Nurses...Heal Thyself

A Multidisciplinary Study of Obesity in the Nursing Profession

By:  Esmerelda Englesius, December 2007

Photo taken by permission of Ms. Latisha Washington and Ms. Kaneisha Johnson

According to the October 11, 2007 issue of U.S. News and World Report magazine, New York Presbyterian, Mount Sinai, and Memorial Sloan-Kettering Cancer Center ranked in the ‘Top Ten’ for their treatment and care of various medical conditions or disease.  New York Presbyterian was honored in thirteen specialties, with one of those honors in psychiatry.  Mount Sinai received ninth place honors for their treatment of digestive disorders, as well as honors amongst five other areas of specialty.  Memorial Sloan-Kettering Cancer Center bears no shame in their four honors.  (America’s Best Hospitals 2007) 

Having worked at Memorial Sloan-Kettering Cancer Center from 1994-1996 in the Gynecology Oncology Surgery Department, I have first hand knowledge of the staff pride surrounding these particular types of coveted honors.  The hospital waiting rooms would be generously supplied with ‘extra’ copies for patients, guests, and staff perusal.  I would dare to suggest these professionally recognized medical institutions would less favorably desire accolades in recognition for the number of overweight nurses currently in their employment. 

From January 2, 2006 through October 1, 2007, at Mount Sinai Hospital in New York, New York, I conducted a study of 66 Registered Nurses, on all shifts, currently practicing in the Cardiac Intensive Care Unit.  Their ages ranged from 26 years of age, spanning up to 53 years of age.  The majority of the controlled population was female (62) with a separate small percentage being male (4).  Their ethical dissection included:   
10% Irish, 23% African American, 2% Italian, 15% Asian, 5% Indian, 40% White.  Martial status was divided as:  24% Single, 41% Married, and 35% Divorced.  Of those homes, 32% were single parent homes, 32% were dual parent homes, while the mildly differentiating percentage of 36%, had no children at all.  There was nothing particularly noteworthy in the demographics associated with this study.  Shockingly, of the above mentioned case study, 86% of this particular populous are overweight, “in excess of that considered normal, proper, healthful, etc.” (Overweight)

Registered Nurses, however, are at the forefront of having appropriate educational materials at their fingertips for the prevention and treatment of obesity, yet as you will see from the below study, they appear to be the worst offenders of carrying an unhealthy amount of excess weight.  By comparison, in accordance with the National Institutes of Diabetes and Digestive and Kidney Disease Organization’s May 2007 statistics for adult obesity in the United States, we know 66% of individuals above the age of 20 are currently overweight. (Williamson, PhD)  This variance highlights a 20% gap between the national average of 66% overweight adults and our controlled study group of 86% rate of obesity amongst the professional nursing staff at Mount Sinai.  My theory states nurses have higher trending patterns toward overweight and obesity as a result of workplace psychological stressors, resulting in negative behavioral patterns particularly common amongst their fellow practitioners.  All, of which, can be negated by encouraging behavioral modification and addressing the psychological need deficiency. 

Proper Diagnosis and Associated Risks:
According to the National Institutes of Health, being overweight can lead to a smorgasbord of associated health related risks such as:  “Heart disease and stroke, high blood pressure, diabetes, some forms of cancer, gallbladder disease and gallstones, osteoarthritis, gout, breathing problems, sleep apnea, asthma and worst case scenario, even death.” (Aim for a Healthy Heart)  I suspect, none of which symptoms would most of us have electively volunteered to have bestowed upon our well-being.  But what actually makes the determination between a ‘few extra pounds’ and being overweight?

There are a plethora of accurate methods in which to assess body fat such as:    total body water, total body potassium, bioelectrical impedance, and dual-energy X-ray absorpitiometry.  The National Heart, Lung, and Blood Institute’s Obesity Education Initiative in cooperation with the National Institute of Diabetes and Digestive and Kidney Diseases combined National Institute for Health’s Evidence Report states “no trial data exist to indicate that one measure of fatness is better than any other for following obesity.” (Pi-Sunyer, M.D. 25)  Unfortunately measuring body fat by the above mentioned techniques is expensive more often than not, and not readily available.  The practical and globally agreed upon and accepted clinical standard for measurement of obesity has been established to include: Body Mass Index (BMI), and Waist-Circumference Measurement. (Pi-Sunyer, M.D. 25)  Body mass index can be applied generally to adults, is simple, inexpensive, and easily calculated by “dividing the weight in pounds (lbs) by the height in inches (in) squared and multiplying by a conversion factor of 703.”  (BMI - Body Mass Index)  A BMI of 25 is a positive clinical indication for being overweight.  By association, a BMI of 30 is defined as obese.

