preparing to undergo or have undergone metabolic/bariatric surgery. The metabolic/bariatric nurse assists in all stages of the surgical pathway such as initial consultation, diagnosis, treatment, recovery and follow-up care, and is responsible for the coordination of care and the education of the multidisciplinary team (Johnson, Dohlin, & Severson, 2009). A metabolic/bariatric nurse is expected
∗ Corresponding author at: Nursing and Midwifery Building 25, Angus Smith Drive, Douglas, QLD, 4811, Australia. E-mail address: [email protected] (M. Bogiatzis).
to provide sensitive, compassionate, experienced, evidence-based care to patients in their care (Neil & Roberson, 2015) and must be able to educate the patient in all aspects of health that relate to metabolic/bariatric surgery. Metabolic/bariatric nurses are valued by healthcare facilities as they offer highly specialised care to patients undergoing surgery for obesity and obesity-related comorbidities, improve patient care, and improve hospital efficiency (McGinley, 2008). Nurses in the United States of America (USA) have shown an interest in metabolic/bariatric certification since the 1990s which led to the introduction of Certified Bariatric Nurses (CBNs) in 2007 (Berger et al., 2010). Metabolic/bariatric nurse coordinator roles have since been implemented in healthcare settings around the world (Sonoda, Seki, Kasama, Kikkawa, & Yotsuya, 2015; Thomas & Rickabaugh, 2008). However, Australia is yet to provide the same level of national education and certification to their metabolic/bariatric nurses, as there are no formal postgraduate courses specific to metabolic/bariatric nursing in Australia. In addition, even for short informal education seminars, there is a very limited range of continuing professional development
https://doi.org/10.1016/j.colegn.2019.11.011 1322-7696/© 2019 Australian College of Nursing Ltd. Published by Elsevier Ltd.
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Summary of Relevance Problem Metabolic/bariatric nursing practice is currently undefined in Australia and there is a limited amount of education available for nurses working in this specialty. What is already known Despite the advances in metabolic/bariatric nursing education and specialisation around the world, Australia is yet to provide the same level of national education and certification to their metabolic/bariatric nurses. What this paper adds This paper defines metabolic/bariatric nursing practice in Australia and provides a list of favoured continuing education topics and preferred modes of education delivery to assist in the development of future education that is relevant and accessible.
Box 1: The four domains of metabolic/bariatric nursing practice. The four domains of clinical practice (Berger et al., 2010, p. 403) Clinical management: provide and document direct and indirect clinical care and education to morbidly obese and bariatric surgery patients/family/support persons.Multidisciplinary team collaboration: communicate and educate to facilitate continuity of care among multidisciplinary teams for optimal patient outcomes, and to improve the quality of care for morbidly obese and bariatric surgery patients.Outreach: provide advocacy, support, and education to individuals, support groups, community groups and healthcare professionals related to morbidly obese and bariatric surgery patients.Program administration: provide leadership and a framework to coordinate services for optimal outcomes, and to improve the quality of care for morbidly obese and bariatric surgery patients.
opportunities for nurses working with metabolic/bariatric patients. To meet registration standards, nurses in Australia are required to achieve a minimum of 20 hours of continuing professional development. “Continuing professional development (CPD) is how nurses and midwives maintain, improve and broaden their knowledge, expertise and competence, and develop the personal and professional qualities required throughout their professional lives” (Nursing & Midwifery Board of Australia, 2016b, p. 4). Examples of CPD include in-service education, attending conferences and seminars or publishing a peer-reviewed journal article (Nursing & Midwifery Board of Australia, 2016a). The NMBA’s ‘Guidelines for Continuing Professional Development’ state that all CPD activities “must be relevant to each nurse’s area of professional practice” (2016a, p. 2). This was the first study to survey Australian metabolic/bariatric nurses on their professional development needs and sought to answer the following questions: 1 What is metabolic/bariatric nursing practice in Australia? 2 What are the professional development needs metabolic/bariatric nurses in Australia?
