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Clinical Nursing Research 2018, Vol. 27(4) 414 –432

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Article

Nurses’ Weight Bias in Caring for Obese Patients: Do Weight Controllability Beliefs Influence the Provision of Care to Obese Patients?

Anne Tanneberger, RN, BSc1 and Cristina Ciupitu-Plath, DrPH, MSc PH1

Abstract Given the pervasive stigma faced by obese individuals in family, work, and health care settings, the present study aimed to explore whether nurses’ weight controllability beliefs influence their perception of how care is provided to obese patients. To this end, 73 nurses from an acute care hospital completed the Weight Control/Blame Subscale of the Antifat Attitudes Test and reported on their perception of discrimination in, and available resources for, the provision of care to obese patients. Nurses endorsing stronger beliefs that weight lies under individual control were more likely to report discrimination of obese patients in clinical practice. Weight bias, higher care intensity, and lack of necessary resources were the main reasons reported for perceived weight discrimination. Our results support theories placing internal attribution of overweight and conflict over resources at the origin of weight stigma and call for appropriate interventions to improve nurses’ work environment and reduce their weight bias.

Keywords weight bias, obesity, weight controllability, obesity stigma, nursing

1Charité—Universitätsmedizin Berlin, Germany

Corresponding Author: Cristina Ciupitu-Plath, Institute for Health and Nursing Science, Charité—Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin 13353, Germany. Email: [email protected]

687443CNRXXX10.1177/1054773816687443Clinical Nursing ResearchTanneberger and Ciupitu-Plath research-article2017

Tanneberger and Ciupitu-Plath 415

Introduction

Many adults living in industrialized countries are obese, with prevalence rates of approximately 23% in Germany (Mensink et al., 2013), 25% in Canada (Navaneelan & Janz, 2014) and the United Kingdom (Health and Social Care Information Centre [HSCIC], 2014), and 36% in the United States (Flegal, Carroll, Kit, & Ogden, 2012). Despite such high prevalence, however, obese individuals experience pervasive stigmatization in education, work, family, and health care settings (Hilbert, 2008; Puhl & Heuer, 2009). Yet being obese and suffering from associated chronic health impairments often results in a higher utilization of health care services and an increased contact with health care personnel in a variety of health care settings (Sikorski et al., 2013; von Lengerke, Wolfenstetter, & John, 2008). Against this back- ground, weight stigmatization in the provision of health care moves beyond the scope of individual encounters to become a public health concern.

Weight stigmatization in health care settings can take multiple forms. On the one hand, clinical equipment that is too small or uncomfortable for larger body builds (chairs, scales, blood pressure cuffs) or is not stored within prac- titioners’ reach may create an unwelcoming environment for obese patients (Phelan et al., 2015). On the other hand, health care providers’ weight bias can impair communication quality, health care outcomes, and patient satis- faction in encounters with obese individuals (Phelan et al., 2015). A first review of weight stigmatization processes in health care settings found that negative stereotypes about obese individuals being lazy, overindulgent, unsuccessful, unattractive, unintelligent, lacking willpower, and having poor personal hygiene were present within most health professions (Puhl & Brownell, 2001). In general, it was shown that providers feel poorly prepared to treat obese patients and are not confident in their abilities to help them lose weight, mainly based on their expectation for obese patients to be noncompli- ant and lack motivation for lifestyle change (Puhl & Heuer, 2009). This may result in health care professionals engaging in less patient-centered, positive communication, as well as spending less time providing obese individuals with relevant health information (Phelan et al., 2015).

Among the explanatory pathways for the emergence of weight stigmatiza- tion described by Puhl and Brownell (2003), the most prominent and suitable for use when exploring weight bias in health care settings appears to be the attribution theory. This theoretical approach posits that weight stigma results from overweight and obese individuals being held responsible for their phys- ical appearance and life circumstances, which are considered to be the result of personal weakness, laziness, lack of discipline, and control (Puhl & Brownell, 2003). Consistently, stronger beliefs that weight is under personal

416 Clinical Nursing Research 27(4)

control were associated with more negative attitudes toward obese individu- als among health care professionals (Sikorski et al., 2013; Swift, Hanlon, El-Redy, Puhl, & Glazebrook, 2013).

