What Evidence Informs the Nursing Care of People with Class III Obesity in an Acute Care Setting? A Scoping Review.

What Evidence Informs the Nursing Care of People with Class III Obesity in an Acute Care Setting? 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A Scoping Review. Beverley Ewens, Vivien Kemp, Amanda Towel-Barnard, Lisa Whitehead This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-31488/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Obesity is a complex psycho-social construct which is strongly linked with health and well-being. The health and socioeconomic impacts of obesity on individuals and health care systems can be significant. The nursing care of people with Class III obesity needs careful attention to ensure the provision of appropriate care. This scoping review aims to synthesise available evidence on the nursing care of Class III obese patients in acute care settings. Methods : A scoping review informed by the Joanna Briggs Institute approach was undertaken. We searched CINAHL Plus, Medline, Scopus, Proquest Central, Web of Science and Embase databases for primary research articles relating to the nursing management of people classified as Class III obese in acute care settings. The methodological quality of all studies that met the inclusion criteria were assessed and data relating to methods and the findings extracted and synthesised into themes. Results : 3809 records were identified. Thirteen studies met the inclusion criteria and were included in the review. Three themes were generated from the synthesis of the findings: Access, knowledge and training related to equipment; Patient care; and Opportunities to improve care. Conclusions : The need for proactive planning to improve the nursing care provided to people classified as class III obese and admitted to acute care settings is vital. Access to appropriate equipment to support moving and handling and education on equipment use to prevent injury to both patients and staff is necessary. Education and support to promote engagement with patients, adapt nursing care practices and promote self-care have the potential to improve patient care and patient outcomes. Nursing Class III obesity nursing care acute care settings bariatric scoping review Figures Figure 1 Introduction Obesity is a complex psychosocial construct and strongly linked with health and wellbeing. The incidence of obesity is increasing worldwide, with over 650 million adults classified as obese and 1.9 billion as overweight (1). Obesity is not confined to developed countries but is an emerging health concern in many developing countries including Bangladesh (2), India (3) and Saudi Arabia (4). Hospital admissions related to obesity as either a primary or secondary diagnosis are increasing (5). The classification of obesity, however, varies within the literature and is further complicated by the use of the term ‘bariatric’ (6). Discrepancies in definitions and perceptions of obesity have been noted, particularly in children (1, 7). Body Mass Index (BMI) remains the most frequently used measure of classification. A BMI of >30 kg/m² signifies obesity and the World Health Organization (WHO) (1) have further categorised obesity into three sub classes with Class III (BMI ≥ 40.00kg/m², very severe) categorised as the highest level of obesity. The health and socioeconomic impacts of obesity on individuals and health care systems can be significant. In young and middle aged adults, obesity is associated with lower educational attainment (8), development of comorbidities (9, 10) and overall reduction in life expectancy (11, 12) Obesity of any classification can increase complexity of care including mobilisation, skin care and perioperative management (13-15) This review will synthesise the evidence on the nursing care of people classified as Class III obese in the acute, non-critical care settings to explore best practice and issues and challenges highlighted in the literature Review question What evidence guides the nursing care of people classified as Class III obese in acute care settings? Review objectives To synthesise evidence on the nursing care of Class III obese patients in acute care settings. Methods Inclusion criteria This review considered primary research studies published in English, involving participants aged 18 years and over and classified as Class III obese. Studies were included if they reported on the nursing care of people classified as Class III obese within acute care settings, using either qualitative or quantitative methods. Exclusion criteria Studies were excluded if they explored the nursing care of Class III obese patients in critical care areas, perioperative care, perinatal care, and in the community. Further exclusions included a focus on patient outcomes without reference to nursing care, and studies reporting prevalence. Search strategy A logic grid was constructed to guide the search strategy (See Additional file, Table A) A three-step search strategy was employed commencing with an initial search of Cumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, Proquest Central, Web of Science and Excerpta Medica Database (Embase) to identify key words and index terms, followed by a second search across all databases using the identified terms. Thirdly, the reference lists of all 36 identified reports and articles were searched for additional studies. The timeframe from 1980 to 26/07/2018 was chosen, because of the proliferation of interest and associated publications within the context of patients with obesity during this timeframe. The search included the following electronic databases: Cumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, Proquest Central, Excerpta Medica dataBASE (Embase), and Web of Science. The keywords used were: Nursing care, patient care, best practice care, hospital care combined with the terms morbidly obese, and morbid obesity. Boolean exact phrase searching was used in conjunction with mesh terms for obesity, morbid including truncation terms morbid* and obes*, with AND/OR (See Additional file Table A for first search in CINAHL). Results Search results A total of 3809 records were identified (Figure 1), of these, 3773 articles were excluded at title (n = 3627) or abstract (110) level where the paper focused on treatment trials and outcomes regarding medical management, peri-operative care, perinatal care, intensive care or emergency care. Thirty-six full text articles were reviewed, and a further 23 articles excluded (Additional file Table B). Thirteen articles were included in the review. These were four case reports, the remaining primary studies included four retrospective registry records studies, two qualitative studies, one naturalistic observational study, one mixed methods study, and one descriptive survey. Insert Figure 1 here Quality appraisal Two independent reviewers assessed the remaining 13 articles that met the inclusion criteria for methodological validity, using the relevant JBI critical appraisal checklist (See Additional file Table C for Quality appraisal Table and JBI Check lists). All authors contributed to paper assessment and critical appraisal and any disagreements were resolved though group discussion. Seven articles were appraised using the JBI Critical Appraisal Checklist for Descriptive/Case Series studies, four articles using the Checklist for Case Reports, and two articles using the Checklist for Interpretive & Critical Research. Articles were included if they scored Yes to 4 or more questions Data extraction A data charting form was developed, and all authors completed data extraction; any disagreement was resolved by discussion to reach consensus. Due to the heterogeneity of the studies, a meta–analysis could not be completed therefore a synthesis was conducted. The extracted data included details about the purpose and setting of the study, the study population and main findings. No missing or unclear information was found (Table 1). Table 1 Characteristics of studies included in the review. Author & date Study Method Setting Purpose Population Demographics Retrospective Registry Records United Kingdom, Hospital To ascertain the number of reported patient safety events involving people with obesity Database search of National Reporting and Learning System 555 records of 'patient safety' incidents involving people living with obesity were identified Broome et al, 2015 Case study Hospital, USA To describe the care of a 'super' bariatric patient A person with class III obesity N=1 Gender: M; Age 56 years old; BMI :73 Drake et al, 2005 Qualitative; focus groups, thematic analysis USA, Hospital To investigate nurses' perceptions of the challenges they face in caring for patients with morbid obesity Nurses whose work includes caring for people with morbid obesity N=17 Gender: M 3, F 14; Mean age 38.32 years old and mean nursing experience 13 years. 