Magnetic resonance imagines (MRI) and computed tomography are precise options for accurate diagnosis of abdominal fat.  However, similar to the multiple alternatives for measuring total body fat, computed tomography and MRI are rather impractical for routine clinical diagnostics based on their expense and lack of immediate availability.  Waist-to-hip ratio (WHR) has been used to show increased risk for diabetes, coronary artery disease, and hypertension, however, waist circumference has been found to be a better marker of abdominal fat content than WHR.  Therefore, the National Institute for Health recommends waist circumference markers as the standard inclusive measure for determining abdominal fat content as it seems to carry greater prognostic significance. 

It should be noted: studies are still unclear as to why waist circumference measurements have better correlation over that of WHR.  (Garrow, JS 149)  The increasing size of waist circumference measurements is in direct correlation to the excess fat ratio in the abdomen (assuming it is out of proportion to total body fat) and remains an independent predictor of risk factors.  As such, waist circumference measurement of “over 40 inches in men and over 35 inches in women are considered positive indications for clinical diagnosis of overweight and can be applied to all adult ethnic or racial groups.”  (Aim for Healthy Heart) 

Workplace Psychological Stressors:
Now that we have established clear guidelines for concluding a diagnosis of ‘overweight’ where do we go from here?  Our next step is to focus on the contributing workplace psychological stressors and resulting behavioral patterns of our clinical study group of overweight and obese nurses.

If stress is a contributing factor, then what is stress?  The term ‘stress’ was first defined by a Canadian endocrinologist, Hans Hugo Bruno Selye, author of “Stress without Distress”Selye was one of the first scientists to conceptualize the physiology of stress as having two components: a set of responses he called the general adaptation syndrome, and the development of a pathological state from ongoing, unrelieved stress as well as being the first to describe the hypothalamus-pituitary-adrenal system.  One of his major points of discovery was the notion that stress differs from other physical responses by noting that stress is stressful whether one received good or bad news, whether the impulse is positive (eustress) or negative (distress).  Secondly, he highlighted what has become known as the alarm state, a resistance state, and an exhaustion state in relationship to the glandular system.  And lastly, he conceptualized the idea of both reservoirs of stress resistance or alternatively stress energy. (Rosch, M.D., F.A.C.P.)

Stress relates to both an individual’s perception of the demands being made on them and their perception of their capability to meet those demands.  When there is a perceived imbalance of the two, an individual’s stress threshold is exceeded, triggering a generally negative stress response.  An individual’s stress threshold is dependent on their own personal characteristics, life time of experiences, their coping mechanisms and the circumstances under which those particular demands are being made.  A single event may or may not be considered a source of stress for the nurse at all times and may in fact have a variable impact depending upon the extent of the mismatch in relationship to the demands.  (Schaufeli 32)  The theory of Fight or Flight Response states the body’s response to a “perceived threat or danger regardless of whether it be emotional or physical, dictates the release of certain hormones such as adrenalin and cortisol, speeding the heart rate, slowing digestion, shunting blood flow to major muscle groups, and changing various other autonomic nervous functions, giving the body a burst of energy and strength.” (Scott, M.S.)  This sudden burst of energy and strength was originally intended to assist man with the ability to physically fight or run away at the sight of danger.  Unfortunately, given modern day, the response is activated in situations that are not appropriate, such as a stressful day at work.  Presumably when the perceived threat (aka: stress) is gone, the body was originally designed to return to normal operating function.  Given the nature of the nurses’ severe, prolonged and unresolved psychological stressor, the body does not return to a relaxed state and continues to cause damage to the body.  For the purpose of this study, our focus will lie only on severe, prolonged and unresolved psychological stressors and resulting behavioral patterns which culminate in observable manifestations of excessive weight gain amongst the nursing population.