An alternative explanation for the varying degrees of weight bias reported by health care professionals might lie in their contact intensity with obese patients, which can both promote or reduce stigmatization by either putting a higher strain on personal resources (patient time, physical strength; Sikorski et al., 2013) or by improving understanding of patients’ complex situations and care needs (Schwartz, Chambliss, Brownell, Blair, & Billington, 2003). In line with the social identity theory, personal weight status might also influ- ence health care providers’ weight bias levels, as suggested by findings that negative attitudes toward obesity decreased with increasing body mass index (BMI) among nurses (Brown, Stride, Psarou, Brewins, & Thompson, 2007) and trainees in various health care professions (Swift et al., 2013).

Nurses play a crucial role in the provision of health services to obese indi- viduals (Brown, 2006). Moreover, in clinical settings, nurses emerge as the professional group whose often complex contact with patients involves higher time and resource allocation (Sikorski et al., 2013). In spite or perhaps because of this intensive patient contact, a tendency toward describing obese individu- als in terms of negative stereotypical features such as lazy, overindulgent, gluttonous, noncompliant, weak-willed, unattractive, untidy, less successful, and less healthy than other people have long been documented and are still being reported in studies conducted with nurses (Bagley, Conklin, Isherwood, Pechiulis, & Watson, 1989; Brown, 2006; Brown et al., 2007; Culbertson & Smolen, 1999; Hoppe & Ogden, 1997; Maroney & Golub, 1992; Peternelj- Taylor, 1989; Poon & Tarrant, 2009; Ward-Smith & Peterson, 2016).

Apart from such explicitly stigmatizing views, implicit weight bias as well as a tendency to attribute obesity to personal choices, behavior, and motiva- tion were also observed among nursing professionals and students (Brown et al., 2007; Waller, Lampman, & Lupfer-Johnson, 2012). However, nurses appear to be aware of weight stigma, are concerned about providing empathic and respectful care to obese patients (Brown & Thompson, 2007; Zuzelo & Seminara, 2006), and display less weight bias compared with other profes- sional groups (Sikorski et al., 2013; Swift et al., 2013).

Several factors such as personal weight status, age, professional experi- ence, and gender were found to be associated with nurses’ attitudes toward overweight patients. Higher weight bias was generally observed among nurses with lower BMI (Brown et al., 2007; Hoppe & Ogden, 1997; Swift et al., 2013; Young & Powell, 1985) and female nurses (Garner & Nicol, 1998; Young & Powell, 1985), whereas associations with nurses’ age (Bagley et al., 1989; Culbertson & Smolen, 1999; Young & Powell, 1985) and work

Tanneberger and Ciupitu-Plath 417

experience (Culbertson & Smolen, 1999; Poon & Tarrant, 2009) are inconsis- tent. However, as illustrated above, most research on weight bias among nurses is outdated, whereas recent studies are scarce and have mainly been conducted in English-speaking countries.

Against this background, the present research set out to explore the extent to which nurses employed in a clinical, inpatient setting in Germany hold stereotypical views of obesity and whether they believe that obese patients receive different care compared with nonobese individuals. A further aim of the study was to assess whether nurses’ weight controllability beliefs affected their clinical practice.

Method

Study Design, Setting, and Participants

A cross-sectional, exploratory, quantitative study design was used. A survey using self-administered questionnaires was conducted among nurses employed in an acute care clinic in the Berlin metropolitan area providing both basic and specialized inpatient health care services.

Both male and female registered nurses aged 18 to 67 years who had com- pleted a 3-year, hospital-based vocational training and were currently employed with a workload of at least 20 hours per week in the study setting were eligible for inclusion in the study. Nursing trainees or retired nurses, or other health care staff who did not provide regular inpatient nursing care (e.g., paramedics, surgical assistants, etc.), were excluded. Study participants were selected based on a quota sampling procedure, which aimed to ensure a high degree of heterogeneity in the study sample by including nurses from all hospital wards.

A sample size calculation was performed based on the total number of nurses employed in the study setting (N = 232) and the standard deviation of weight controllability beliefs in a nationally representative study (SD = 0.68; Hilbert, Rief, & Braehler, 2008) using the Weight Control/Blame (WCB) subscale of the Antifat Attitudes Test (AFAT) (Lewis, Cash, Jacobi, & Bubb- Lewis, 1997). Accordingly, including 100 participants was deemed appropri- ate and sufficient for addressing the exploratory research aims, as this would allow for the estimation of the true WCB mean in the study population within an error margin of approximately 0.1 units (score range: 1-5).

