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Abstract

Introduction

Given the increased prevalence of obesity and the existence of negative attitudes among health care providers toward patients with obesity (PWO), strategies are needed to assist nursing students in identifying and examining attitudes and beliefs related to the provision of care for individuals with obesity. Nursing school curricula should incorporate effective interventions for students in order to reduce stigmas and to modify negative attitudes and behaviors that interfere with quality nursing care for PWO. This article describes the process of developing and implementing an innovative bariatric sensitivity intervention (BSI) for prelicensure nursing students.

Methods

The BSI includes six trigger films that address the multi-faceted aspects of caring for PWO and provoke reflection on obesity-related attitudes and beliefs, as well as a facilitated debrief.

Conclusion

We discuss the practical aspects of video production and the successful use of multimedia instruction to affect prelicensure nursing students’ behaviors.

Keywords

educational intervention nursing students obesity < chronic illnesses stigma

Introduction

Stigma and biases related to obesity that is prevalent in the popular media (Greenberg et al., 2003) can influence the attitudes of health care professionals (Fruh et al., 2016; Hauff et al., 2019). Negative attitudes may be expressed through behaviors such as ridiculing, teasing, insulting, stereotyping, name-calling, and using demeaning language (Phelan et al., 2015). Patients with obesity (PWO) report that negative attitudes and disrespectful treatment from healthcare providers have caused them to avoid needed medical care. (Alegria Drury & Louis, 2002; Amy et al., 2006; Fruh et al., 2016; Lillis et al., 2011). Nurses have participated in the stigmatization and negative stereotyping of PWO (Tanneberger & Ciupitu-Plath, 2018) and nursing students who care for PWO have reported being repulsed by them and feeling discomfort while providing to them (Barra & Singh Hernandez, 2018; Puhl & Brownell, 2003). Given that more than 41% of Americans are obese (Centers for Disease Control, 2020), nursing students will likely provide care for PWO during their clinical rotations and their professional careers.

Educational strategies that expose students to the causes of obesity and to the difficulties in controlling body weight faced by PWO early in the nursing curriculum may decrease discrimination and prejudice (Frederick et al., 2015). While nursing schools typically provide didactic lectures about obesity, content related to sensitivity or empathy toward PWO is often excluded (Sabol et al., 2012). By incorporating obesity content into nursing curricula along with effective educational strategies that help students to explore potential biases and prejudices, nursing faculty can interrupt the cycle of insensitive treatment toward PWO (Darling & Atav, 2019; Frederick et al., 2015). Awareness regarding the challenges of obesity is a first step toward changing negative behaviors and attitudes affecting the treatment of PWO (Falker & Sledge, 2011).

To ensure that teaching methods are effective, educators should consider the preferred teaching and learning strategies of students when planning lessons. Most nursing students today are Generation Y (Gen-Y) born 1980–1994, or Generation X (Gen-X) born 1995–2010. These groups of students often prefer interactive experiential learning, group work, multimedia instruction, or practical applications as opposed to classroom lectures (Rosen, 2011; Smith-Trudeau, 2016). Twenty-first century students are (a) comfortable with technology, (b) familiar with accessing information instantly, and (c) adaptable to fast-paced changes (Smith-Trudeau, 2016). In a previous study, we tested the effects of utilizing trigger films, a type of multimedia strategy to explore and expose the attitudes of prelicensure students regarding obesity (Molloy et al., 2016). In that study, trigger films aligned with students’ preferred teaching strategies, fostered learners’ reflections, and produced short-term improvements in their ethical perceptions toward patients who are obese. The purpose of this paper is to provide guidance for educators who may want to replicate the development of trigger films for presenting obesity content by describing how we developed and deployed the bariatric sensitivity intervention (BSI) trigger films.