5 participants held a baccalaureate degree, 9 held an associate degree, 2 held a diploma of Nursing. Drake et al, 2008 Descriptive, survey USA, Hospital To determine what nurses perceive as challenges in caring for people with morbid obesity Members of the National Association of Bariatric Nurses N=109 Gender: M 9 (8.3%), F 100 (91.7%); Mean age 44.6 years (range 24-63); Race: White 93 (85.3%), Black 13 (11.9%), Other 3 (1.8%) Ecklund & Kurlak, 2004 Case study USA, Hospital Use a case report to highlight issues involved in caring for a person who is morbidly obese. A person with class III obesity N=1 Gender: M; Age 39 years old; BMI :91 Gardner and Gibbs, 2013 Descriptive, Retrospective; Records USA, Hospital To ascertain the number of reported patient safety events involving people with class III obesity Database search of the Pennsylvania Patient Safety Authority's Patient Safety Reporting System from 2007-2011 Part 1: 1,774 records of 'patient safety' incidents involving people living with Class III obesity of these there were 180 equipment use event reports (10% of total reports) Part 2: State-wide survey administered to all hospitals in Pennsylvania of hospital readiness to accommodate Class III obese patients. Response rate 35.3%; N= 85 of 241. Gardner and Pagano 2013a Descriptive, Retrospective; Records USA, Hospital To ascertain the reported number of serious skin integrity events involving people with class III obesity Database search of the Pennsylvania Patient Safety Authority's Patient Safety Reporting System from 2007-2011 Part 1: 1,774 Event reports of people living with Class III obesity, and 33.1% (n=588) were skin integrity reports. Part 2: 2012 Hospital state-wide survey that included questions about class III obese patient skin care protocols (35.3% response rate, n = 59) Gardner and Pagano, 2013b Descriptive, Retrospective; Records USA, Hospital To ascertain the reported number of falls event reports involving people with class III obesity Database search of the Pennsylvania Patient Safety Authority's Patient Safety Reporting System from 2007-2011 Part 1: 1,774 event reports involving people living with class III obesity, and 20% of these (357 of 1,774 were falls event reports) Part 2: 2012 Hospital state-wide survey that included questions about hospital preparedness to care for Class III obese patients. Response rate was 35.3% ( n= 85 of 241 ) Hignett & Griffiths, 2007 Descriptive. Mixed methods (focus groups and questionnaire) United Kingdom, Special Interest Groups To identify and explore manual handling risks and process planning pathways for patients with morbid obesity Members of the National Back Exchange (NBE) Special Interests Group on Bariatrics and The National Ambulance Risk and Safety Forum (NARSF). 25 participants (5 from the Ambulance Service and 20 were from the NBE) attended four focus groups; data from the focus groups was used to develop a questionnaire that was sent to all members of the NBE (n= 1289) Surveys were sent to members of the NBE (n =1289) and the NARSF (n=71). There were 224 responses from the NBE Holland et al, 2001 Case study USA, Hospital To use a case report to illustrate care and discharge planning for a patient with morbid obesity A person living with class III obesity N=1 Gender M; Age 49 BMI 72.6 kg/m 2 Palmer, 2009 Case study United Kingdom, Hospital To illustrate that even when specialist equipment is available, it may not be suitable A person living with class III obesity N=1Gender F; Age not reported, BMI not reported Rose et al, 2007 Cross-sectional, naturalistic observation USA, Hospital To compare resource requirements in caring for non-obese and morbidly obese patients Nursing staff observed carrying out identified nursing tasks on obese and non-obese patients Group 1 : N=30 non-obese patients Group 2 N=30 morbidly obese patients Rose et al, 2010 Descriptive, Qualitative, semi-structured interview USA, Professional Association members To examine nurses' perception of safety concerns when caring for patients with morbid obesity Nurses who are members of the National Association of Bariatric Nurses (NABN) N= 23, 4 eliminated because had no contact with patients. Interviewed 19 nurses describing adverse events they had experienced. Events were categorised as Adverse events, Near misses and out-of-control situations Data synthesis The findings were narratively synthesized by analyzing the articles, identifying common concepts and themes that were then iteratively grouped firstly into subordinate and finally into four superordinate themes. It was found that there were variations in the definition of Class III obesity across the 13 studies, from no definition at all, definitions based on the Body Mass index (BMI) to whether weight exceeded equipment size (Table 2). Table 2 Definitions of Class III obesity. Definition Author No definition Booth et al, 2011 Drake et al, 2005 Drake et al, 2008 Rose et al, 2007 Class III obese patients have a BMI greater than or equal to 40 or 100 pounds more than their ideal body weight Gardner and Gibbs, 2013 Gardner and Pagano, 2013a, 2013b Morbid obesity greater than 100 pounds above desirable weight. Severe obesity BMI greater than or equal to 50km/m 2 Ecklund & Kurlak, 2004 Morbid obesity is a body mass index greater than 40 kilograms per square meter Holland et al, 2001 Palmer, 2004 Morbidly obese (BMI > 40), super obese (BMI > 50) and super, super obese (BMI >60) Broome et al, 2015 Morbidly obese patient ( BMI > 35) Rose et al, 2010 Some definitions were by pre-determined weight, some by predetermined size, others when weight exceeded predetermined value and/or exceeded equipment size Hignett et al, 2007 Three major themes emerged from the synthesis (Table 3): these were Access, knowledge and training related to equipment; Patient care; and Opportunities to improve care. Table 2 Themes generated from the findings. Themes Authors Superordinate Themes Subordinate themes Booth et al, 2011 Broome et al, 2015 Drake et al, 2005 Drake et al, 2008 Ecklund & Kurlak, 2004 Gardner & Gibbs 2013 Gardner & Pagano, 2013a Gardner & Pagano,2013b Hignett et al, 2007 Holland et al , 2001 Palmer, 2004 Rose et al, 2007 Rose et al , 2010 Frequency Access, knowledge and training related to equipment Appropriate equipment available X X X X X X X X X X X 11 Appropriate equipment unavailable X X X X X X X X X X X 11 Equipment failure/malfunction X X X X X 5 Staff knowledge about how to use equipment X X X 3 Weight capacity of equipment identified and known X X X X 4 Patient Care Circulation issues X 1 Elimination (and personal hygiene)needs X X X 3 Gait and mobility issues X X X X X X X X X X 10 Maintaining patient comfort and dignity X X X X X X X X 8 Maintaining patient safety X X X X X X X X X X 10 X X 2 Pain and symptom management X X 2 Patient care plan (daily routine) X X X X X 5 Patient education about their own self-care X X 2 Patient’s psychosocial care and needs X X X X 4 Respiration issues X X X X 4 Skin integrity issues identified X X X X 4 Opportunities to improve care Communication between staff members X X X X 4 Nurses’ concerns/attitudes/safety X X X X X X 6 Patient’s acuity and independence levels determined how challenging nursing patients with class III obesity was X X 2 Protocols available on the care of people living with class III obesity X X X X X X X X X X 10 Hospital policies and procedures for the care of patients with class III obesity either not in place or not followed X X X X X 5 Increased resources needed to care for patients with class III obesity X X X X X X X X 7 Infrastructure/facility not retro-fitted or lack of space to accommodate necessary equipment (including lifts, floors and doors) X X X X X X X X X 9 Multidisciplinary/interdisciplinary approach to the care of patients with class III obesity X X X X X 5 Access, knowledge and training related to equipment Thirty-four findings from 12 studies contributed to this theme. Equipment was identified as a challenge to providing care for people classified as Class III obese and all findings related to either lack of access to appropriate equipment or knowledge and skills to use equipment appropriately. The specific issues raised were accessing appropriate equipment (16-21); the storage of equipment (17) staff knowledge around how to use equipment (19-21); patient distress and discomfort through the use of incorrect equipment (16, 22-24); putting people at risk of harm through the use of inappropriate equipment (16, 17, 20, 22-24); lack of equipment to measure vital signs (19) and delay in access to rental equipment (17, 19, 20). Other issues identified were equipment failure or malfunction (22, 24) and, the ability of staff to identify the weight capacity of equipment (19, 21). Higher levels of staff satisfaction were reported when adequate equipment was available to safely care for the patient (18) Patient care Forty-two findings from 12 studies contributed to the theme on patient care. Fundamental nursing care was described as becoming more challenging due to the patient’s body habitus, including changing dressings, checking for bowel sounds and heart sounds (17, 24). Management of respiratory function (including obstructive sleep apnoea, oxygen saturation levels) and skin integrity (local care to wounds, pressure reduction equipment) were also reported (21, 25, 26). Supporting people to mobilise, and maintaining patient safety were the most frequently reported issues (n=10, 77%), it was noted for example that gait instability (27) or a patient overestimating their mobility capacity (16) could pose a threat to patient safety. The need to develop a comprehensive care plan was identified as being vital to assist both staff and patients to anticipate the patient’s individual care needs (21) and to build a therapeutic alliance (16, 25). Communication was the second most common concern reported by staff in the review. Effective communication between staff and patients was described as essential in promoting a therapeutic relationship (16, 19), and between staff in order to meet patient care needs (18) and communicate needs at handover (16). The role of nurses in promoting self-care for these patients was also described (16, 25). Opportunities to improve care Forty-eight findings from 12 studies contributed to this theme. References were made to specific policies on the care of people classified as Class III obese