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2. Literature review Since the first metabolic/bariatric surgery in the USA in 1954, nurses have been involved in: educating patients prior to surgery; coordinating patient care; caring for the patients in surgical theatres, on the wards and at follow-up appointments through surgical practices, hospitals and community health services around the world. Articles on the role and importance of metabolic/bariatric nursing have been found from Japan to the USA, exemplifying how other countries have addressed a growing need in their health services and how a new specialty of nursing has arisen (Sonoda et al., 2015; Thomas & Rickabaugh, 2008). In 2007 the first metabolic/bariatric nursing certification was held in the USA and following its success, a research paper outlining how the certification was developed was published. The US study leading to the introduction of CBNs was produced by Berger et al. (2010) and was the first practice analysis study of bariatric nurses, which officially defined and documented the role of the bariatric nurse for the first time. The study collected 504 surveys from nurses working with bariatric patients across the US. The various positions of nurses included bariatric nurse coordinators 33 %, bariatric program coordinators 28 %, hospital floor nurses 24 % and ‘other’ roles 15 % such as operating room nurses, nurse practitioners and nurses in an office setting (Berger et al., 2010). This practice analysis study by Berger et al. (2010) was able to define the practice of bariatric nursing in terms of four domains of clinical
practice, which included 45 tasks and 54 knowledge areas. (See Box 1). This practice analysis described the tasks and knowledge areas that metabolic/bariatric nurses would need in order to become a Certified Bariatric Nurse. This work became a foundation for the development of a formal certification examination for eligible nurses who had two or more years of experience in bariatric nursing to become a Certified Bariatric Nurse (CBN) and thus be recognised a nurse to have advanced knowledge in bariatrics. There are now over 2000 CBNs in the USA (personal communication, Dr. Narelle Storey, Certified Bariatric Nurse Committee Member). In 2008, while American nurses were starting to become Certified Bariatric Nurses (CBNs), another article from the US by Thomas and Rickabaugh described a new position for nurse coordinators in the metabolic/bariatric acute care setting. Thomas and Rickabaugh (2008, p. 63) stated: “a bariatric nurse coordinator is an emerging role requiring a nurse with specialised, competent knowledge in bariatric patient care who has the visionary and management skills to coordinate patient care throughout a healthcare system”. Educating nurses about the reasons patients seek metabolic/bariatric surgery, including sensitivity training as well as physical nursing management, has been documented as beneficial to the patient through more informative, compassionate and unbiased patient care (Neil & Roberson, 2015). In 2009, a Minnesota hospital in the USA also described the introduction of a new position of a bariatric program coordinator (Johnson et al., 2009) and demonstrated multiple benefits not just to patients, but also to the nurses and hospital. Patient care improved with the education of nurses on topics surrounding pre-surgery and post-surgery metabolic/bariatric nursing and the patient’s length of stay was shortened reducing costs for both the patient and hospital. As the role of metabolic/bariatric nurses continued to prove beneficial in the USA, other countries, such as Japan, documented their experience of introducing the role of a Bariatric Nurse Coordinator. A Japanese observational study by Sonoda et al. (2015) examined the introduction of the role by comparing the patient’s transition through surgery with the nurse, to their transition with a physician. After observing 337 patients receiving metabolic/bariatric surgery, the average number of days from the initial consultation to the operative date was 67.9 days under physician supervision and 43.1 days with nursing intervention (Sonoda et al., 2015). This showed a substantially shortened pre-operative process leading to practice that was more efficient when a metabolic/bariatric nurse was involved. Metabolics/bariatrics is a highly challenging and complex specialty as obese patients are at risk of developing many comorbidities at an earlier age leading to premature mortality (National Health & Medical Research Council (NHMRC), 2013), including elevated
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blood pressure, high cholesterol, insulin resistance, coronary heart disease, ischaemic stroke, Type 2 diabetes and a range cancers that also increase steadily with increasing BMI (Australian Institute of Health & Welfare, 2017a). Given the increased risk of operating on, and caring for, metabolic/bariatric patients, there is now international recognition that a multidisciplinary team specifically designed to cater for the complex needs of metabolic/bariatric patients is beneficial. As a result, metabolics/bariatrics is quickly becoming an area of nursing specialisation around the world. If metabolic/bariatric nursing is to be a nursing specialty in Australia, then specialist education will be required. This quantitative descriptive study sought to define metabolic/bariatric nursing practice in Australia and to identify the professional development needs of metabolic/bariatric nurses in Australia.