Procedures

After obtaining the approval of the nursing management of the clinic and informing the nurse department heads about the study topic, aims, and

418 Clinical Nursing Research 27(4)

procedures, data were collected over a time frame of 3 weeks in July 2015. Potential participants from all hospital wards were approached at their work- place and informed about the study by their ward managers, who had been previously briefed on the study aims and procedures by the first author. Only one attempt was made to recruit potential participants from each ward. Questionnaires were then distributed according to the percentage of nurses employed on each ward as compared with the nursing staff structure of the clinic as a whole. A written information sheet was attached to each question- naire, to allow eligible nurses to make an informed decision regarding their participation. However, participants were not required to fill in a written informed consent form to warrant their anonymity and promote their willing- ness to participate in the study. Along the same line of thought, participants were asked to drop the questionnaire in a sealed box after completing the survey. With the submission of the questionnaire, consent to take part in the study was implicitly assumed.

The first part of the study questionnaire consisted of selected items of the AFAT developed by Lewis et al. (1997), including the complete WCB sub- scale, for which a German version had been previously validated by Hilbert and colleagues (2008). The WCB scale aims to assess personal beliefs that obesity lies under personal control and consists of nine items (e.g., “If fat people really wanted to lose weight, they could,” “The idea that genetics causes people to be fat is just an excuse,” “Fat people have no will power,” or “Most fat people buy too much junk food.”) which can be rated on a 5-point Likert-type scale ranging from strong disagreement to strong agreement. After recoding the only positively phrased item, a summary mean score was computed, with higher scores indicating a stronger belief in individuals being personally responsible for their weight status. Similar to previous research (Hilbert et al., 2008), the WCB displayed adequate internal consistency in the study sample (α = .737).

Subsequently, participating nurses were asked to report on the frequency with which they provide care to obese individuals, the availability and quality of resources required for providing adequate care to this patient group, and their perception as to whether fellow nurses or they themselves have ever treated obese patients differently compared with normal-weight patients. All questions could be rated on 5-point Likert-type scales ranging from daily to never for contact frequency and from very good to very poor for available resource quality. Moreover, participants could also rate the resources listed (e.g., staffing, training opportunities, and mobilization aids) as not available.

Questions regarding the perceived discrimination of obese patients in nursing care could be rated on the same 5-point Likert-type scale used for the AFAT items, ranging from strong disagreement to strong agreement. Participants were further given the opportunity to argue for their choice

Tanneberger and Ciupitu-Plath 419

by answering an open question inquiring into the specific reasons why they believed obese patients to be treated differently compared with other patients.

The anonymous data collection procedure was conducted according to the World Medical Association Declaration of Helsinki and was approved by the competent data protection authority.

Data Analysis

A descriptive analysis was initially performed for all items, consisting of fre- quency analyses for discrete variables and descriptive statistics (mean, stan- dard deviation) for continuous variables. Moreover, participants’ agreement to both personally and their colleagues displaying discriminatory behavior against obese patients was recoded for inferential analyses into two addi- tional discrete variables with three (disagreement, indecisive, agreement) and two (agreement: yes/no) categories, respectively. A dichotomous variable was also recorded to indicate a negative evaluation of each category of spe- cific resources required for providing adequate care to obese patients (e.g., staffing ratio, mobilization aids, etc.). Chi-square tests were then performed to establish whether perceived discrimination of obese patients in nursing care was associated with a negative rating of available resources, both vari- ables being assessed at a dichotomous level.

Subsequently, an analysis of variance with an associated Tukey’s post hoc test was used to assess the association between nurses’ weight controllability beliefs and their degree of agreement to them or fellow nurses applying a dif- ferent treatment to obese patients.

The third analysis step consisted of the logistic regression of participants’ agreement to personally or their colleagues having ever discriminated against obese patients in their nursing practice (0: no, 1: yes) on their level of weight controllability beliefs, controlling for respondents’ age, gender, weight status, and contact frequency with obese patients. Free-text answers to the final, open question on nurses’ reasons for applying a different treatment to obese patients were initially postcoded independently by both authors and subjected to a frequency analysis after consensus had been reached.