in most studies. Several issues were identified in relation to the implementation of policies, procedures and protocols across all aspects of care. This finding related to whether there were policies and procedures in place on the one hand, and whether the policies and procedures were followed on the other (20). This included the benefit of specific discharge planning (16, 21) and evacuation planning (19), as well as the capability to weigh and measure patients on admission to hospital so that the appropriate equipment for each patient was both accessible and available (19, 25). Other issues identified included staff training and education (16, 19, 20, 22, 23) skin care protocols (16, 19, 21) and the inconsistency in the use of the term ‘bariatric’ (17, 20). Not all hospitals had established policies relating to the manual handling of people classified as Class III obese (20). These issues are a concern because Class III obese patients were found to require a greater proportion of staff numbers to care for them, require larger rooms, specialised equipment and other resources in acute care settings compared to other patients (28). In the four case studies included in this review, it was found that patient comfort, dignity and appropriate care was compromised when appropriate equipment was unavailable. However, issues were resolved when staff collaborated with other disciplines to devise an overhead ceiling lift and obtained appropriate equipment (23), proactive efforts of staff enhanced collaboration with other health care staff (25) and through the development of a daily schedule to establish a patient care routine (16). Discussion This scoping review has identified a paucity of evidence to inform the nursing care of people classified as Class III obese in acute care settings. Nurses are caring for patients across the BMI spectrum and the number of people admitted to acute care settings classified as obese is increasing. The availability of guidance to inform and support care will be vital if patient outcomes are to be optimised. The risk of sustaining a musculoskeletal injury for both patients and staff is higher when the patient is classified as class III obese (29). Issues related to timely access of appropriate equipment dominated the findings. Inadequacies in the provision, access and resourcing of specialist equipment to care for patients, as well as time taken to source the equipment has been reported as a significant issue for staff (30). Lack of adequate bariatric equipment accounted for most clinical incidents reported in one study (22). Lack of equipment was also associated with patient harm (19). Whilst there is a perception that patients who are obese have higher care needs (28, 31), perceptions such as these have not been extensively validated. The identification of patients within the National Hospital Morbidity Database and outcomes related to length of stay, morbidity and readmission rates would provide a clearer picture and identify the need for change (32). To ensure clinical staff deliver care based on best available evidence, it is essential to develop and make widely available, policies and procedures that focus on lifting protocols, lift teams, appropriate equipment and algorithms to promote safety and dignity. This review also found a lack of consistency within the literature relating to terminology and definitions used to define obesity. Inconsistency can lead to confusion, inaccuracy, and a lack of transferability when developing protocols and systems within acute care and pose clinical risk to both patients and staff. Evidence of organisational-wide innovations in the care of the Class III obese patient was limited. The creation of dedicated manual handling teams lead to a reduction in hospital-acquired pressure ulcers, staff injuries, health care costs and an increase in staff satisfaction (33). Patient and staff satisfaction were increased when a safe patient handling coordinator was appointed to oversee policy and procedures and to provide education for nursing staff (34). The role included the coordination of patient care in the healthcare system, including planning and decision making with key stakeholders in different departments. This review found that nurse-led patient case conferences (21), ongoing moving and handling assessments (23) and streamlined admission processes to anticipate equipment needs (19) were opportunities to improve practice but there is a lack of evidence in the literature that these initiatives have been evaluated or widely implemented. The concept of weight bias was not a major issue raised in this review but has been acknowledged in the general population, and a range of health care providers (35-37). This may be an area that requires further attention in future research to ensure that care is not compromised. There is limited evidence on interventions to reduce weight bias (38), but simulated educational techniques have shown promise (39, 40). Inter-professional research into methods to reduce weight bias and incorporating the patient’s voice have been called for (38). One study explored the Class III obese patient experience during an acute care admission (40). The findings reported that even though the admission was an elective (planned) admission, the equipment needed was either not available or appropriate. While the evidence is limited, in the two case studies included in the review, the the findings were similar. More evidence is needed to determine the patient experience across a range of contexts to inform and guide care. Limitations The review was limited by the heterogeneity of the available studies, low quality evidence and studies published in the English language. Of the studies in the review less than 50% (6) studies have been published since 2010. Conclusion The areas of care reported as the most challenging for nurses included wound management, mobilisation, maintaining dignity, comfort and safety. Specific guidelines that inform these aspects of care will support nurses to deliver optimum care and go some way to de-stigmatising the management of this population within acute care. There was minimal evidence of proactive planning, to the availability of well-educated staff, familiar and confident with the use of suitable equipment to assist with manual handling to prevent injury to both patient, staff, and to maintain patient dignity. What was evident in the literature was the inconsistency with terminology that defines this group of patients. This could lead to inaccurate application of guidelines when caring for this population. Abbreviations BMI – Body Mass Index CINAHL - Cumulative Index to Nursing and Allied Health Literature Plus with Full Text Class III obesity - BMI≥ 40 Embase - Excerpta Medica Database JBI – Joanna Briggs Institute MEDLINE - Medical Literature Analysis and Retrieval System Online WHO – World Health Organization Declarations As this was a Scoping Review of extant literature, ethics approval was unnecessary. We affirm that all authors have made substantial contributions to this manuscript. The conception and design of the study originally conceptualised by Amanda Towell-Barnard and developed by all other authors. Vivien Kemp conducted the literature search and initially screened all articles. All authors contributed to article appraisal, and the inclusion or exclusion of identified articles. Data extraction, analysis and interpretation was conducted by all authors. Contributions to drafting the article or revising it critically for important intellectual content: Amanda Towell-Barnard wrote the introduction, Vivien Kemp wrote the method and results section, and Beverly Ewens the discussion and conclusion. Lisa Whitehead provided critical revision for important intellectual content at each stage. All authors agreed to final approval of the version. All data generated or analysed during this study are included in this published article (and its supplementary information files available in Additional Files). Funding statement: No external funding. Conflicts of interest: The authors declare there are no conflicts of interest. Acknowledgements – N/A References World Health Organistaion. Obesity and overweight Fact sheet: World Health Organistaion; 2016 [Available from: http://www.who.int/mediacentre/factsheets/fs311/en/. Sultana N, Afroz S, Tomalika N, Momtaz H, Kabir M. 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A Qualitative Exploration of Weight Bias and Quality of Health Care Among Health Care Professionals Using Hypothetical Patient Scenarios. Inquiry : a journal of medical care organization, provision and financing. 2018;55:46958018774171. Alberga AS, Pickering BJ, Alix Hayden K, Ball GD, Edwards A, Jelinski S, et al. Weight bias reduction in health professionals: a systematic review. Clinical obesity. 2016;6(3):175-88. Boyle SL, Janicke DM, Robinson ME, Wandner LD. Using Virtual Human Technology to Examine Weight Bias and the Role of Patient Weight on Student Assessment of Pediatric Pain. Journal of clinical psychology in medical settings. 2019;26(1):106-15. Hales C, Gray L, Russell L, MacDonald C. A Qualitative Study to Explore the Impact of Simulating Extreme Obesity on Health Care Professionals' Attitudes and Perceptions. Ostomy Wound Management. 2018;64(1):18-24. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-31488","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":635318,"identity":"22a98199-2293-411a-a2ac-0b226d44f77c","order_by":0,"name":"Beverley Ewens","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACAygtB6HYSNBiTLqWxAaitZgzMB+T+LijLr2f/YwBw4eywwz8MxLwa7FsYEuTnHnmcO7MnhwDxhnnDjNI3CCgxeAAj9lt3rYDuRtu8Bgw87YdZmAgrIX/2+2/bXXp9iAtf4Fa5Imwhe02YxtzgoEEUAsjUIsBIS2WzWzmP3vbDhvOOJNWcLDnXDqP4ZkH+LWYszc/NvjZVifP335444MfZdZycscJ2MLAjMQ+AMQ8BNSPglEwCkbBKCAGAADlcEDr7V472QAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-2008-7214","institution":"","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Beverley","middleName":"","lastName":"Ewens","suffix":""},{"id":635319,"identity":"dcdd5da7-5578-40bf-a682-ef1ef142b808","order_by":1,"name":"Vivien Kemp","email":"","orcid":"","institution":"Edith Cowan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vivien","middleName":"","lastName":"Kemp","suffix":""},{"id":635320,"identity":"927d3bd4-2cab-4cfc-a262-5d5ef8563ea1","order_by":2,"name":"Amanda Towel-Barnard","email":"","orcid":"","institution":"Edith Cowan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Amanda","middleName":"","lastName":"Towel-Barnard","suffix":""},{"id":635321,"identity":"52afd08c-c439-4aba-ba71-9dc20504b061","order_by":3,"name":"Lisa Whitehead","email":"","orcid":"","institution":"Edith Cowan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Lisa","middleName":"","lastName":"Whitehead","suffix":""}],"badges":[],"createdAt":"2020-05-26 03:17:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-31488/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-31488/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1265986,"identity":"d32a5e5c-6d80-4d8d-b418-aa56e30f75ab","added_by":"auto","created_at":"2020-06-05 18:52:08","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":80053,"visible":true,"origin":"","legend":"Prisma Flow Diagram (http://prisma.thetacollaborative.ca/)","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-31488/v1/Fig1.jpg"},{"id":13537270,"identity":"b940eccc-9d58-42e1-83af-1089bf5b5d71","added_by":"auto","created_at":"2021-09-17 01:35:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":504804,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-31488/v1/8b634204-437e-4b1f-ad19-d809d4d15bb4.pdf"},{"id":1265988,"identity":"7f15154c-1452-4f70-ab38-a837ea5a56bd","added_by":"auto","created_at":"2020-06-05 18:52:08","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20824,"visible":true,"origin":"","legend":"","description":"","filename":"AdditionalFileForScopingReviewMay18.docx","url":"https://assets-eu.researchsquare.com/files/rs-31488/v1/AdditionalFileForScopingReviewMay18.docx"}],"financialInterests":"","formattedTitle":"\u003cp\u003eWhat Evidence Informs the Nursing Care of People with Class III Obesity in an Acute Care Setting? A Scoping Review.\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObesity is a complex psychosocial construct and strongly linked with health and wellbeing. The incidence of obesity is increasing worldwide, with over 650 million adults classified as obese and 1.9 billion as overweight (1). Obesity is not confined to developed countries but is an emerging health concern in many developing countries including Bangladesh (2), India (3) and Saudi Arabia (4). Hospital admissions related to obesity as either a primary or secondary diagnosis are increasing (5). The classification of obesity, however, varies within the literature and is further complicated by the use of the term \u0026lsquo;bariatric\u0026rsquo; (6). Discrepancies in definitions and perceptions of obesity have been noted, particularly in children (1, 7). Body Mass Index (BMI) remains the most frequently used measure of classification. A BMI of \u0026gt;30 kg/m\u0026sup2; signifies obesity and the World Health Organization (WHO) (1) have further categorised obesity into three sub classes with Class III (BMI \u0026ge; 40.00kg/m\u0026sup2;, very severe) categorised as the highest level of obesity.\u003c/p\u003e\n\u003cp\u003eThe health and socioeconomic impacts of obesity on individuals and health care systems can be significant. In young and middle aged adults, obesity is associated with lower educational attainment (8), development of comorbidities (9, 10) and overall reduction in life expectancy (11, 12) Obesity of any classification can increase complexity of care including mobilisation, skin care and perioperative management (13-15) This review will synthesise the \u0026nbsp;evidence on the nursing care of people classified as Class III obese in the acute, non-critical care settings to explore best practice and issues and challenges highlighted in the literature\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReview question\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWhat evidence guides the nursing care of people classified as Class III obese in acute care settings?\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReview objectives \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo synthesise evidence on the nursing care of Class III obese patients in acute care settings.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eInclusion criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review considered primary research studies published in English, involving participants aged 18 years and over and classified as Class III obese. Studies were included if they reported on the nursing care of people classified as Class III obese within acute care settings, using either qualitative or quantitative methods.\u003c/p\u003e\n\u003cp\u003eExclusion criteria\u003c/p\u003e\n\u003cp\u003eStudies were excluded if they explored the nursing care of Class III obese patients in critical care areas, perioperative care, perinatal care, and in the community. Further exclusions included a focus on patient outcomes without reference to nursing care, and studies reporting prevalence.\u003c/p\u003e\n\u003cp\u003eSearch strategy\u003c/p\u003e\n\u003cp\u003eA logic grid was constructed to guide the search strategy (See Additional file, Table A) A three-step search strategy was employed commencing with an initial search of Cumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, Proquest Central, Web of Science and Excerpta Medica Database (Embase) to identify key words and index terms, followed by a second search across all databases using the identified terms.\u0026nbsp;\u0026nbsp; Thirdly, the reference lists of all 36 identified reports and articles were searched for additional studies. The timeframe from 1980 to 26/07/2018 was chosen, because of the proliferation of interest and associated publications within the context of patients with obesity during this timeframe.\u003c/p\u003e\n\u003cp\u003eThe search included the following electronic databases:\u003c/p\u003e\n\u003cp\u003eCumulative Index to Nursing and Allied Health Literature Plus with Full Text (CINAHL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Scopus, Proquest Central, Excerpta Medica dataBASE (Embase), and Web of Science. The keywords used were: Nursing care, patient care, best practice care, hospital care combined with the terms morbidly obese, and morbid obesity. Boolean exact phrase searching was used in conjunction with mesh terms for obesity, morbid including truncation terms morbid* and obes*, with AND/OR (See Additional file Table A for first search in CINAHL).\u003c/p\u003e"},{"header":"Results ","content":"\u003cp\u003e\u003cstrong\u003eSearch results \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 3809 records were identified (Figure 1), of these, 3773 articles were excluded at title (n = 3627) or abstract (110) level where the paper focused on treatment trials and outcomes regarding medical management, peri-operative care, perinatal care, intensive care or emergency care. Thirty-six full text articles were reviewed, and a further 23 articles excluded (Additional file Table B). Thirteen articles were included in the review. These were four case reports, the remaining primary studies included four retrospective registry records studies, two qualitative studies, one naturalistic observational study, one mixed methods study, and one descriptive survey.\u003c/p\u003e\n\u003cp\u003eInsert Figure 1 here\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuality appraisal\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eTwo independent reviewers assessed the remaining 13 articles that met the inclusion criteria for methodological validity, using the relevant JBI critical appraisal checklist (See Additional file Table C for Quality appraisal Table and JBI Check lists). All authors contributed to paper assessment and critical appraisal and any disagreements were resolved though group discussion. Seven articles were appraised using the JBI Critical Appraisal Checklist for Descriptive/Case Series studies, four articles using the Checklist for Case Reports, and two articles using the Checklist for Interpretive \u0026amp; Critical Research. Articles were included if they scored Yes to 4 or more questions\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eData extraction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA data charting form was developed, and all authors completed data extraction; any disagreement was resolved by discussion to reach consensus. Due to the heterogeneity of the studies, a meta\u0026ndash;analysis could not be completed therefore a synthesis was conducted. The extracted data included details about the purpose and setting of the study, the study population and main findings. No missing or unclear information was found (Table 1).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n\u003ccaption language=\"En\"\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCharacteristics of studies included in the review.