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experts who trialled the survey for face validity. Based on feedback received, the survey was revised and a final version produced. 3.5. Data collection Data collection commenced following approval from the James Cook University Human Research Ethics Committee. The survey was open for two weeks from the first invitations distributed by ANZMOSS in December 2017. After this time, a reminder email from the organisation (ANZMOSS) was sent and an additional week was allocated for any remaining survey entries. A total of 37 eligible metabolic/bariatric nurses from across Australia completed the online survey (See Fig. 1). 3.6. Data analysis
3. Methods 3.1. Study design A quantitative, descriptive, cross-sectional survey was used in this study. The survey was cross-sectional as it provided data that represented the professional development needs of metabolic/bariatric nurses in Australia at one point in time. A national sample was collected to represent the diversity in metabolic/bariatric nursing in Australia and the different roles that make up the area of practice. A representation of nurses from around Australia gives a wider indication of current sources of metabolic/bariatric nursing knowledge and the gap in available education for nurses working in this sector. Using an anonymous survey method gave a voice to the nurses so they could openly express their views while allowing the researcher to remain objective. 3.2. Eligibility criteria and setting Participants included in the study were persons consenting to participate in the study and were currently employed as registered nurses in Australia who work specifically with patients who have had or are having metabolic/bariatric surgery. This study excluded registered metabolic/bariatric nurses from outside of Australia. 3.3. Recruitment The survey was disseminated via the professional organisation ANZMOSS (Australian and New Zealand Metabolic Obesity Surgery Society). An email containing a brief explanation of the study and a link to the survey was sent from ANZMOSS to the nursing membership and their networks to facilitate snowballing recruitment. To prevent any non-metabolic/bariatric nurses responding, the initial questions of the survey reaffirmed the inclusion criteria and nonsuitable applicants were exited from the survey. No identifying data was collected. Participants’ email addresses were accessed by the ANZMOSS organisation to ensure privacy, anonymity and remove any suggestion of coercion by the researchers. 3.4. Survey development Online databases and published literature were searched for validated survey tools that could be modified to address the aims of this study. No validated surveys could be found that obtained information from metabolic/bariatric nurses about their professional development needs. Similarly there were none from other nursing specialties that could be easily adapted. For this reason, a new survey had to be developed and validated. The survey tool was developed by the primary researcher and two research advisors in Qualtrics Online. The survey tool was validated by lay people and
Numerical data has been described using participant numbers, percentages and mean and standard deviation (SD) values to show distribution. Categorical data has been described using participant numbers and percentages. Statistical analysis was conducted using the computer software Microsoft Excel 2016 and the online survey platform Qualtrics. All textual data was analysed using colour-coding and framework analysis (Ritchie & Spencer, 1994). In this study, framework analysis has been used to compare the metabolic/bariatric nursing practice in Australia to that in the US based on the four domains of clinical practice as defined by Berger et al. (2010). Participant answers were exported from Qualtrics to Microsoft Excel 2016 to enable the nurses’ daily tasks to be broken down into single lines, that is, one nursing task per line. This allowed nursing tasks to be calculated and analysed for sorting into the four domains of practice. Identifying details were changed to avoid recognition of an individual nurse’s circumstances. 4. Results 4.1. Sample Of the 40 participants who gave consent and commenced the survey, 95 % (n = 38) were living in Australia and 5 % were not (n = 2). The two participants who did not live in Australia were not able to progress with the survey and were excluded from the study as they did not meet the inclusion criteria. 4.1.1. Geographic distribution There was representation from five of the eight states/territories of Australia: NSW 56.8 % (n = 21), QLD 29.7 % (n = 11), VIC 8.1 % (n = 3), SA 2.7 % (1), WA 2.7 % (n = 1), NT 0 %, ACT 0 % and TAS 0 %. One participant who did not select their state/territory of residence also did not progress with the survey. This left 37 surveys for analysis. 4.1.2. Gender and age Females represented 97 % of the participants (n = 36) and 3 % were male (n = 1). The most common age bracket of the 37 participants was the under 30 yrs with 27 % (n = 10), 31-40yrs with 24 % (n = 9), 41–50 with 24 % (n = 9), 51-60 yrs with 22 % (n = 8) and the over 60 yrs with 3 % (n = 1). 4.1.3. Years of experience in nursing All 37 participants confirmed they were registered nurses (RNs) and were registered between the years of 1976 and 2017. The years of nursing experience ranged from 0 years to 42 years. RNs who claimed 0 years’ experience were most likely new graduate nurses in their first year of nursing, however, had not completed one full year of experience. Years of nursing experience averaged 16 years (SD +/- 11).
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Fig. 1. Participant flow chart.
Legend: Australian and New Zealand Metabolic Obesity Surgery Society (ANZMOSS).
