Health researchers have more in common with wordsmiths and artists than you might think. The gaps within our health system can be brought to life and better understood with thoroughly researched semantics and articulated and expanded into solutions, resulting in shifts in healthcare culture.
One of those minding the gaps is Dr Caz Hales, Senior Lecturer, School of Nursing, Midwifery and Health Practice, Victoria University of Wellington.
Driven by her motif ‘How can I serve? How can I make the health sector easier and better for all people?’ Dr Hales is one of New Zealand’s leading research experts on improving bariatric care.
Dr Hales was working as a nurse in the Intensive Care Unit (ICU) both at Wellington Hospital and at Wakefield Hospital and was regularly confronted by the health experiences of larger sized people.
“My PhD in 2010 came out of working at the bed sides of people of larger size. I could see the inequities in the quality and levels of care within different areas, between hospitals, and the different levels of care within hospitals themselves. There wouldn’t be any equipment for any larger sized people. So we would have a reactive response to people being admitted to hospital. My PhD studies looked at the influences and culture for dealing with people of larger size in the ICU.
“I found that people of larger size don’t physically fit the standard equipment. That things like weighing people was problematic.
“Medically the cannulation lines were not long enough to get through fatter tissue. When doctors tried putting in chest drains in intensive care their fingers don’t easily get through cavities in bigger patients rib cages. Socially these patients don’t fit in the realms of what we consider ‘normal bodies’,”
She found a lot of media around stigmatising larger people.
“It’s challenging for doctors and nurses too as they don’t want to support that stigma. They wouldn’t know how to approach some questions so in some cases they would pretend that the person wasn’t large. They’d normalise their size, for example when they bring the commode in and the person would say ‘I won’t’ fit that’ and they’d say ‘don’t worry no one fits in that!’ Many didn’t know how to manage that stigma and manage their own thoughts and those of the patient, and they’d go out of their way to show they had no stigma or judgement. Typically health professionals want to help, and not hurt, people so they would be aware of how people of larger size were being stigmatized in the community and they were loathe to be a part of that.”
So Dr Hales, like a veritable medical Will.I.Am, was part of a collaboration with Capital and Coast District Health Board (CCDHB) services.
“Initially the hospital would take one two or even three days to get a chair to sit in to go to the toilet for a patient, so I worked with the DHBs to develop bariatric care packages. For those with mobility and those who were bedbound. We did a really significant collaboration with Essential HelpCare specialist providers of bariatric care equipment and created bariatric care bundles.
The bariatric care bundle was first used in CCDHB in 2016. It includes a bariatric bed that has a scale in it among other things, explains Dr Hales.
“So as soon as a patient arrived they would have a gown and lifting equipment, a larger bed pan, and the bariatric bed. Our goal was to reduce the number of days it was taking to get the equipment – down to within an hour – we ended up getting it delivered within 30 minutes. Christchurch and Auckland now also have the equipment packages.”
And as the bundle stays with the person from when they come into the hospital until when they leave, the bundle also reduces operational bureaucracy in searching for appropriate equipment when there are finite resources.
“Wards are often reluctant to share equipment with another ward like a chair or a bed because it can go missing. Having person centred bundles means that equipment is not the wards it will always remain with the patient. This is a simple solution to what is a very real problem for patients and healthcare staff”
Dr Hales is now in the process of getting funding to undertake a review of how effective the bariatric care bundles are.
“Anecdotally they work. We need to do the research to close the inequity gap not just between DHBs, but in primary healthcare too.”
Another piece of work has seen Dr Hales running weight stigma empathy sessions for healthcare professionals.
“We asked “how do we communicate in a non-judgemental way and how do we make that interaction safe for that person so they will want to come back and engage in healthcare?” she explains.
Larger sized patients, like any group who feels stigmatised or alienated by the healthcare system, will avoid the healthcare system and end up presenting when things have deteriorated.
“Larger sized people attend GP practises less often than smaller sized people. They often don’t turn up to check-ups because they don’t want to for fear of being stigmatized.”
She says that the person may not be being stigmatized but because of their past experiences they may feel like they are being stigmatized.
“It’s a minefield, managing their vulnerability, and their fear of being stigmatised.”
Dr Hales says the language we use is very important.
“One way to counter this was rather than saying you’re too fat for that chair – you can say the chair won’t fit you because of the fat around your thighs and back. Or a nurse taking your blood pressure saying- this is going to hurt when I pump up the arm band because of the fat on your arm, and it may leave a mark on your arm.
“Yes, we’ve come a long way from reports of mortuaries weighing people of larger size with zoo equipment – a practise only stopped in the last ten years. We now understand just how inappropriate that was.
She also worked on a small-scale project with Lesley Gray, Senior Lecturer, University of Otago, Wellington, where health professionals put on body size simulation suits and then go out into the world.
“It was a profound experience as health professionals reported the comfortability of going from being visible to invisible despite being the most physically visible person. There are ethics around putting on body simulation suits, we need someone experienced in the programme to lead it so that it is safe for those people with sensitivities in the classroom. People often make jokes and laugh when they feel awkward and we don’t want anyone in the room to feel stigmatised at all.”
She has researched with Lesley Gray, the weight of the words we use.
The word “Weight” is seen as non-judgemental in healthcare settings– but can be highly problematic in practical terms as it does not meaningfully describe the clinical relevance of the person’s size.
The award-winning Dr Hales explains that funding around obesity is more readily available for how to prevent obesity, manage weight and how to lose weight as opposed to the practical type of study she does.
Dr Hales is presenting study findings at the New Zealand Aged Care conference in Wellington in October.
“We are working with the aged care sector because we know our ageing population is living longer and are getting heavier.
“Together with Dr Helen Rook, Lecturer, Victoria University of Wellington, she is exploring how the sector is preparing for a larger population. Looking at infrastructure and if it’s suitable for people of a larger size. A part of that is looking at current funding models. In August a report will come out from the government on how to fund the Aged care sector which will inform our recommendations for bariatric care of older adults. Also we will be looking at how staff are prepared to work with bariatric patients. It will be a very important piece of work for New Zealanders and from there we want to look at other primary care areas such as palliative care.
“We know that in our older population when we look at the peak age of 65 more people are obese than other categories. Nationally, 24 per cent of 75-year-olds and over are classed as obese, one per cent of those aged 75 are morbidly obese which means they have a BMI of 40 or more.
A lot more knowledge is needed to provide high quality equitable healthcare for bariatric patients, she says.
“Of course while a patient might start their journey in a hospital how will they be provided for when they are discharged? How can they be supported if they are going elsewhere other than home – and how to help them if they are going home? And we’d like to increase the workforce’s knowledge around the larger body, and the challenges of mobility and skin care for example.”