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor \u0026amp; date \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Method\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u003cstrong\u003eDemographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eRetrospective\u003c/p\u003e\n\u003cp\u003eRegistry Records\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUnited Kingdom,\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo ascertain the number of reported patient safety events involving people with\u0026nbsp; obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDatabase search of National Reporting and Learning System\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003e\u0026nbsp;555 records of 'patient safety' incidents involving people living with obesity\u0026nbsp;\u0026nbsp; were identified\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eBroome et al, 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eCase study\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eHospital, USA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo describe the care of a 'super' bariatric patient\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eA person with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN=1 Gender: M; Age 56 years old; BMI :73\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDrake et al, 2005\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eQualitative; focus groups, thematic analysis\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo investigate nurses' perceptions of the challenges they face in caring for patients with morbid obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eNurses whose work includes caring for people with morbid obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN=17 Gender: M 3, F 14; Mean age 38.32 years old and mean nursing experience 13 years. 5 participants held a baccalaureate degree, 9 held an associate degree, 2 held a diploma of Nursing.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDrake et al, 2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDescriptive, survey\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo determine what nurses perceive as challenges in caring for people with morbid obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eMembers of the National Association of Bariatric Nurses\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN=109\u003c/p\u003e\n\u003cp\u003eGender: M 9 (8.3%), F 100 (91.7%); Mean age 44.6 years (range 24-63); Race: White 93 (85.3%), Black 13 (11.9%), Other 3 (1.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eEcklund \u0026amp; Kurlak, 2004\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eCase study\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUse a case report to highlight issues involved in caring for a person who is morbidly obese.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eA person with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN=1 Gender: M; Age 39 years old; BMI :91\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eGardner and Gibbs, 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDescriptive, Retrospective; Records\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo ascertain the number of reported patient safety events involving people with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDatabase search of the\u0026nbsp; Pennsylvania Patient Safety Authority's Patient Safety Reporting System\u0026nbsp; from 2007-2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003ePart 1:\u0026nbsp; 1,774 records of 'patient safety' incidents involving people living with Class III obesity of these there were 180 equipment use event reports (10% of total reports)\u003c/p\u003e\n\u003cp\u003ePart 2: State-wide survey administered to all hospitals in Pennsylvania of hospital readiness to accommodate Class III obese patients.\u0026nbsp; Response rate 35.3%; N= 85 of 241.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eGardner and Pagano 2013a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDescriptive, Retrospective; Records\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo ascertain the reported number of serious skin integrity events involving people with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDatabase search of the\u0026nbsp; Pennsylvania Patient Safety Authority's Patient Safety Reporting System\u0026nbsp; from 2007-2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003ePart 1:\u0026nbsp; 1,774 Event reports of people living with Class III obesity, and 33.1% (n=588) were skin integrity reports.\u003c/p\u003e\n\u003cp\u003ePart 2: 2012 Hospital state-wide survey that included questions about class III obese patient skin care protocols (35.3% response rate, n = 59)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eGardner and Pagano, 2013b\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDescriptive, Retrospective; Records\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo ascertain the reported number of falls event reports involving people with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDatabase search of the\u0026nbsp; Pennsylvania Patient Safety Authority's Patient Safety Reporting System\u0026nbsp; from 2007-2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003ePart 1:\u0026nbsp; 1,774 event reports involving people living with class III obesity, and 20% of these (357 of 1,774 were falls event reports)\u003c/p\u003e\n\u003cp\u003ePart 2: 2012 Hospital state-wide survey that included questions about hospital preparedness to care for Class III obese patients. Response rate was 35.3% ( n= 85 of 241 )\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eHignett \u0026amp; Griffiths, 2007\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDescriptive. Mixed methods (focus groups and questionnaire)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUnited Kingdom, Special Interest Groups\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo identify and explore manual handling risks and process planning pathways for patients with morbid obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eMembers of the National Back Exchange (NBE) Special Interests Group on Bariatrics and The National Ambulance Risk and Safety Forum (NARSF).\u0026nbsp; 25 participants (5 from\u0026nbsp; the Ambulance Service and 20 were from the NBE) attended four focus groups; data from the focus groups was used to develop a questionnaire that was sent to all members of the NBE (n= 1289)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eSurveys were sent to members of the NBE (n =1289) and the NARSF (n=71). There were 224 responses from the NBE\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eHolland et al, 2001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eCase study\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo use a case report to illustrate care and discharge planning for a patient with morbid obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eA person living with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN=1 Gender M; Age 49 BMI 72.6 kg/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003ePalmer, 2009\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eCase study\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUnited Kingdom, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo illustrate that even when specialist equipment is available, it may not be suitable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eA person living with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN=1Gender F; Age not reported, BMI not reported\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eRose et al, 2007\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eCross-sectional, naturalistic observation\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo compare resource requirements\u0026nbsp;\u0026nbsp; in caring for non-obese and morbidly obese patients\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eNursing staff observed carrying out identified nursing tasks on obese and non-obese patients\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eGroup 1 : N=30 non-obese patients Group 2 N=30 morbidly obese patients\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eRose et al, 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eDescriptive, Qualitative, semi-structured interview\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eUSA, Professional Association members\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eTo examine nurses' perception of safety concerns when caring for patients with morbid obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eNurses who are members of the National Association of Bariatric Nurses (NABN)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"155\"\u003e\n\u003cp\u003eN= 23, 4 eliminated because had no contact with patients. Interviewed 19 nurses describing adverse events they had experienced. Events were categorised as Adverse events, Near misses and out-of-control situations\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eData synthesis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings were narratively synthesized by analyzing the articles, identifying common concepts and themes that were then iteratively grouped firstly into subordinate and finally into four superordinate themes. It was found that there were variations in the definition of Class III obesity across the 13 studies, from no definition at all, definitions based on the Body Mass index (BMI) to whether weight exceeded equipment size (Table 2).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n\u003ccaption language=\"En\"\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDefinitions of Class III obesity.