4.1.4. Years of experience in metabolic/bariatric nursing The first RN from this study to commence work with metabolic/bariatric patients did so in 1983. The total years of experience in metabolic/bariatric nursing varied between the individual RNs (n = 37) from 0 to 26 years of experience. The average years of experience in metabolic/bariatric nursing was 7.5years (SD +/- 6). 4.1.5. Formal post-graduate education Of the 35 RNs who responded to this item, 13 had formal postgraduate qualifications (37 %) and 22 did not (63 %). The most common postgraduate courses were graduate certificates and diplomas in acute care nursing or critical care nursing, graduate certificate of stomal therapy, masters in surgical nursing and a graduate diploma of health management. One nurse had completed a graduate certificate in chronic disease nursing. 4.2. What is metabolic/bariatric nursing practice in Australia? 4.2.1. Current role All 37 participants worked in metabolic/bariatric areas or with metabolic/bariatric patients at the time of the survey. There were six nursing roles within metabolic/bariatric nursing identified by the survey including ward nursing 48 % (n = 20), practice nursing 24 % (n = 10), theatre nursing 12 % (n = 5), nursing management 7 % (3), research nurse 7 % (n = 3) and nurse academic 2 % (n = 1). The total number of responses is equal to 42, as some nurses indicated they had multiple roles. 4.2.2. Percentage of hours spent working in the metabolic/bariatric specialty According to the 37 participants, the average percentage of time worked in the metabolic/bariatric specialty varied across roles. Practice nurses spent most of their time in the specialty (82 %) followed by theatre nurses (80 %), ward nurses (68 %), research nurses (67 %), nurse managers (57 %) and nurse academics (10 %). 4.2.3. The daily nursing tasks Daily tasks of the 36 RNs who responded to this question were exported to Excel and categorised according to the domains of practice for metabolic/bariatric nurses identified in the practice analysis study by Berger et al. (2010). Nurses in the academic and research roles did not list any clinical tasks in their daily roles, however the ward nurses, theatre nurses, nurse managers and practice nurses listed daily tasks that represented all four domains of practice.
The analysis of categorical and ordinal data revealed that the role of the metabolic/bariatric nurse in Australia was very similar in daily task descriptions to that of metabolic/bariatric nurses in the US. The following daily nursing tasks have been further described and segmented using the four domains of practice as described in the US study by Berger et al. (2010). This is an appropriate framework for analysis as this is the only country that has been known to produce a practice analysis report of metabolic/bariatric nurses. 4.2.3.1. Domain 1: clinical management. Berger et al. (2010, p. 403) define clinical management tasks as “providing and documenting direct and indirect clinical care and education to morbidly obese and bariatric surgery patients/family/support persons”. In the survey, metabolic/bariatric nurses in Australia listed 44 daily tasks that fit within this definition of clinical management duties. The most frequently occurring tasks listed were: pre-operative and post-operative education, monitoring health status of the patient, wound and pain management, monitoring fluid intake, dietary advice, recognising and alerting the surgeon to potential complications and being the main point of contact for staff and patients, offering reassurance and support. The diversity of tasks across different nursing roles was apparent with such an extensive list of tasks performed on a daily basis. A third of all nursing tasks in clinical management can be attributed to the pre-operative phase and sometimes this could involve the care of patients from rural/remote areas via phone consultations or Skype. As one of the few nursing specialities that requires the nurse to care for patients at times without face-to-face consultation, it is apparent that a metabolic/bariatric nurse requires the skills to develop rapport, educate and offer support, not only face-to-face, but also through other modes of communication (e.g. phone consultation, videoconferencing, email). 4.2.3.2. Domain 2: multidisciplinary team collaboration. Berger et al. (2010, p. 403) define multidisciplinary team (MDT) collaboration as providing “communication and education to facilitate continuity of care among multidisciplinary teams for optimal patient outcomes, and to improve the quality of care for morbidly obese and bariatric surgery patients”. Metabolic/bariatric nurses in Australia listed nine daily tasks that involved the collaboration of the MDT. For example, participants made reference to: “Working as part of a team with the receptionist, practice manager, dietitian, psychologist, meditation support nurse, doctors and surgeons”.