At the top of the psychological stressors, negatively impacting the nursing profession, one must address work place stressors such as “workload, leadership/management, professional conflict, emotional labor, and low job influence.”  (Herschbach 83)

Workload imbalance and role ambiguity is a result of inadequate staffing levels in support of the daily functionality required of the members of the nursing staff.  Some issues included, but not limited to are: recruiting, scheduling, and retaining qualified nursing professionals.  Part of this disparity can be attributed to the industrialization and commercialization of healthcare, where productivity and profit is the bottom line.  As a result of this emphasis on ‘the bottom line’, many nurses are ‘on the go’ from the minute work begins to the end of a shift.  Often they are working double shifts due to the inability to ‘find that extra nurse’ or simply by not having enough experienced staff rostered for the shift.  As a direct result, nurses receive inadequate breaks, which only further their already overwhelming stress levels. (Curry, RN)

Hospital and nursing leadership/management should be based on an inclusive and supportive style that encourages group cohesion and professional empowerment with particular emphasis on respect and fairness, while addressing and minimizing conflict, harassment, and discrimination amongst the workplace relationships.  By addressing these particular elements, the leadership and management workforce solutions can contribute to employee harmony and satisfaction; thus resulting in continued staff retention and thereby positively affecting the aforementioned workload balance concerns.

Emotional labor consisting of nurturance and support, often considered the cornerstone of a successful nurse-patient relationship, requires the ability of nursing professionals to cope not only with the sick patients’ physical and emotional needs, but with the psychological needs of their families as well.  Despite the nature of their function, most nurses believe the ability to ‘feel’ for their patient is of vital importance in the dimension of treatment.  Unfortunately, this level of emotional commitment can result in a hefty price tag of personally sacrificed needs and desires.  Workplace tensions continue to escalate as nurses are required to care for patients and families experiencing progressive illness, even death and bereavement thus increasing their own awareness of losses and vulnerabilities, heightening their fear of death, and thereby raising anxiety and stress levels.  As if that weren’t enough stress in and of itself, “acts of violence, threats to safety, exposure to abusive language and aggressive behavior from patients,” and family are all to common according to a 2003 study by Macquarie University. (Pollard)   Furthering their emotional dissatisfaction, thus contributing to high levels of psychiatric morbidity and burnout amongst this population, is the expectation placed on nurses to provide and secure appropriate quality of care (getting the patient better) while functioning within the confines of institutional and organized healthcare referendums. (Sharma 59)

I would be remiss if I did not address the emotional impact of transference and counter transference in communication between nursing staff and the patient.  The pivotal juncture of any medical treatment plan is the therapeutic alliance, whereby patient and doctor establish a rational (implicit) agreement or mental contract which supports the elective course of treatment.  For example, a patient who is afraid that he or she is seriously ill may adopt a helpless child-like role and project an omnipotent parent-like quality on to the nursing staff and expect them to provide a solution to their physical and emotional ailments.  By way of another example, assume a patient has an ear infection and has a rational expectation that the nursing staff is appropriately qualified, will complete a thorough history and physical suitable enough to assist the physician in determining an appropriate diagnosis, which ultimately results in an appropriately prescribed course of treatment, and concludes with comprehensive and adequate medical care by the nursing staff.  Conversely, the nursing staff has the implied emotional expectation the patient seeking medicinal care will generally do his or her best in an effort to comply with the treatment regime.  However, as the patient’s needs become more complex, this alliance may become distorted and imbalanced.  Sometimes even the best treatment will not always be good enough, and patients hoping for a cure will be left disappointed, confused, afraid, hostile or angry, whether justifiable or not. (Hughes and Kerr 58)

Transference is not a conscious decision, and the patient unconsciously transfers feelings and attitudes (that may or may not be verbally expressed but that is instead enacted) from a situation in their past and unwittingly projects a need on to the medical staff in the present, thus adding to the already overbalanced work stress of the nursing service provider.  Unfortunately by nature of the interaction, most patients find themselves in the position of fear, loss of control and helplessness, thereby increasing his or her displaced need for this protective relationship; a need that nurses often fulfill either voluntarily or involuntarily.  Too often, patients will long for a  personal relationship with the medical staff, adding pressure to not only respond to that need as a professional but, also, as a ‘friend’. (Hughes and Kerr 59)