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eDefinition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eAuthor\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eNo definition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eBooth et al, 2011\u003c/p\u003e\n\u003cp\u003eDrake et al, 2005\u003c/p\u003e\n\u003cp\u003eDrake et al, 2008\u003c/p\u003e\n\u003cp\u003eRose et al, 2007\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eClass III obese patients have a BMI greater than or equal to 40 or 100 pounds more than their ideal body weight\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eGardner and Gibbs, 2013\u003c/p\u003e\n\u003cp\u003eGardner and Pagano, 2013a, 2013b\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eMorbid obesity greater than 100 pounds above desirable weight. Severe obesity BMI greater than or equal to 50km/m\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eEcklund \u0026amp; Kurlak, 2004\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eMorbid obesity is a body mass index greater than 40 kilograms per square meter\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eHolland et al, 2001\u003c/p\u003e\n\u003cp\u003ePalmer, 2004\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eMorbidly obese (BMI \u0026gt; 40), super obese (BMI \u0026gt; 50) and super, super obese (BMI \u0026gt;60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eBroome et al, 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eMorbidly obese patient ( BMI \u0026gt; 35)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eRose et al, 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"330\"\u003e\n\u003cp\u003eSome definitions were by pre-determined weight, some by predetermined size, others when weight exceeded predetermined value and/or exceeded equipment size\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"214\"\u003e\n\u003cp\u003eHignett et al, 2007\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThree major themes emerged from the synthesis (Table 3): these were Access, knowledge and training related to equipment; Patient care; and Opportunities to improve care.\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\n\u003ccaption language=\"En\"\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eThemes generated from the findings.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"43%\"\u003e\n\u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"14\" width=\"56%\"\u003e\n\u003ch2\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003c/h2\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"13%\"\u003e\n\u003cp\u003e\u003cstrong\u003eSuperordinate Themes \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eSubordinate themes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eBooth et al, 2011\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eBroome et al, 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eDrake et al, 2005\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eDrake et al, 2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eEcklund \u0026amp; Kurlak, 2004\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eGardner \u0026amp; Gibbs 2013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eGardner \u0026amp; Pagano, 2013a\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eGardner \u0026amp; Pagano,2013b\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eHignett et al, 2007\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eHolland et al , 2001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003ePalmer, 2004\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eRose et al, 2007\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eRose et al , 2010\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eFrequency\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"5\" width=\"13%\"\u003e\n\u003cp\u003e\u003cstrong\u003eAccess, knowledge and training related to equipment\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eAppropriate equipment available\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eAppropriate equipment unavailable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e11\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eEquipment failure/malfunction\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eStaff knowledge about how to use equipment\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eWeight capacity of equipment identified and known\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"12\" width=\"13%\"\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Care \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eCirculation issues\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eElimination (and personal hygiene)needs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e3\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eGait and mobility issues\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eMaintaining patient comfort and dignity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eMaintaining patient safety\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003ePain and symptom management\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003ePatient care plan (daily routine)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003ePatient education about their own self-care\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003ePatient\u0026rsquo;s psychosocial care and needs\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eRespiration issues\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eSkin integrity issues identified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"8\" width=\"13%\"\u003e\n\u003cp\u003e\u003cstrong\u003eOpportunities to improve care \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eCommunication between staff members\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eNurses\u0026rsquo; concerns/attitudes/safety\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003ePatient\u0026rsquo;s acuity and independence levels determined how challenging nursing patients with class III obesity was\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eProtocols available on\u0026nbsp; the care of people living with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eHospital policies and procedures for the care of patients with class III obesity either not in place or not followed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eIncreased resources needed to care for patients with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eInfrastructure/facility not retro-fitted or lack of space to accommodate necessary equipment (including lifts, floors and doors)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e9\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"30%\"\u003e\n\u003cp\u003eMultidisciplinary/interdisciplinary approach to the care of patients with class III obesity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"5%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"4%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"2%\"\u003e\n\u003cp\u003eX\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"3%\"\u003e\n\u003cp\u003e5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAccess, knowledge and training related to equipment \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThirty-four findings from 12 studies contributed to this theme. Equipment was identified as a challenge to providing care for people classified as Class III obese and all findings related to either lack of access to appropriate equipment or knowledge and skills to use equipment appropriately. The specific issues raised were accessing appropriate equipment \u0026nbsp;(16-21); the storage of equipment (17) staff knowledge around how to use equipment (19-21); patient distress and discomfort through \u0026nbsp;the use of incorrect equipment \u0026nbsp;(16, 22-24); putting people at risk of harm through the use of inappropriate equipment (16, 17, 20, 22-24); lack of equipment to measure vital signs \u0026nbsp;(19) and delay in access to rental equipment \u0026nbsp;(17, 19, 20). Other issues identified were equipment failure or malfunction (22, 24) and, the ability of staff to identify the weight capacity of equipment (19, 21). Higher levels of staff satisfaction were reported when adequate equipment was available to safely care for the patient (18)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePatient care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eForty-two findings from 12 studies contributed to the theme on patient care. Fundamental nursing care was described as becoming more challenging due to the patient\u0026rsquo;s body habitus, including changing dressings, checking for bowel sounds and heart sounds (17, 24). Management of respiratory function (including obstructive sleep apnoea, oxygen saturation levels) and skin integrity (local care to wounds, pressure reduction equipment) were also reported (21, 25, 26). Supporting people to mobilise, and maintaining patient safety were the most frequently reported issues (n=10, 77%), it was noted for example that gait instability (27) or a patient overestimating their mobility capacity (16) could pose a threat to patient safety. The need to develop a comprehensive care plan was identified as being vital to assist both staff and patients to anticipate the patient\u0026rsquo;s individual care needs (21) and to build a therapeutic alliance (16, 25). Communication was the second most common concern reported by staff in the review. Effective communication between staff and patients was described as essential in promoting a therapeutic relationship (16, 19), and between staff in order to meet patient care needs (18) and communicate needs at handover (16). The role of nurses in promoting self-care for these patients was also described (16, 25).