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“Work with the surgeon and anaesthetist to provide optimal recovery of the patients”. Both of these participant responses exemplify the number of professional relationships that the metabolic/bariatric nurse is required to maintain in order to provide optimal and holistic care. For metabolic/bariatric surgery, patients could be required to meet with a dietician, psychologist, gastroenterologist, metabolic/bariatric nurse, metabolic/bariatric surgeon, anaesthetist, sleep study technician, exercise physiologist and any specialist the patient is already seeing, such as a cardiologist. All members of the MDT influence the decision of whether a patient is an eligible candidate for surgery. Coordinating the care of the patient was a common task listed in this domain of practice, particularly gathering the reports from all MDT members and presenting them to the surgeon for confirmation of surgery. MDT collaboration commences prior to surgery and continues throughout the follow-up phase of patient care. 4.2.3.3. Domain 3: outreach. The third domain, Outreach, is defined as “providing advocacy, support, and education to individuals, support groups, community groups, and healthcare professionals related to morbidly obese and bariatric surgery patients” (Berger et al., 2010, p. 403). It is primarily focussed on the education of staff and the community in relation to morbid obesity to help people understand the life-threatening disease, how it affects the patient’s physical and mental health, the process of undergoing metabolic/bariatric surgery and what this means for the patient’s future health. The nurses listed 13 daily tasks that supported outreach, mostly through education and research. Examples of the listed tasks that fall into this domain are: Educating nurses on the ward or in the hospital, educating undergraduate nursing students during their practical experience on the wards, collaborating with the US on metabolic/bariatric research and developing educational seminars for nurses. Three nurses specifically mentioned the daily task of collecting data to contribute to the Bariatric Surgery Registry (BSR), which collates data on all metabolic/bariatric surgery performed in Australia. 4.2.3.4. Domain 4: program administration. The fourth domain of practice for metabolic/bariatric nurses is to “provide leadership and a framework to coordinate services for optimal outcomes and to improve the quality of care for morbidly obese and bariatric surgery patients” (Berger et al., 2010, p. 403). There were thirteen daily tasks listed within this domain of program administration. Ward nurses, practice nurses, theatre nurses, research nurses and academic nurses were all represented in this domain. Some of the daily tasks of nurses practising in this domain were: coordination of theatre bookings and operating lists for all surgeons, coordination of application to become a Centre of Excellence in Metabolic and Bariatric Surgery, managing a GIT bariatric ward, advocating for patient safety and education, and managing clinical research trials. 4.3. What are the professional development needs of metabolic/bariatric nurses in Australia? 4.3.1. Professional development over the last 12 months Participants were asked to list all forms of continuing professional development (CPD) they had attended over the previous 12 months. Of the 32 RNs who responded, 16 (50 %) attended metabolic/bariatric conferences/meetings, 7 (22 %) attended metabolic/bariatric seminars, 6 (19 %) provided metabolic/bariatric education to colleagues and the multidisciplinary team, 4 (13 %) attended metabolic/bariatric education in their workplace, 1 (3 %)
Fig. 2. Nursing resources for metabolic/bariatric patient care information. Legend: Multi-Disciplinary Team (MDT).
Fig. 3. Postgraduate education opportunities for metabolic/bariatric nurses. Legend: Continuing Professional Development (CPD).
attended the US certification of bariatric nursing examination, 1 (3 %) took part in a journal club and 10 (31 %) did not attend any education specific to metabolic/bariatric nursing in the preceding 12 months. 4.3.2. Accessing further information When looking for advice or more information, participants accessed a variety of resources. (See Fig. 2). Of the 35 nurses who answered this question, 30 (86 %) said they would ask the metabolic/bariatric surgeon for advice regarding the care of a patient if they needed more information. The next most frequently reported source of additional information was fellow nurses, with 17 of the 35 (49 %) approaching fellow nurses for advice regarding patient care. 4.3.3. Preferred future postgraduate education The majority (63 %) of the 34 respondents who answered this question believed that a formal graduate certificate in metabolic/bariatric nursing should be available for RNs in Australian universities. Three-day workshops and one-day seminars were also highly valued. (See Fig. 3). 4.3.4. Desired topics for further education Of the 26 who responded, 22 metabolic/bariatric nurses listed 41 topics on which they would like to have more education. These are presented in Table 1. Four nurses answered that they did not require any further education at the time. The education topics have been listed using terminology as close to the participants’ requests as possible, while also allowing similar statements to be grouped together where necessary. While all requested topics may be beneficial to all nursing roles, the topics have also been listed with nominal data to show which nursing role was requesting each topic. This can be viewed in Supplementary Material.