“Counter transference is the negative and disruptive emotional response or feelings usually exposed during times of trauma, need, or loss that are elicited in the medical service provider, by the patient’s unconscious transference communications.” (Hughes and Kerr 61)  Face it; dealing with ill patients is stressful.  Patients have the ability to project onto the people who are treating them, illogical, unrealistic desires and painful states of mind as a consequence of their attempt to deal with their own internal anger and hostility,  As a result of the counter transference, the nurse may suffer their own set of unrecognizable and irrational feelings of confusion, fear, despair, impatience, resentment, anger, resulting guilt and emotional exhaustion, creating a downward spiral which contributes to low emotional morale. (Pearson, RN, FNP, MSN 9) 

Lastly there has been some suggestion that environmental factors such as work stress in conjunction with high job strain (workload) may contribute to weight gain leading to overweight and obesity. 

For the purpose of this study we define high job strain as “high job demands combined with low influence and poor sense of accomplishment in jobs reflective of the process of decision-making without considering the knowledge and experience of the nurses which directly affect their daily work in significant ways.” (Overgaard  461)

Negative Behavioral Patterns:
What are the resulting behavior patterns as a consequence of the workplace psychological stressors unique to the nursing profession?  Interestingly enough, the four most frequently reported methods of coping with the work related stressors for nurses are: talking to friends, utilizing antecedents of humor throughout the course of the day, drinking coffee or eating, and watching television. (Kash 1626)  Sadly, two of the behavioral patterns reported as stress relief responses, if participated in excess, can contribute to attributes of overweight and obesity: eating as an emotional response (while overeating) and watching television (at the risk of negating physical exercise for a sedentary lifestyle).

In a 1998 study of lifestyle practices and health promoting environments of hospital nurses it was reported “nurses eat more than others as their personal coping mechanism.” (Hope, Kelleher, and O'Connor 439)  In response to these emotions, overeating, and the resulting energy imbalance of ingesting more calories than you burn off contributes to weight gain.  By definition, a nutritional calorie is “a unit of energy-producing potential equal to this amount of heat that is contained in food and released upon oxidation by the body.” (Calories)  Our bodies can not do without calories to ensure daily physiological functioning such as breathing, digestion, and regular metabolic activities.  However, in a world of 24 hour food options offered by grocery stores in the form of pre-packaged, processed food and frozen foods (that tend to be high in fat, sugar, and calories), take-out and order-in food, combined with the enticing offerings of convenient drive-through and fast food restaurants, choosing foods from these areas may inadvertently contribute to an excessive caloric intake.  Contributing to the same challenge, portion sizes have augmented, thus increasing the likelihood individuals may eat more during the course of their meal or while consuming a snack.  Excess weight exasperated by stressful and busy careers, late-night shifts, and high-fat eating particularly before bed (disordered eating) is an occupational hazard peculiar to nurses according to a 2007 study on nurses’ health conducted by the Centers for Disease Control.  The premise is “Nurses put the needs of others above their own needs.” (Davis)  Eating in response to a lack of basic need satisfaction in accordance with Maslow’s hierarchy of needs (emotions) may lead to consumption of excessive calories with resulting weight gain. (Timmerman and Acton 693). 

In fairness to the nursing population, including those in New York City, merely walking in a ten block radius can be dangerous to their health.  I am not referring to the possibility of a mugging.  Instead I am referring to an assault, but not the kind of assault one might ordinarily infer by the term I have just described.  I am speaking of an assault on their senses.  As the nurse strolls, he or she takes a deep breath in and lets their mind sift through the aromas.  The nurse might smell garbage, repugnant body odors, flowers or even a whiff of a recently perfected confectionary delight.  Their eyes might gaze longingly, through a bakery or delicatessen window, at the beautiful creations, filled with creams or covered with frostings, perhaps accented with cheerful fruit such as kiwi or sun-ripened strawberries.  The nurse begins to salivate as they remember the last time something so utterly decadent and delectable passed through their lips if only to be savored on your tongue.  He or she remembers the feel of the pastry, perhaps warm or even gooey in their hands. 