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eOpportunities to improve care\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eForty-eight findings from 12 studies contributed to this theme. References were made to specific policies on the care of people classified as Class III obese in most studies. Several issues were identified in relation to the implementation of policies, procedures and protocols across all aspects of care. This finding related to whether there were policies and procedures in place on the one hand, and whether the policies and procedures were followed on the other (20). This included the benefit of specific discharge planning (16, 21) and evacuation planning (19), as well as the capability to weigh and measure patients on admission to hospital so that the appropriate equipment for each patient was both accessible and available (19, 25).\u0026nbsp; Other issues identified included staff training and education (16, 19, 20, 22, 23) skin care protocols (16, 19, 21) and the inconsistency in the use of the term \u0026lsquo;bariatric\u0026rsquo; (17, 20). Not all hospitals had established policies relating to the manual handling of people classified as Class III obese (20). These issues are a concern because Class III obese patients were found to require a greater proportion of staff numbers to care for them, require larger rooms, specialised equipment and other resources in acute care settings compared to other patients (28).\u003c/p\u003e\n\u003cp\u003eIn the four case studies included in this review, it was found that patient comfort, dignity and appropriate care was compromised when appropriate equipment was unavailable. However, issues were resolved when staff collaborated with other disciplines to devise an overhead ceiling lift and obtained appropriate equipment (23), proactive efforts of staff enhanced\u0026nbsp; \u0026nbsp;collaboration with other health care staff (25) and through the development of a daily schedule to \u0026nbsp;establish a patient \u0026nbsp;care routine (16).\u003c/p\u003e"},{"header":"Discussion ","content":"\u003cp\u003eThis scoping review has identified a paucity of evidence to inform the nursing care of people classified as Class III obese in acute care settings. Nurses are caring for patients across the BMI spectrum and the number of people admitted to acute care settings classified as obese is increasing. The availability of guidance to inform and support care will be vital if patient outcomes are to be optimised. The risk of sustaining a musculoskeletal injury for both patients and staff is higher when the patient is classified as class III obese (29). Issues related to timely access of appropriate equipment dominated the findings. Inadequacies in the provision, access and resourcing of specialist equipment to care for patients, as well as time taken to source the equipment has been reported as a significant issue for staff (30). Lack of adequate bariatric equipment accounted for most clinical incidents reported in one study (22). Lack of equipment was also associated with patient harm (19). Whilst there is a perception that patients who are obese have higher care needs (28, 31), perceptions such as these have not been extensively validated. The identification of patients within the National Hospital Morbidity Database and outcomes related to length of stay, morbidity and readmission rates would provide a clearer picture and identify the need for change (32). To ensure clinical staff deliver care based on best available evidence, it is essential to develop and make widely available, policies and procedures that focus on lifting protocols, lift teams, appropriate equipment and algorithms to promote safety and dignity.\u003c/p\u003e\n\u003cp\u003eThis review also found a lack of consistency within the literature relating to terminology and definitions used to define obesity. Inconsistency can lead to confusion, inaccuracy, and a lack of transferability when developing protocols and systems within acute care and pose clinical risk to both patients and staff.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvidence of organisational-wide innovations in the care of the Class III obese patient was limited. The creation of dedicated manual handling teams lead to a reduction in hospital-acquired pressure ulcers, staff injuries, health care costs and an increase in staff satisfaction (33). Patient and staff satisfaction were increased when a safe patient handling coordinator was appointed to oversee policy and procedures and to provide education for nursing staff (34). The role included the coordination of patient care in the healthcare system, including planning and decision making with key stakeholders in different departments. This review found that nurse-led patient case conferences (21), ongoing moving and handling assessments (23) and streamlined admission processes to anticipate equipment needs (19) were opportunities to improve practice but there is a lack of evidence in the literature that these initiatives have been evaluated or widely implemented. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe concept of weight bias was not a major issue raised in this review but has been acknowledged in the general population, and a range of health care providers (35-37). This may be an area that requires further attention in future research to ensure that care is not compromised. There is limited evidence on interventions to reduce weight bias (38), but simulated educational techniques have shown promise (39, 40). Inter-professional research into methods to reduce weight bias and incorporating the patient\u0026rsquo;s voice have been called for (38).\u003c/p\u003e\n\u003cp\u003eOne study explored the Class III obese patient experience during an acute care admission (40). The findings reported that even though the admission was an elective (planned) admission, \u0026nbsp;the equipment needed was either not available or appropriate. While the evidence is limited, in the two case studies included in the review, the the findings were similar. More evidence is needed to determine the patient experience across a range of contexts to inform and guide care. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe review was limited by the heterogeneity of the available studies, low quality evidence and studies published in the English language. Of the studies in the review less than 50% (6) studies have been published since 2010.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe areas of care reported as the most challenging for nurses included wound management, mobilisation, maintaining dignity, comfort and safety. Specific guidelines that inform these aspects of care will support nurses to deliver optimum care and go some way to de-stigmatising the management of this population within acute care. There was minimal evidence of proactive planning, to the availability of well-educated staff, familiar and confident with the use of suitable equipment to assist with manual handling to prevent injury to both patient, staff, and to maintain patient dignity. What was evident in the literature was the inconsistency with terminology that defines this group of patients. This could lead to inaccurate application of guidelines when caring for this population.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI \u0026ndash; Body Mass Index\u003c/p\u003e\n\u003cp\u003eCINAHL - Cumulative Index to Nursing and Allied Health Literature Plus with Full Text\u003c/p\u003e\n\u003cp\u003eClass III obesity - BMI\u0026ge; 40\u003c/p\u003e\n\u003cp\u003eEmbase - Excerpta Medica Database\u003c/p\u003e\n\u003cp\u003eJBI \u0026ndash; Joanna Briggs Institute\u003c/p\u003e\n\u003cp\u003eMEDLINE - Medical Literature Analysis and Retrieval System Online\u003c/p\u003e\n\u003cp\u003eWHO \u0026ndash; World Health Organization\u003c/p\u003e"},{"header":"Declarations ","content":"\u003cp\u003eAs this was a Scoping Review of extant literature, ethics approval was unnecessary.\u003c/p\u003e\n\u003cp\u003eWe affirm that all authors have made substantial contributions to this manuscript. \u0026nbsp;The conception and design of the study originally conceptualised by Amanda Towell-Barnard and developed by all other authors. Vivien Kemp conducted the literature search and initially screened all articles. All authors contributed to article appraisal, and the inclusion or exclusion of identified articles. Data extraction, analysis and interpretation was conducted by all authors.\u0026nbsp; Contributions to drafting the article or revising it critically for important intellectual content: Amanda Towell-Barnard wrote the introduction, Vivien Kemp wrote the method and results section, and Beverly Ewens the discussion and conclusion. Lisa Whitehead provided critical revision for important intellectual content at each stage. All authors agreed to final approval of the version.\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article (and its supplementary information files available in Additional Files).\u003c/p\u003e\n\u003cp\u003eFunding statement: No external funding.\u003c/p\u003e\n\u003cp\u003eConflicts of interest: The authors declare there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eAcknowledgements \u0026ndash; N/A\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organistaion. Obesity and overweight Fact sheet: World Health Organistaion; 2016 [Available from: http://www.who.int/mediacentre/factsheets/fs311/en/.