Results

Sample Characteristics

A total of 73 out of 100 distributed questionnaires were returned, resulting in a response rate of 73%. Participants represented 31.5% of the 232 eligible

420 Clinical Nursing Research 27(4)

nurses employed in the study setting. Based on a post hoc power calculation, this sample size still allowed for the estimation of the true WCB mean in the study population within an error margin of approximately 0.13 units (score range: 1-5).

Participating nurses who reported sociodemographic information (n = 60) had a mean age (SD) of 39 (10.7) years, and the majority were female (78.3%). Based on self-reported weight and height data, most nurses included in the study had a normal-weight status, whereas none was underweight (BMI < 18.5) and 41.1% were overweight (BMI ≥ 25), out of which a small minority (12.5%) was classified as obese (BMI ≥ 30) according to international BMI reference values. Participants from all wards in the study setting could be recruited for the survey. However, respondents practicing in the surgical, intensive care unit (ICU) and car- diology wards made up 72.6% of all study participants, while relatively fewer participating nurses worked on the internal medicine, pediatrics, and gynecology wards. All study participants had been exposed to caring for obese patients, while the great majority (86.8%) reported having daily contact with obese patients.

Regarding their weight controllability beliefs, participating nurses reported an average score (SD) of 3.15 (0.55) on the WCB subscale of the AFAT questionnaire. A nonsignificant Shapiro–Wilk test (p = .865) indi- cated a normal distribution of WCB scores in the study sample. When asked whether they believed fellow nurses treated obese patients differ- ently compared with other patients, most participants (50.7%) provided a positive answer, 18.3% disagreed and 31% were indecisive. In turn, 52.1% of participating nurses disagreed and only 28.2% agreed to the possibility of having personally applied a different treatment to obese compared with other patients. A detailed overview of sample characteris- tics is presented in Table 1.

Resources in Providing Care to Obese Patients

As part of the survey, participating nurses were asked to report on the avail- ability and quality of personal and material resources necessary for providing care to obese patients (see Table 2). In this respect, 27.1% and 18.1% of study participants reported not having access to special walking frames and lifters, respectively. However, when available, the quality of such patient mobiliza- tion aids was rated as good to average (45.7% and 65.2%, respectively), as was also the case for special beds for obese patients (91.5%) and transfer/ mobilization chairs (64.8%). Specific training opportunities were considered average to good by most study participants (73.6%), whereas the staffing

Tanneberger and Ciupitu-Plath 421

Table 2. Availability and Quality of Resources Facilitating Nursing Care Provision to Obese Patients.

Not available (%) Poor (%) Average (%) Good (%)

Appropriate staffing ratio patients/nurse/shift (n = 71)

1.4 38.0 40.0 21.1

Training opportunities (e.g., kinaesthetics) (n = 72)

2.8 23.6 38.9 34.7

Accommodation and space resources (n = 71)

1.4 53.5 29.6 15.5

Lifter (n = 72) 18.1 16.7 20.8 44.4 Special beds for overweight

patients (n = 71) 2.8 5.6 18.3 73.2

Special walking frames (n = 70) 27.1 27.1 14.3 31.4 Transfer and mobilization

chair (n = 71) 8.5 26.8 28.2 36.6

Table 1. Characteristics of Nurses Included in the Study Sample.

Gender (n = 60) % male 21.7 % female 78.3 Department (n = 73) % surgery 31.5 % ICU 24.7 % cardiology 16.4 % internal medicine 11.0 % pediatrics 9.6 % gynecology 6.8 Age in years (n = 60) M ± SD 39.0 ± 10.7 Weight status (n = 56) % normal weight 58.9 % overweight 28.6 % obese 12.5 Frequency of contact with obese patients (n = 68) % daily 86.8 % weekly 10.3 % less often 2.9 Weight Control/Blamea (n = 70) M ± SD 3.2 ± 0.6

Note. ICU = intensive care unit; AFAT = Antifat Attitudes Test. aWeight Control/Blame subscale pertaining to the AFAT developed by Lewis, Cash, Jacobi, and Bubb-Lewis (1997).

422 Clinical Nursing Research 27(4)

ratio was deemed average to poor by 78% of respondents. With regard to their quality/appropriateness for the provision of care to obese individuals, the available accommodation and space resources received a poor rating from over half of participating nurses (53.5%).