‘How could the enjoyment of a pastry be dangerous to the nurses’ health?’  I don’t mean to suggest that one such pastry would place any given individual in a high risk health category, but rather an accumulation of these pastries in excess of one’s caloric requirements over time, which in turn could translates into a condition of overweight or even obesity.  Surely, being overweight can not be all bad if even William Shakespeare was quoted  Julius Caesar, 1.2 as saying “Let me have men about me that are fat; Sleek-headed men, and such as sleep o’nights.” (Shakespeare)  Unfortunately, given our case study group….it is all bad.    

In the instance of overweight and obese nurses, clearly there are health related concerns associated with excess weight beyond what is considered normal healthy limits. But, is it really within the right of the hospital administration to restrict the offerings available to a staff that is already practically held hostage by the lack of staff shift coverage and overburdened by their workloads, when by self-admission their unhealthful food choice feeds their emotional need of the moment? (See Appendix A)  A notion such as mandating only healthful options in hospital vending machines or cafeterias truly is unacceptable in a modern day society.  While the notion is at best admirable, it will only lead to further longing for that which has been proven no good in excess, in turn fueling overweight and obesity.  For some, paradise can be found in the forbidden fruit resembling that of an Italian cannoli, piece of rhubarb pie, or maybe even a chocolate cupcake.   

Others would state my theory is mere hog-wash, and that nurses are overweight because they spend an abnormal amount of time sitting behind desks, documenting charts, which leads to a sedentary lifestyle.  One must then address the tendency of grateful patients and family to drop off all sorts of empty caloric delicacies that are only in arms length of the nurse documenting a patient’s progress or lack thereof.  However, by simple observation I do not believe this assumption could be supported.  The simplified theory surrounding food at a mere arms length distance would mean that 86% of the employees working at McDonald’s would be overweight or obese.  Myself, having been a fan of McDonald, I can honestly say casual observance would certainly disclaim this particular notion.   

I couldn’t help but say to myself, I wonder what Dr. Unger have to say about my soft-shoe theory surrounding overweight nurses, so I decided to call her and ask her directly what her thoughts were.  By way of introduction, I have known Dr. Judith Unger, DACBN for approximately 28 years.  We were neighbors in a small housing addition outside of Andale, Kansas.  I babysat all four of her children from the time I was in 8th grade and through my first year of college.  The thing I remember most from my babysitting days was never finding ‘good things’ to eat at her house when I was babysitting (ie:  cookies, chips and empty caloric junk food). 

I picked up the phone on Sunday, November 3, 2007 to call her, and after a few minutes of catching up on her ‘little ones’,  I shared my thesis with Dr. Unger, nutritionist.  I proceeded to inform her that I would like her completely unedited, gut jerk response both personal and professional opinion as to why people become overweight and obese.  Dr Unger laughed out loud and stated, “Now when have you known me to hold back?”  I giggled in response, because I knew if anyone would tell me their completely unedited and apolitically correct response, it would be Dr. Unger.  Dr. Unger has a unique dry sense of humor.  She is amazingly bright and yet has a very earthy, reverent feel about her.  One always senses a certain respect for nature and a very natural calmness about her. 

“People eat too much and they are lazy,” she states.  Wow!  Okay, Dr. Unger, please don’t hold back!  Everything I have researched tells me that ‘people and more specifically nurses eat too much’, and ‘they don’t exercise enough’, that much I already understood.  I asked her; why she thinks nurses eat too much.  Dr. Unger rattled off several reasons:  Portion size, socialization, conditioning, emotional reasons (boredom, stress, anxiety, depressions), marketing, television, lack of self-discipline.  It should be noted contrary to my theory she does not think there are any unique challenges associated with the nursing profession. 

During the course of our conversation, most of her comments made sense to me, but I was curious to know what a ‘professional’ in this field thought about the concept surrounding the notion of “lack of self-discipline.”  I asked her to expand her comments on this topic.  Dr. Unger states, “Eating healthy is a way of life.”  She says “It’s simple to say no to bad food choices, but Americans and nurses want that instant gratification and mood pick up.”  “Self-discipline is work and Americans as well as nurses are adverse to anything that doesn’t make them feel good or constitutes work.”  Dr. Unger says she never longs for sweets, chocolate or chips.  I thought to myself, I wish that was the case for me!  She says the reason she never longs for these empty caloric offerings is because her body is adequately fueled with the right nutrients and because her body is fueled correctly, it does not crave the empty calories.  She has exercised self-discipline and retrained her body to want what is good. 