Brief Review/Discussion of the Topic

Trigger Films as a Teaching-Learning Strategy: Trigger films are short video vignettes that illustrate a specific theme. The theme may present a social or practice issue and is intended to “trigger” a response by the viewer and initiate reflection and discussion (Molloy et al., 2016; Nichols, 1994). Trigger films have been employed as short, educational films that focus student audiences on social guidance themes that engage the affective domain. Trigger films are typically 2–4-min video vignettes of simulated ethically challenged scenarios that end abruptly before committing to a course of action or predetermined ending (Nichols, 1994). The abrupt ending “triggers” students’ reflection and discussion. The trigger films’ ethical dilemmas provide emotive content for reaction, reflection, and active discussion among students (Blasco et al., 2006; Nichols, 1994). Self-efficacy theory proposes that individuals can learn by watching others when there is a close similarity between actor and observer (i.e., when students can imagine themselves actually being in situations like the ones portrayed in the trigger films). When students see the relevance of what they are being taught in class to the real world, their level of interest improves dramatically (Blasco et al., 2006). Nichols used trigger films in nursing education as a medium to portray real-life patient care situations requiring professional nursing decisions (Nichols, 1994). In another study, medical students were challenged to draw from classroom theory and knowledge, and from their own clinical experiences and observations, in order to formulate a plan for resolving the situation presented in the trigger film (Alroy & Ber, 1982).

Our use of short trigger films to address attitudes toward obesity was an innovative approach as it engaged learners and stimulated reflection and discussion on sensitive topics in a safe environment (Molloy et al., 2016). In the past, lengthier multimedia strategies that expose students to attitudes about obesity information have been used. In 2009, the Rudd Center for Food Policy and Obesity produced a 17-min film, “Weight Bias in Healthcare,” hosted and narrated by former supermodel and activist Emme. The video features expert commentary from obesity researchers and portrays a dramatic clinical situation in which a PWO is a victim of weight bias. The benefits of this video are that it (a) is available online as open-access, (b) is effective in using multiple strategies to promote stigma reduction, and (c) presents common perceptions of PWO and examples of the negative treatment they experience from medical personnel. One potential drawback of this film is that it is too long and lacking in action, and thus, may not be an effective tool for nursing students. A trigger film, on the other hand, is short, interactive, and allows learners both to engage in realistic simulated scenarios and to obtain immediate feedback from their peers and facilitators (Fleming et al., 2009). This type of teaching strategy is effective for both Gen Y and Gen Z learners.

Development of the Trigger Films: The Bariatric Sensitivity Intervention (BSI) was developed as “an intervention for helping nursing students to self-identify their current attitudes and beliefs about caring for obese individuals” (Molloy et al., 2016). The BSI included development of six video vignettes less than four minutes long, followed by a facilitated debriefing opportunity (Figure 1). In the pre-production phase, resources available for the development of the films included the specification of selected themes relevant to the overall topic of obesity, six written scripts, 12 volunteer actors, a dedicated setting, a videographer, and a video producer. In this project, the video producer served as the project leader, and the videographer also served as video editor. Prior to beginning the project, the team discussed the timeline for project completion, including the amount of time needed for rehearsal, filming, and video editing, and how the video should be formatted for distribution (i.e., an MP 3 file, YouTube, TikTok, or other multimedia platform).

Figure 1.

Components of bariatric sensitivity intervention (BSI).

The themes of the trigger films were derived from common nursing encounters, demonstrated nonprofessional nursing behavior, and focused on obesity issues (e.g., perceptions of causality, biases, and care concerns) that potentially could affect nursing students’ attitudes toward PWO (Table 1). Each film highlighted an interaction among nursing staff members in a clinical setting and, in several instances, within earshot of patients. Content expertise on the topics was sought from four experienced nurses who were involved in the care of PWO in hospitals and outpatient clinic settings. Trigger film topics were informed by content experts (nurses experienced with working with PWOs). The project was approved by the authors’ Institutional Review Board as an exempt study. All actors gave verbal consent and were informed that the trigger films would be used for academic purposes and dissemination.

Table 1.

Themes of Six Trigger Films Created for Bariatric Sensitivity Intervention.