Chi-square tests did not indicate any significant association between per- ceived discrimination of obese patients (either by study participants or their colleagues) and a negative rating for any of the available resource categories (p values > .05). Only the association between nurses’ perceived personal discrimination of obese patients and a poor rating of the staffing ratio approached statistical significance (p = .074).

Association Between Weight Controllability Beliefs and Perceived Discrimination of Obese Patients

Analyses of variance revealed significant associations between nurses’ weight controllability beliefs and their perception of obese patients being treated differently compared to other patients both by other nurses, F(2, 65) = 4.43, p = .016, and by themselves, F(2, 65) = 3.71, p = .030. In both cases, Tukey’s post hoc test indicated statistically significant differences only between mean weight controllability beliefs among nurses who agreed and those who disagreed with the possibility of different treatment being applied to obese patients (see Table 3).

Logistic regression results point to weight controllability beliefs as the only significant predictor of nurses’ perceived personal discrimination of obese patients (see Table 4). Accordingly, each increase of one unit in nurses’ weight controllability beliefs (score range: 1-5) was associated with an increase of 5.45 in their probability of agreeing to ever having applied dis- criminatory behavior to obese patients. In contrast, none of the respondents’ personal characteristics significantly predicted their perception that obese patients are treated differently by fellow nurses in a logistic regression model including participants’ weight controllability beliefs, age, gender, weight sta- tus, and frequency of contact with obese patients.

In their free-text answers to the open question regarding perceived reasons for the discrimination of obese patients in nursing care, 37 out of 73 (50.7%) participating nurses provided a total of 48 justifications for perceived dis- criminatory behavior toward obese patients, which could be collapsed into five main categories: personal limitations (12.5%), insufficient access to external resources (20.8%), weight bias (25%), higher nursing care intensity (18.8%), and no discrimination (22.9%).

Personal limitations referred to nurses’ physical make-up, abilities, and strength, which prevent them from providing obese patients with standard care.

423

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Tanneberger and Ciupitu-Plath 425

Due to working almost daily with obese patients, at some point one can hardly still care for these patients with full body strength. (Female, 25, ICU)

Moreover, insufficient access to external resources such as technical aids, an adequate staffing ratio or appropriate accommodation facilities also contrib- uted in nurses’ view to the provision of poorer care to obese patients.

I would say that it depends on the aids and the staffing ratio. If one is alone, positioning [the patient] is more difficult, as is the case when there are not enough or no aids at all. (Male, 56, cardiology)

Inadequate or lacking external resources was often mentioned in associa- tion with a higher nursing care intensity required by obese patients.

It annoys me when, due to space conditions (e.g., in the narrow washing corner or between two patient beds, if, for example, a monitor or a walking aid are also standing in between), I have to provide, for instance, help with personal hygiene under difficult conditions and the patient’s obesity requires more space and makes him “heavier.” In doing so I am sometimes forced into abnormal body postures even as a normal-weight nurse. (Male, 56, cardiology)

Investing more time and effort in providing care to obese patients, in turn, was perceived as presenting them with a relative advantage.

Higher care intensity is perceived as unfair toward other patients. (Male, 34, ICU)

In addition, more overt weight bias and negative stereotypical associations with obese individuals such as “disgust” or “unattractive, some body odor” were also placed at the origin of negative discrimination in nursing care.

Lack of understanding about how someone can let it come so far, to reach such a high weight and so get into this situation (comorbidities, immobility due to high weight in bed). (Female, 33, pediatrics)

However, many participants invoked a no discrimination policy among nurses, as they referred to nursing ethics and advocated for an equal right to care for all patients, irrespective of their personal characteristics.

Particularly as a nurse, one should not differentiate between obese, normal- weight, old, young, etc. people. They are patients, who want/have to be cared for. (Female, 20, cardiology)

426 Clinical Nursing Research 27(4)

A patient is a patient, whether fat, thin, brown . . . : everyone has the right to equal care. (Male, 25, ICU)

Discussion

The present study draws upon and expands the findings of previous research on weight bias among nursing staff in clinical settings. Similar to other health care professional groups (e.g., physicians, physiotherapists, etc.), nurses practicing in the study setting endorsed negative stereotypes about obese individuals, as previously illustrated by Sikorski and colleagues (2013) in another German sample. Accordingly, several participants reported applying a differential treatment to obese patients out of disapproval or disapproba- tion, while others described obese individuals as physically unattractive or as having an unpleasant body odor. Another argument invoked by participants as a justification for the potential negative bias against obese patients in the provision of nursing care was lack of understanding for these patients, who were held personally responsible for their weight and health status.