This sounded pretty simple to me.  However, I wanted to know how nurses could get to become an adequately fueled machine by exercising self discipline and retraining their body and mind.  Even as I stress over something as simple as completing my paper on time for a Saturday morning deadline, I am stress eating on what I perceive as the absolutely most decadent and fattening cookies known to man.  I really don’t care what anyone says, carrot sticks are not what I want when I am stressed.  How could it be any different for nurses?  Forget it; the mere thought of a diet causes such anxiety that I am nearly instantly hungrier than I’ve ever been in my life.  It’s silly really. 

Behavior Modification:
Dr. Unger’s strategy for retraining the mind and body is to change one bad eating habit per week.  For instance, if the nurse always has a bag of King size M&M’s at work around 2pm every day, she said he or she should eliminate that element from their day and instead have a piece of fruit, every day for seven days.  The next week, she recommends the nurse focuses on another bad habit, perhaps their favorite Chai Tea Latte from Starbucks.  Once the nurse has eliminated all ‘extras’ from their eating habits, then they need to focus on substituting the proper elements into their meals each and every day.  Be aggressive about it, not lazy.”  What does that mean?  She says, “Nurses really need to think about what they are eating.”  As if they don’t have enough to think about already. 

Dr. Unger stated for those nurses that are environmentally friendly, they should “Pretend they are thinking green all the time,” she says.  “One can never get enough green, so eat more green.”  Dr. Unger, also faxed me a dart board looking device that showed foods in the inner circle (bull’s-eye) that were foods good enough to choose every day, “but don’t eat like a pig….remember portion control.”  The next outer ring is yellow and is cautionary foods, good enough to eat a couple of times per week, but be careful.  The last ring around the bull’s-eye is red.  Yes, red means STOP and think about whether you want/need these items.  They should rarely if ever be eaten…items that are sugary and/or full of empty calories, like the one my hands are reaching for instinctively even as I type.  Dr. Unger said nurse should think of their body as a car.  If they fill their car up with premium unleaded, their car will run at premium performance.  Conversely, if their car is filled with regular leaded gas, it will knock and ping the more they drive it.  “No more dieting,” she states.  Just fuel your car properly and with care.  “You wouldn’t drive your new car and park it in the local landfill, would you?  No, instead, you park it in the farthest parking lot away from the wayward shopping carts to avoid dings.  Choosing bad food is choosing to park your brand new BMW in the middle of a landfill and it just doesn’t make any sense at all.”

Her last comment to me in the stern voice that only she can get away with was this:  “Nurses need to eat right, get off their duff, turn off the television, stop making excuses for themselves, get onto the treadmill, take the stairs, climb a mountain, take up dance lessons, but really, truly get moving and stop being lazy.”  In other words, fuel up on the good foods in the right amounts and exercise restraint while exercising our bodies.  Dr. Unger believes the above mentioned prescription is applicable to not only the nursing population, but the general population, me included.

All joking aside, the occasional watching television in and of itself is not an associated risk for weight gain.  However, performed in excess, the risk of negating physical exercise for a sedentary lifestyle becomes quite plausible.  Despite all the benefits of a physically active lifestyle, most nurses are sedentary. (LaVelle)  In addition to televisions, technology has created many time and labor saving products including cars, elevators, computers, and dishwashers.  Cars have replaced walking or riding bicycles for running errands and commuting to work.  Individuals may choose not to walk to the store or work because of their opposition in getting to their destination sweaty and the negative response from their interpersonal groups, organizations or community and societal influences.  Who takes the stairs, when they can take the elevator?  As a result, of these lifestyle changes, the overall amount of energy expended in our daily lives has been reduced thus contributing to the energy imbalance and decreased metabolism. (Obesity and Overweight: Contributing Factors)  As John F Kennedy, 35th President of the United States once said, “We are under exercised as a nation. We look instead of play. We ride instead of walk. Our existence deprives us of the minimum of physical activity essential for healthy living.” (Kennedy)  This is behavior we can change, without question, but we will have to work at it. 