Please cite this article in press as: Bogiatzis, M., et al. Australian bariatric nurses: What do they do and what do they need? Collegian (2020), https://doi.org/10.1016/j.colegn.2019.11.011
Ward (n = 11)
Practice (n = 7)
9
5
4
5 4 3 3 3
1 1 1 1 1
2 3 1 1
3 2 2 2 2 2 2
1 1 1 1 1
1 1 2
Manager (n = 2)
Research (n = 2)
Academic (n = 1)
1
1
1 1
1
1
1
1
1
1 1 1 2 1 1
1 1 1 1 1
1 1 1 1
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2 1 1
1 1 1 1 1
Theatre (n = 3)
1 1 1 1 1 1
1 1 1 1 1
1 1 1 1 1 1
1 1 1 1 1 1 1
1 1 1
1 1 1 71
1
1 1 1
1 23
1 32
5
2
5
4
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Total Requests
Regular ongoing education to update staff on new surgeries, procedure changes or policy changes Accessing and keeping up to date with metabolic/bariatric nursing research Endoscopic sleeve surgery How to manage post-operative complications The benefits of metabolic/bariatric surgery How to adopt and ensure evidence-based practice in the metabolic/bariatric setting Strengthening the role of metabolic/bariatric nursing in Australia Anatomy and physiology of the metabolic processes and digestive system How to give advice on health and nutrition Post-operative malnutrition issues, vitamin deficiencies What happens after a patient leaves hospital-the recovery process Signs and symptoms of deterioration after surgery Psychological health of metabolic/bariatric patients and how to address concerns Intragastric balloon procedure Education and support for patients with eating disorders Education, dietary advice and support for managing weight regain at follow-up appointments Dietary advice for increasing protein in the first few months post-operatively How to manage hypoglycemia perioperatively and long term. How to manage nausea and vomiting post-operatively- short and long term How to access lap band ports and make adjustments How bariatric surgery physically and mechanically changes the digestive process The different metabolic/bariatric surgeries performed in Australia Watch a metabolic/bariatric surgery being performed Dumping syndrome Post-operative care of the metabolic/bariatric patient Discharge advice regarding patient’s post-operative diet and symptoms of potential complications Developing a hospital menu for post-bariatric surgery patients Role of the practice nurse Management of a bariatric clinic Educating new graduate nurses or nurses new to metabolic/bariatric surgery Sensitivity training-encouraging compassionate nursing through knowledge of the patient’s experience Treating the whole metabolic disease. Resolving comorbidities before and after surgery The process of psychological review before and after surgery Attending metabolic/bariatric conferences-national and international Developing clinical pathways for metabolic/bariatric patients post-operatively How to address poor attendance to follow-up appointments What does the dietician and physiotherapist tell the patient? Education of patients at the pre-surgery appointment to prepare them for the recovery phase in hospital Manual handling expectations Complications post-omega loop, roux en y bypass and duodenal switch Pharmaceutical options for weight loss Total requests per role
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Requested topics for further education
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Table 1 Requested topics for further education.
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The most requested topic was to have more ongoing or frequent education to update nursing staff on new surgeries, procedure changes or policy changes: “On-going education in all areas as this a growing industry. We need to be kept up-to-date with new procedures, endoscopic procedures in particular” (P7). “It would be nice if on-going education was an option regarding changes in bariatric surgery. As improvements or changes happen quite often, the VMO [Visiting Medical Officer] have the procedure done before liaising with nursing staff regarding post-op care. An example of this would be the endoscopic sleeve gastrectomy. . . .I find different VMO’s have different post-op preferences which often leads to confusion in patient care” (P22). 5. Discussion 5.1. What is metabolic/bariatric nursing practice in Australia? The analysis of data in this study revealed that the role of the metabolic/bariatric nurse in Australia was very similar in daily task descriptions to that of metabolic/bariatric nurses in the USA, the only country that has been known to produce a practice analysis report of metabolic/bariatric nurses. The daily tasks of metabolic/bariatric nurses in Australia were successfully categorised into Berger’s four domains of clinical management, MDT collaboration, outreach and program administration (2010), indicating that this study supports Berger’s Four Domains of Practice as a validated structure in defining the practice of metabolic/bariatric nursing in Australia. Defining the practice of any nursing specialty is an important step before being able to develop a set of population-specific clinical practice guidelines and clinical competencies to improve nursing practice. This was highlighted for another two specialty nurse roles (breast and colorectal cancer screening nurses) in Spain, where the identification of daily nursing activities allowed them to develop competencies, a necessity for evaluating nursing care (Benito et al., 2016). Implementing the competencies ensured the development of evidence-based practices, personalised care and quality healthcare practices for these two emerging specialty roles. Benito et al. (2016, pp. 356-357) also concluded “nurses should continually reassess their competencies and identify their needs for additional knowledge, skills, personal growth, and integrative learning experiences”. Implementation of specialised metabolic/bariatric coordinators and the provision of workplace education has been linked with improved hospital efficiency, decreased costs to patient and research informed nursing practice (McGinley, 2008). 5.2. What are the professional development needs of metabolic/bariatric nurses in Australia? Responses in this study clearly indicate that some hospitals are yet to develop clinical pathways for nursing care of metabolic/bariatric patients and associated nursing competencies. The nurses expressed concern that regular ongoing education in this specialty is lacking and this education gap often leaves them without the relevant knowledge on new procedures and policies. A one-day seminar for metabolic/bariatric nurses hosted annually by ANZMOSS was the only form of nationally available education mentioned in the survey responses. In-services or seminars held in practices or hospitals were the only forms of frequent specialty education reported by the nurses in this study. The nurses in this study reported that they relied on surgeons and fellow nurses for education and advice on patient care, however a third still felt their CPD had not been relevant enough for their practice development