On average, study participants reported higher weight controllability beliefs than in the general population, as indicated by a mean WCB value of 3.15 as compared with 3.01 in the study of Hilbert and colleagues (2008). Despite this minimal mean value difference, the fact that nurses endorse higher weight controllability beliefs than respondents in the general popula- tion is alarming, considering that by virtue of their professional training, nurses should be better informed about the complex determination of obesity and about the limited success rates of lifestyle change interventions for weight reduction, which have been well documented in the literature (Laddu, Dow, Hingle, Thomson, & Going, 2011; Reinehr, 2013).

On one hand, the relatively high weight controllability beliefs reported by study participants might be due to low awareness of the negative impact of obesity stigma in Germany, not only in the general public but also at the managerial level of health organizations and ultimately among individual nurses. On the other hand, this finding could be explained by the fact that German nurses only receive a vocational training of 3 years, which may not sufficiently focus on theoretical aspects (e.g., stigma theories, diversity management) and the development of the scientific sensitivity required for adequately reviewing and integrating current research findings into their daily practice. In this respect, current efforts to improve access to an aca- demic education by establishing bachelor’s and master’s degree programs for traditionally vocational health care occupations in Germany (e.g., nurs- ing, midwifery, physiotherapy etc.; Wissenschaftsrat, 2012) could arguably contribute to increasing evidence-based, reflective practice in nursing care

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in the long term. Nevertheless, it appears necessary that currently practic- ing nurses in and beyond the study setting receive more information and reflect on the etiology of and risk factors for obesity, as interventions addressing such topics have already shown promising results in reducing antifat attitudes among health professionals (McVey et al., 2013). Also, more research should be conducted on nurses’ knowledge of obesity causes in larger, representative samples.

A more plausible explanation for nurses’ weight bias, however, might lie in the fact that the large majority of study participants had daily contact with obese patients, yet reported having limited access to quality resources required for providing adequate care to this patient group. Although direct associations between negative quality ratings of available resources and per- ceived discrimination of obese individuals in nursing care failed to reach statistical significance in the present study (possibly due to insufficient statis- tical power), both descriptive data and participants’ justifications for different treatment being applied to obese patients provide support for this explanatory pathway. For instance, 18% and 27% of the study sample reported that lifters and special walking frames were not available for use in the study setting, respectively. This puts additional strain on nurses’ physical resources, leading them to consider obese patients as requiring more intensive care and to seeing themselves unable to care for this patient group in the same way as they would care for normal-weight individuals. Consequently, nurses face an inner conflict between their task of providing their patients with the best pos- sible care and preserving their own health (e.g., avoiding musculoskeletal damage). Moreover, labeling obese patients as being more difficult to care for can also create a moral conflict, as nurses might see themselves torn between providing equal care to all patients and having to spend more time and effort in the provision of care to obese individuals. In this context, a particularly challenging issue reported by participating nurses was the poor staffing ratio. This finding is supported by previous studies reporting that, consistent with the significant nursing staff reductions in German hospitals over the past two decades (Isfort, Klostermann, Gehlen, & Siegling, 2014), a registered nurse in Germany has to care for the highest number of patients (13 patients per registered nurse) when compared with nurses in 11 other European countries and the United States (Aiken et al., 2012).

Despite a certain degree of observed weight bias, however, some partici- pants (22.9%) advocated for the equal right of patients to receive quality health care irrespective of their personal characteristics. This is in line with previous research findings (Brown & Thompson, 2007; Zuzelo & Seminara, 2006) suggesting that nurses are aware of the general negative societal bias against obese individuals and strive to treat all patients equally.