\u003c/li\u003e\n\u003cli\u003eSultana N, Afroz S, Tomalika N, Momtaz H, Kabir M. Prevalence of childhood obesity and undernutrition among urban school children in Bangladesh. 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Nursing Care of the Super Bariatric Patient: Challenges and Lessons Learned. Rehabilitation Nursing. 2015;40(2):92-9.\u003c/li\u003e\n\u003cli\u003eDrake D, Dutton K, Engelke M, McAuliffe M, Rose MA. Challenges that nurses face in caring for morbidly obese patients in the acute care setting. Surgery for Obesity and Related Diseases. 2005;1(5):462-6.\u003c/li\u003e\n\u003cli\u003eDrake DJ, Baker G, Engelke MK, McAuliffe M, Pokorny M, Swanson M, et al. Challenges in caring for the morbidly obese: differences by practice setting. Southern Online Journal of Nursing Research. 2008;8(3):13p-p.\u003c/li\u003e\n\u003cli\u003eGardner L, Gibbs C. Class III obese patients: Is your hospital equipped to address thier needs? . Pennsylvania Patient Safety Advisory. 2013;March 10(1):11-8 Retrieved from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Mar;10(1)/documents/11.pdf.\u003c/li\u003e\n\u003cli\u003eHignett S, Chipchase S, Tetley A, Griffiths P. Risk Assessment and Process Planning for Bariatric Patient Handling Pathways. Norwich, UK: Health and Safety Executive,: http://www.hse.gov.uk/research/rrpdf/rr573.pdf; 2007.\u003c/li\u003e\n\u003cli\u003eHolland DE, Krulish YA, Reich HK, Roche JD. How to creatively meet care needs of the morbidly obese. . Nursing Management,. 2001;36(2):39-41.\u003c/li\u003e\n\u003cli\u003eBooth CMA, Moore CE, Eddleston J, Sharman M, Atkinson D, Moore JA. Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice. Postgraduate Medical Journal. 2011;87(1032):694.\u003c/li\u003e\n\u003cli\u003ePalmer R. Moving and handling bariatric patients safely: a case study. International Journal of Therapy \u0026amp; Rehabilitation. 2004;11(1):31-3.\u003c/li\u003e\n\u003cli\u003eRose MA, Pokorny M, Waters W, Watkins F, Drake DJ, Kirkpatrick M. Nurses' Perceptions of Safety Concerns When Caring for Morbidly Obese Patients. Bariatric Nursing and Surgical Patient Care. 2010;5(3):243-7.\u003c/li\u003e\n\u003cli\u003eEcklund MM, Kurlak SA. Caring for the bariatric patient with obstructive sleep apnea. Critical Care Nursing Clinics. 2004;16(3):311-7.\u003c/li\u003e\n\u003cli\u003eGardner L, Pagano M. Skin Integrity, Immobility, and Pressure Ulcers in Class III Obese Patients Pennsylvania Patient Safety Advisory. 2013a;Jun;10(2):50-4 Retrieved from http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2013/Jun;10(2)/Pages/50.aspx.\u003c/li\u003e\n\u003cli\u003eGardner L, Pagano M. Class III Obese Patients: The Effect of Gait and Immobility on Patient Falls. Pennsylvania Patient Safety Advisory. 2013b;Sept. 10(3): 96-8 Retrieved from http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/Documents/2013_prepub_fallsobesity.pdf.\u003c/li\u003e\n\u003cli\u003eRose MA, Baker G, Drake DJ, Engelke M, McAuliffe M, Pokorny M, et al. A Comparison of Nurse Staffing Requirements for The Care of Morbidly Obese And Non-Obese Patients in The Acute Care Setting. Bariatric Nursing and Surgical Patient Care. 2007;2(1):53-6.\u003c/li\u003e\n\u003cli\u003eAustralain Safety and Compensation Council. Manual handling risks associated with the care , treatment and transportation of bariatric (severely obese) patients and clients in Australia In: Government A, editor.: Commonwealth of Australia, https://www.safeworkaustralia.gov.au/system/files/documents/1702/manualhandlingrisks_caretreatmenttransportation_fbariatricseverelyobesepatients_australia_2009_pdf.pdf 2009.\u003c/li\u003e\n\u003cli\u003eLumley E, Homer CV, Palfreyman S, Shackley P, Tod AM. A qualitative study to explore the attitude of clinical staff to the challenges of caring for obese patients. Journal of clinical nursing. 2015;24(23-24):3594-604.\u003c/li\u003e\n\u003cli\u003eHales C. Morbidly obese patients' experiences of mobility during hospitalisation and rehabilitation: A qualitative descriptive study. , 34(1), 20-31. http://ezproxy.ecu.edu.au/login?url=http://search.ebscohost.com/login.aspx?direct=true\u0026amp;db=rzh\u0026amp;AN=131588904\u0026amp;site=ehost-live\u0026amp;scope=site. Accessed April August 17 2017. Nursing Praxis in New Zealand. 2018;34(1):20-31. https://www.nursingpraxis.org/341-morbidly-obese-patients-experiences-of-mobility-during-hospitalisation-and-rehabilitation-a-qualitative-descriptive-study.html.\u003c/li\u003e\n\u003cli\u003eAustralian Institue of Health and Welfare, van der Zwaag D, Pointer S, Harrison J. Obesity and injury in the National Hospital Morbidity Database. Injury research and statistics series no. 82. Cat. no. INJCAT 158. Canberra: AIHW. Retrieved from http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129543226; 2013.\u003c/li\u003e\n\u003c/ol\u003e\n\u003col start=\"33\"\u003e\n\u003cli\u003eWalden CM, Bankard SB, Cayer B, Floyd WB, Garrison HG, Hickey T, et al. Mobilization of the Obese Patient and Prevention of Injury. 2013;258(4):646-51.\u003c/li\u003e\n\u003cli\u003eThomas SA, Rickabaugh B. Bariatric nurse coordinator: carving out a new role in bariatrics. Bariatric Nursing and Surgical Patient Care. 2008;3(1).\u003c/li\u003e\n\u003cli\u003ePanza GA, Armstrong LE, Taylor BA, Puhl RM, Livingston J, Pescatello LS. Weight bias among exercise and nutrition professionals: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity. 2018;19(11):1492-503.\u003c/li\u003e\n\u003cli\u003ePhelan SM, Puhl RM, Burke SE, Hardeman R, Dovidio JF, Nelson DB, et al. The mixed impact of medical school on medical students' implicit and explicit weight bias. Medical education. 2015;49(10):983-92.\u003c/li\u003e\n\u003cli\u003eSeymour J, Barnes JL, Schumacher J, Vollmer RL. A Qualitative Exploration of Weight Bias and Quality of Health Care Among Health Care Professionals Using Hypothetical Patient Scenarios. Inquiry : a journal of medical care organization, provision and financing. 2018;55:46958018774171.\u003c/li\u003e\n\u003cli\u003eAlberga AS, Pickering BJ, Alix Hayden K, Ball GD, Edwards A, Jelinski S, et al. Weight bias reduction in health professionals: a systematic review. Clinical obesity. 2016;6(3):175-88.\u003c/li\u003e\n\u003cli\u003eBoyle SL, Janicke DM, Robinson ME, Wandner LD. Using Virtual Human Technology to Examine Weight Bias and the Role of Patient Weight on Student Assessment of Pediatric Pain. Journal of clinical psychology in medical settings. 2019;26(1):106-15.\u003c/li\u003e\n\u003cli\u003eHales C, Gray L, Russell L, MacDonald C. A Qualitative Study to Explore the Impact of Simulating Extreme Obesity on Health Care Professionals' Attitudes and Perceptions. Ostomy Wound Management. 2018;64(1):18-24.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Class III obesity, nursing care, acute care settings, bariatric, scoping review ","lastPublishedDoi":"10.21203/rs.3.rs-31488/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-31488/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Obesity is a complex psycho-social construct which is strongly linked with health and well-being. The health and socioeconomic impacts of obesity on individuals and health care systems can be significant. The nursing care of people with Class III obesity needs careful attention to ensure the provision of appropriate care. This scoping review aims to synthesise available evidence on the nursing care of Class III obese patients in acute care settings.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods :\u003c/strong\u003e A scoping review informed by the Joanna Briggs Institute approach was undertaken. We searched CINAHL Plus, Medline, Scopus, Proquest Central, Web of Science and Embase databases for primary research articles relating to the nursing management of people classified as Class III obese in acute care settings. The methodological quality of all studies that met the inclusion criteria were assessed and data relating to methods and the findings extracted and synthesised into themes.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults :\u003c/strong\u003e 3809 records were identified. Thirteen studies met the inclusion criteria and were included in the review. Three themes were generated from the synthesis of the findings: Access, knowledge and training related to equipment; Patient care; and Opportunities to improve care. \u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusions :\u003c/strong\u003e The need for proactive planning to improve the nursing care provided to people classified as class III obese and admitted to acute care settings is vital.\u0026nbsp;Access to appropriate equipment to support moving and handling and education on equipment use to prevent injury to both patients and staff is necessary. Education and support to promote engagement with patients, adapt nursing care practices and promote self-care have the potential to improve patient care and patient outcomes.\u003c/p\u003e","manuscriptTitle":"What Evidence Informs the Nursing Care of People with Class III Obesity in an Acute Care Setting? A Scoping Review.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-06-05 18:52:07","doi":"10.21203/rs.3.rs-31488/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1b1029b8-cc17-45a1-be8a-7ec76117f19d","owner":[],"postedDate":"June 5th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":114076,"name":"Nursing"}],"tags":[],"updatedAt":"2020-08-19T18:24:59+00:00","versionOfRecord":[],"versionCreatedAt":"2020-06-05 18:52:07","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-31488","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-31488","identity":"rs-31488","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}