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needs. When looking to other members of the multidisciplinary team receiving education in this field, dietitians in Australia have already been completing metabolic/bariatric workshops that certify them to care for and offer dietary advice to metabolic/bariatric patients since 2017. The Australian Nursing and Midwifery Federation (ANMF) dictates that registered nurses require access to continuing professional development, should seek financial support from their employers for post-graduate courses, and that education facilities should aim to provide CPD courses to nurses and employers that reflect their learning needs (Australian Nursing & Midwifery Federation, 2016). 5.3. Implications 5.3.1. Education The results from this study may be used to assist in the development of education for metabolic/bariatric nurses at the workplace, conference and university level. By providing a list of the nurses’ requested education topics and a table of topics nurses found most important, education facilities have the data to inform their education content so it may be tailored to the metabolic/bariatric nursing field and the identified nursing roles within it. 5.3.2. Practice By highlighting the gap in the literature and available education resources, this study may indirectly improve the care of a high-risk group of patients by advocating for more education of metabolic/bariatric nurses in Australia. 5.3.3. Policy The results of this study have suggested multiple forms of education that would support education providers in the development of future CPD activities for metabolic/bariatric nurses. The findings from this study support ANMF policy on encouraging nurses to seek their required CPD and provides the impetus for healthcare facilities to provide ongoing evidence-based education to nursing staff through in-services, nursing grand rounds and scholarships. Addressing the learning needs of metabolic/bariatric nurses in Australia will allow nurses and employers to meet nursing policy requirements and will support the introduction of a new nursing role (a metabolic/bariatric nurse coordinator) within healthcare facilities. 5.3.4. Research This study has identified a gap in previous Australian research and has reinforced the international research on metabolic/bariatric nursing specialisation to date. Further research on this topic in varying contexts or countries will continue to strengthen the knowledge of metabolic/bariatric nursing practice internationally. 5.4. Strengths and limitations This was the first study to survey metabolic/bariatric nurses in Australia regarding their professional development needs. This gap in the literature lead to the development of a new survey that was rigorously tested by metabolic/bariatric health professionals, non-metabolic/bariatric health professionals and lay people. The survey was easily accessible for participants using the online survey platform Qualtrics. This allowed successful nation-wide delivery. Potential bias of this study would be the invitation of nurses primarily from a professional organisation for metabolic/bariatric surgery. The nurses in this organisation could potentially be more eager for education in this field than non-member nurses who still work with metabolic/bariatric patients.
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Due to the time restriction on this study, a limited period of three weeks was allowed for data collection. This time restriction may have contributed to the small sample size. Given the relatively small population of bariatric nurses in Australia however, this sample is considered adequately representative to support the conclusions drawn. Therefore the sample size and associated results may not be generalisable to the whole of the metabolic/bariatric nursing population in Australia. Inferences can, however, be drawn from the analysis that have implications for practice and future research. The structure of this survey may be used on a larger scale to further investigate the role of metabolic/bariatric nurses, their educational needs, how they currently receive education on an international scale. 6. Conclusion This quantitative descriptive study surveyed 37 RNs working with metabolic/bariatric patients from around Australia. The findings define the practice of metabolic/bariatric nursing in Australia and report the professional development needs of metabolic/bariatric nurses in this context. The results indicate metabolic/bariatric nurses are requesting more education across a variety of topics, in particular, they wish for more frequent education sessions to keep informed about this rapidly changing and growing specialty. The participants showed strong support for more CPD opportunities with post-graduate certificates and one-day seminars being highly rated as preferred methods of education delivery. The findings and recommendations from this study have the ability to improve metabolic/bariatric nursing practice and patient care across Australia. Author agreement The authors declare that this article is the authors original work. This article has not received prior publication and is not under consideration for publication elsewhere. All authors have seen and approved the manuscript being submitted. The authors abide by the copyright terms and conditions of Elsevier and the Australian College of Nursing. Ethical Approval Ethical approval was sought and obtained from the Human Research Ethics Committee on the 27th November, 2017. Ethics Approval Number: H7209.