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Nevertheless, nurses included in the study sample do believe that obese individuals receive different treatment in nursing care compared with other patients. Presumably as a means of eliminating cognitive dissonance, study participants were more readily inclined to report fellow nurses applying dif- ferent treatment to obese patients. Moreover, based on participants’ elabora- tions on their answers, obese patients were most often believed to receive poorer care than their normal-weight or underweight peers. However, as nurses could only provide reasons for enacted weight bias in nursing care in general, their justifications for the different treatment being applied to obese patients were often unspecific, so that it remains unclear whether they were justifying their own behavior or that of fellow nurses. Therefore, although the free-text comments provided valuable insight into nurses’ attitudes toward obese patients, complementing and enriching the information obtained from standardized questions, further qualitative research is needed to gain deeper insight into nurses’ perceived reasons for and subjective rationalizations of their bias toward obese patients.

When looking into factors influencing the probability that nurses would report having ever treated obese patients differently compared with other patients, weight controllability beliefs were the single statistically significant predictor. Although only a minority of study participants (28.2%) believed that they have personally discriminated against obese patients in their clinical practice, the probability of doing so was significantly higher for nurses who endorsed the belief that weight is under personal control and accordingly placed the blame for patients’ overweight with the patients themselves. Similar to previous research (Sikorski et al., 2013; Swift et al., 2013), this finding provides further empirical support for theoretical approaches placing internal attribution of overweight (i.e., beliefs that weight is controllable and is associated with personal behavior, willpower and self-discipline) at the origin of weight stigma. Moreover, given the sensitive nature of the study topic, the risk of reporting bias cannot be excluded, in the sense that nurses may have responded to questions regarding their behavior toward obese patients in a socially desirable manner, as an image management strategy. Accordingly, the association between internal attribution of obesity and nurses’ bias in the provision of care to obese patients could be stronger than that observed in the present study.

However, the regression analysis results might be biased by the fact that some participants did not report any sociodemographic information, presum- ably as a means of excluding the possibility of their answers being traced back to them, despite the anonymous data collection procedure. This might have been particularly the case for male nurses, who, despite being overrep- resented compared with the national percentage of male nurses in inpatient

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care (21.7% vs. 15.5% based on federal public health monitoring data, Gesundheitsberichterstattung des Bundes, 2015), were underrepresented compared with female nurses in the study sample. Consequently, it is unclear whether factors such as age or gender would have reached statistical signifi- cance as predictors of perceived discrimination against obese patients, had the sample size used for the regression analysis been larger. Moreover, as sociodemographic information was only available for participating nurses, differences between respondents and nonrespondents could not be assessed.

The nonprobabilistic nature of the study sample and the use of information from a single clinical health care setting further limit the generalizability of our findings. Accordingly, replicating the present research in other settings is warranted to investigate the observed association between weight controlla- bility beliefs and enacted weight stigma in nursing care using larger, repre- sentative nurse samples and preferably direct observation of health care encounters and/or experimental study designs.

Overall the strength of the present study lies in its theoretical foundation and the use of both quantitative and qualitative data. In contrast, its main limitations consist of using a cross-sectional design and a small, nonprobabi- listic sample drawn from a single acute care setting, as well as the limited scope of the qualitative information used to address the research aims. Beyond its limitations, however, the present study adds to the currently lim- ited body of knowledge regarding nurses’ latent and enacted weight bias in the provision of care to obese patients. Given the high prevalence of obesity among adults in industrialized countries, our results point to the need for developing appropriate educational interventions for nursing staff with regard to the various forms of weight bias and specific means of avoiding or reduc- ing discrimination against obese patients in clinical practice. Moreover, by improving the availability and quality of necessary resources for caring for obese patients, health care institutions should strive to reduce barriers pre- venting obese patients from accessing nonbiased, inclusive health care ser- vices and nurses from providing quality care to patients of all sizes without fearing negative consequences for their own health.

Acknowledgments

The authors are deeply indebted to all nurses who participated in the study. The authors express their gratitude to Prof. Dr. Michael Ewers, Andrea Ernert, and Christiane Schaepe, MPH, for critically reviewing the study results.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

430 Clinical Nursing Research 27(4)

Funding

The author(s) received no financial support for the research, authorship, and/or publi- cation of this article.

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Author Biographies

Anne Tanneberger, RN, BSc, is an alumna of the Institute of Health and Nursing Science, Charité—Universitätsmedizin Berlin.

Cristina Ciupitu-Plath, DrPH, MSc PH, is a research associate at the Institute of Health and Nursing Science, Charité—Universitätsmedizin Berlin.