Film	Actors	Location	Content	Theme addressed
1	Nurse, patient	Patient's room	Nurse gives condescending and disrespectful lecture about how to lose weight to an obese patient, without having been asked to do so	• Bias: obese patients can lose weight if they are motivated and if they exercise self-control • Nurse verbalizes negative attitudes about obesity with intent of “motivating” patient
2	Nurse, unit clerk	Nursing station	Loud discussion about special equipment needed to care for a bariatric patient (bariatric gown, scale, chair)	• Insensitive conversation about patient needs can be overheard by other patients and visitors • Possible HIPAA violation
3	Two staff nurses	Break room	Nurses express surprise that bariatric patient is author of a best-selling romance novel	• Bias among healthcare providers that obese patients are lazy and unsuccessful in both work and personal life
4	Two NPs	Nursing station	NPs discuss their conflicting beliefs about whether obesity is controllable and whether obesity should be treated as a disease	• Bias among healthcare providers that obesity is caused by lack of self-control, irrespective of genetic and environmental factors
5	Nurse preceptor, two nurse orientees	Hall outside patient's room	Preceptor jokes that patient is “TFTB” (too fat to breathe); nurse orientees are visibly shocked	• Poor role modeling by healthcare provider in position of power • Public expression of derogatory stereotypes about obesity (which patient might overhear)
6	Two staff nurses	At (open) door of obese patient's room	Female nurse asks male nurse to help her raise obese patient in bed to avoid “wasting time” with the ceiling-mounted lift; he tells her to spare his back and use the lift	• Non-adherence to best practices in nursing care of obese patients • Gender stereotyping • Insensitivity (patient is likely to overhear conversation indicating that both nurses are reluctant to provide care)

Initial scripts for the actors were written by the project lead, a nurse educator who also served in the role of video producer. Although actors were scripted, some improvisation was acceptable. Actors were recruited as volunteers from the school of nursing and included three staff members from the simulation lab, six faculty/staff members, and three nursing students. Criteria for the acting role included passion about the project and a strong desire to make a positive difference in nursing students’ attitudes about obesity.

The videographer set up the lights, microphones, and discussed specifics about the shoot with the actors in each trigger film. Six high-quality trigger films were produced over a 3-period in the school of nursing simulation laboratory, which provided a realistic hospital setting for the scenarios.

The postproduction phase was important for assembling the elements of the project into coherent scenes. The project lead served as the content expert and provided feedback to the videographer during the editing process.

Based on Alroy and Ber's (Alroy & Ber, 1982) experience using trigger films for teaching doctors, patients, and medical students, we developed the following development guidelines for the BSI trigger films:

Volunteer actors played roles that corresponded to their actual professions (i.e., nurses played nurses, students played students, and nurse practitioners played nurse practitioners). Actors were not required to memorize their scripts but were asked to master the content and improvise as needed.

Trigger film scripts focused on only one theme per scene in order to prompt discussion.

Each trigger film featured only two or three actors in order to avoid overwhelming viewers.

Trigger films were viewed by six groups comprised of 10–12 students.

Implementing the Trigger Films: The project was designed as a one-group repeated-measures format which used two surveys; The Nurses’ Attitudes Toward Obesity and Obese Patients (NATOOPS) and The Beliefs About Obese Patients (BAOP) scale. These valid (Lacroix et al., 2017) and reliable measures (Allison et al., 1991; Watson et al., 2008) were administered at three intervals; immediately before the intervention, immediately after the intervention, and 30 days after the intervention to evaluate the effects of the BSI on nursing students’ attitudes toward obesity and beliefs about obese persons (Molloy et al., 2016).

The BSI was delivered in a 1 hour class period and included the following:

Step 1: Introduction and prebrief of the experience (5 min)

Step 2: Viewing of the trigger films (35 min)

Step 3: Debriefing the simulation (15 min)

Step 4: Wrap up of the experience (5 min)

Using the prebrief, group norms were established by the project lead before students were shown the films, including respect, open communication, and confidentiality (INACSL Standards Committee et al., 2021a, 2021b, 2021c). In addition, following the INACSL Standards of Best Practice: Simulation^SM (INACSL Standards Committee, 2016), student participants were informed that their level of participation in the discussion would be evaluated.

Immediately after viewing each film, the facilitator asked the students to consider two questions:

What could be done to provide a patient-centered approach in this scenario?