Behavior modification may seem easily addressable, unfortunately, habits have to be broken and new ones established through employer offered educational workshops.  These classes should be free of charge to employee and offered through the training department of the hospital designed to cover topics such as adequate coping skills, time management, assertiveness, and understanding adult sleep requirements. 

What happens in those instances when we really just want a lot of food?  We are hungry and want to feel full.  Who’s to say we can’t have a lot of food from time to time?  If a nurse’s plate was filled to overflowing with mescaline with all sorts of colorful and crunchy vegetables, I would say go ahead.  Thus the term ‘free vegetables’, without limit and true freedom to have as much as one want without restrictions.  But pass on that salad dressing!  However, one of the most important educational requirements relates to the understanding and development of a healthy portion-controlled diet, avoiding junk food and eating at regular intervals to obtain optimum weight and maintain metabolism.   What are appropriate portion sizes, and what does a healthy diet consist of?  Well, according to the American Cancer Society, the looks of normal portion sizes are illustrated below: 

In accordance with the U.S. Department of Health and Human Services as well as the U.S. Department of Agriculture the key recommendations for Americans’ nutritional requirements constitutes the following elements: 

Yvonne Sanders-Butler, a grade school principal at Browns Mill Elementary School in Lithonia, Georgia took the issue of ‘avoiding junk food’ to a new level.  Ms. Sanders-Butler was celebrated for creating what would become the first sugar-free school.  In a recent magazine article, Yvonne proudly proclaims “Our school is sugar free.  No Sugar!” ("She Created the First Sugar-Free School" 97) The article proceeds further by providing illustrations of Ms. Sanders-Butler nixing refined sugars, revamping school lunches and physical education classes for her students in 1999.  Interestingly enough, within the year of these mandated reforms student disciplinary problems dropped, reading and math scores improved by fifteen percent and visits to the school nurse declined. 

Like the first sugar-free school, Hospital administrations could institute the first sugar free hospital.  Vending machines could be filled with only healthful solutions, could they not?  The hospital cafeteria menu could be redone to present only options in support of the recommendations listed above.  Nutritional values and caloric quantity should be offered for these perfectly balanced and portion-controlled meals.  In addition, the cafeteria could offer pre-cooked, healthful, well balanced, portion controlled meals for take home, at cost for their employees.  This would save nurses time, and certainly encourage a healthful alternative to their empty caloric counterpart.   Patient’s families could be advised not to bring in sweets for the nurses.  Instead it could be suggested they bring in fruit or vegetable platters.  If there is no option of negative food choices, then seemingly the population would be forced to sway toward positive choices.

However, as W. Somerset Maugham once wrote in Of Human Bondage, “You know, there are two good things in life, freedom of thought and freedom of action.” (Maugham)  By comparison, and sadly at that, the thought of perhaps enforcing only mandated healthy options in the vending machine waiting rooms or cafeteria at hospitals ‘freedom of action (or choice)’ is taken away.  One of the great foundations this country was built upon was the freedom to choose, whether it is right or wrong.  One could argue this smells remotely of a communistic society where decisions are mandated by the governing authority, and in this particular case, the hospital administration?  One might just as well have guards posted, patrolling the premises for illegal or smuggled contraband in the form of unhealthful food choices.  When all freedom of choice has been stripped from us, do we not lose the will to think independently and instead become like sheep, blindly following after one another with no individual thought or notion?  What could be worse than a lobotomized society?  Perhaps…..but I believe the only thing worse is a fat unhealthful society having their ills cared for by an overweight and obese professional nursing population. 