Appendix A. Supplementary data Supplementary material related to this article can be found, in the online version, at doi:https://doi.org/10.1016/j.colegn.2019.11. 011. Declaration of Competing Interest The authors have no conflicts of interest to report. References Australian Institute of Health and Welfare. (2017a). Weight loss surgery in Australia 2014–15: Australian hospital statistics. Cat. No. HSE 186. Canberra: AIHW. Australian Institute of Health and Welfare. (2017b). Impact of overweight and obesity as a risk factor for chronic conditions: Australian Burden of Disease Study. Australian Burden of Disease Study series no.11. Cat. no. BOD 12. Canberra: AIHW. Australian Nursing and Midwifery Federation. (2016). Nursing education: Registered nurse Retrieved from. http://anmf.org.au/documents/policies/P Nursing education RN.pdf Benito, L., Binefa, G., Vidal, C., Lluch, M. T., Puig, M., Padrol, I., et al. (2016). Identifying nursing activities in population-based colorectal and breast cancer screening programs in Spain: A Delphi study. Collegian, http://dx.doi.org/10. 1016/j.colegn.2016.07.005 Berger, N. K., Carr, J. J., Erickson, J., Gourash, W. F., Muenzen, P., Smolenak, et al. (2010). Path to bariatric nurse certification: The practice analysis. Surgery for Obesity and Related Diseases, 6(4), 399–407. http://dx.doi.org/10.1016/j.soard. 2010.04.003 Buchwald, H., & Oien, D. M. (2013). Metabolic/bariatric surgery worldwide 2011. Obesity Surgery, 23(4), 427–436. http://dx.doi.org/10.1007/s11695-012-0864-0 Johnson, A., Dohlin, E., & Severson, K. (2009). The CNS role: Coordination of a bariatric surgery program across the continnum. Clinical Nurse Specialist, 23(4), 224. McGinley, L. D. (2008). The vital role of a clinical nurse specialist in a bariatric setting, Philadelphia. National Health and Medical Research Council (NHMRC). (2013). Clinical practice guidelines for the management of overweight and obesity in adults, adolescents and children in Australia. Melbourne: National Health and Medical Research Council. Neil, J. A., & Roberson, D. W. (2015). Enhancing nursing care by understanding the bariatric patient’s journey. AORN Journal, 102(2), 132. http://dx.doi.org/10. 1016/j.aorn.2015.05.014 Nursing and Midwifery Board of Australia. (2016). Guidelines: Continuing professional development Retrieved from. http://www.nursingmidwiferyboard. gov.au/Codes-Guidelines-Statements/Codes-Guidelines/Guidelines-cpd.aspx Nursing and Midwifery Board of Australia. (2016). Registration standards: Continuing professional development Retrieved from. http://www. nursingmidwiferyboard.gov.au/Registration-Standards/Continuingprofessional-development.aspx Ritchie, J., & Spencer, L. (1994). Qualitative data analysis for applied policy research. In A. Bryman, & R. G. Burgess (Eds.), Analysing qualitative data (pp. 219–262). London: Routledge. Sonoda, K., Seki, Y., Kasama, K., Kikkawa, E., & Yotsuya, T. N. (2015). Role of the bariatric nurse/coordinator in bariatric surgery in Japan New York. Thomas, S. A., & Rickabaugh, B. (2008). Bariatric nurse coordinator: Carving out a new role in bariatrics. Bariatric Nursing and Surgical Patient Care, 3(1), 63–72. http://dx.doi.org/10.1089/bar.2008.9989
Funding This study received no funding.
Please cite this article in press as: Bogiatzis, M., et al. Australian bariatric nurses: What do they do and what do they need? Collegian (2020), https://doi.org/10.1016/j.colegn.2019.11.011