What do you think you will remember from this scenario?

A volunteer recorded the students’ answers, and the responses were discussed after the final film had been viewed.

The goal of the post-viewing facilitated debrief was to provide viewers an opportunity to consider personal experiences and to discuss ideas for resolving issues posed by the trigger films. Using a facilitated debrief is a critical element of the learning process (INACSL Standards Committee et al., 2021a, 2021c) and an essential component for using trigger films as a tool for educators to help nursing students explore and better understand their biases. During this project, the post-film debrief discussion allowed students to explore their emotional responses to the films and the potential impact of those responses on their care for PWO. Further topics discussed during the debrief included the importance of (a) using supportive language, (b) being aware of insensitive language, and (c) assuming the role of patient advocate. The trigger films were purposefully designed not to lead viewers toward a particular course of action, but rather to encourage conversations regarding how health-care providers might interact with PWO to achieve optimal health-related outcomes. By looking at the situation from the patient's perspective, students experienced how it would feel to be on the receiving end of insensitive remarks and behaviors.

Conclusion and Importance for Nursing

In the future, the authors and the group facilitator will design a toolkit that includes a self-guided workbook for interested educators. The workbook will include instructions on how to develop and utilize the BSI. The workbook will also include guidelines for the facilitator and a small-group-discussion log for the six trigger films. The authors plan to host the free toolkit on a website for interested educators. The trigger films are currently stored digitally, but they could be transferred to our university's online learning framework to allow access by viewers both on our campus and at other centers of learning. A follow-up vignette will be filmed that will suggest evidence-based approaches for providing sensitive and culturally competent care for PWO.

A gap exists in nursing education related to fostering empathy and appreciation for the challenges experienced by PWO. Given that more than 41% of Americans are overweight or obese (Centers for Disease Control, 2020), it is imperative for nurse educators to implement methods to address stigma reduction early in the nursing curricula (Puhl & Brownell, 2003). Achieving this goal will promote increased awareness of a sensitive issue, and foster positive nurse-patient interactions that will result in improved patient outcomes. A multimedia BSI that explores such obesity-related issues as perceptions of causality, ethical perceptions, conscious and unconscious biases, and care concerns is an effective approach. Technology-supported learning can prepare nursing students to deal with the complexities of nursing care.

Implementing trigger films along with a facilitated debrief allows nursing students to explore potentially difficult situations in a safe environment. Students are given the time to interpret what they see in the trigger films and to make their own decisions about what should happen next. Combined with a facilitated debrief, trigger films enhance the classroom experience and foster highly interactive discussions among nursing students. This innovative teaching strategy shows promise for incorporating key learning points such as the multifactorial etiologies of obesity.

Importantly, trigger films can be designed to explore an array of diverse subjects and can prepare students to address experiences to which they may be exposed with empathy and understanding. We are currently using trigger films in a workshop to confront racism and promote, diversity, equity, and inclusion. Other complex professional issues have also been explored using this medium, such as how to deal with vulnerable patient populations (Blackburn & Stathi, 2019) or how to teach professionalism. (McConville & Lane, 2006).

Creating trigger films is an effective way to educate a wide audience. Consistent information can be delivered in a student-centered, interactive manner. Establishing a film production team that is committed and passionate about training caring, empathetic, and professionally sensitive nursing students is key to the project's success. Trigger films serve as a medium for fostering awareness of negative behaviors toward PWO and may change nursing students’ attitudes and beliefs. An initial investment in resources is required, but the benefits of using trigger films as a teaching strategy are substantial. The use of trigger films prompts nursing students to engage in active discussions on a wide array of issues in a safe educational environment. Trigger films are an impactful and effective teaching tool that Nurse educators can employ to optimize student learning.

Footnotes

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.

Funding

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

ORCID iD

Margory A. Molloy

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Development of Trigger Films to Explore Nursing Students’ Attitudes Toward Patients with Obesity

Abstract

Introduction

Methods

Conclusion

Keywords

Introduction

Brief Review/Discussion of the Topic

Conclusion and Importance for Nursing

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References