So, rather than mandate sugar-free institutions, regular exercise should be encouraged and incorporated as a part of nurses’ daily routine.  The 2007 American College of Sports Medicine in conjunction with the American Heart Association basic recommendations of physical activity guidelines for healthy adults under the age of 65 are as follows:  Do moderately intense cardio 30 minutes a day, five days a week or do vigorously intense cardio 20 minutes a day, 3 days a week and do eight to ten strength-training exercises, eight to twelve repetitions of each exercise twice a week.  “Moderate-intensity physical activity means working hard enough to raise your heart rate and break a sweat, yet still being able to carry on a conversation. It should be noted that to lose weight or maintain weight loss, 60 to 90 minutes of physical activity may be necessary. The 30-minute recommendation is for the average healthy adult to maintain health and reduce the risk for chronic disease.” ("Physical Activity & Public Health Guidelines")  Hospitals could further encourage these recommendations by offering discounted life insurance for those that exercise and maintain a regular exercise pattern in accordance with the American Heart Association’s recommendations for cardiovascular fitness.

Sadly, when I conjure up the image of physical fitness in my mind, I usually envision myself wearing some ratty, ripped, perhaps paint splattered, drab looking t-shirt and some really comfortable loose yoga pants, most likely bearing holes in them as well.  I already imagine the headache I will get from the bobbing of my ponytail placed strategically high on my head to avoid nasty neck sweat.  I know that at the end of my work out the repugnant odor under my armpits could probably slay small dogs and children at the slightest lift of my arm.  How can one person really smell that bad?  I know without a doubt my bangs will be matted with sweat.  My face will be red and well beyond the image of the proverbial beautiful female glow.  Face it, sweating is unattractive at best.  I could never look like one of those perfectly coiffed, manicured, perky and petite gym bunnies that look just as good at the end of their exercise regime as they looked at the beginning.  I always manage to end up looking more like the bride of Frankenstein.  Given all that, why is that I exercise?  Simply, the physical and mental health benefit.  Exercise isn’t just about the physical fitness resulting from the efforts, but more importantly the mental reward gained from the experience such as increased self-esteem, reduced stress, and increased relaxation.

We have already established the fact nurses have an inordinately amount of psychological stressors and very little time in which to address the relief of those stressors.  I suspect, the most important challenge is that of the addressing some of their exercise deficiencies in an inviting manner.  For an exercise program to be effective on a long-term basis, I believe the medical institutions should offer practical solutions that fit into the lifestyle of the nursing population while combining elements of camaraderie, friendship and emotional support.  These solutions don’t necessarily need to appear as bleak and regimented as the illustration used at the beginning of this paper.  It can and should be designed ‘fun’ to make it as appealing as possible.

Hospital Management could offer a ‘Walk to Work’ day once a month for all employees, clearly more practical for those that live relatively close to work.  At the end of the walk, the medical institution could offer a free healthful breakfast.  Employees could pair up with their colleagues living close by and use the walking time for fellowship.  Another option it to develop ‘lunch time group walks’.  The hospital floor could be divided into groups adequately sized to offer continued maximum staff coverage, while allowing the nurses to ‘escape’ from the stress in a healthful manner that not only addresses the physical need for exercise but the emotional needs of taking care of one’s mind.  For every 30 group walks (or so) an employee participates in, the hospital could reward the employee with a raffle ticket for an exercise bike donated by a local exercise equipment supplier.  The winner’s name would be published in all internal employee communications websites and newsletter.

Another suggestion is for the hospital to organize and sponsor employee team sports such as a baseball team, a bowling league, basketball team, volleyball team, dodge ball or even a running group, roller-skating or in-line skating parties, or even Frisbee tournaments, simply anything fun that will get nurses moving in a healthful way.  How about organized volunteer carpentry work in the neighborhood or through a professional volunteer organization.  Once again, the element of camaraderie and group bonding is entailed.  Instead of going out to the local bar after the sporting activity, the hospital could open the facility pool for an employee group sport participant’s only swimming party….fun and more exercise (secretly snuck in). 

Personally, I love the idea of pool therapy and unlimited employee shower facility access for perusal associated with any form of exercise facilitated through the hospital, in the hospital, or in conjunction with the hospital.  Unfortunately it does come with some negatives.  It requires the hospital administration to hire lifeguards, someone to provide upkeep on the pool, as well as maintaining the shower and subsequent laundering requirements.  The human capital and costs required to offer such an indulgence is immense.  Does it truly outweigh the lack of perceived self-discipline evidenced by the overweight individuals?  These unexpected costs can only further the variance between the operating costs and profit.  One could argue, the ending result can be increased nursing shortages, which ultimately has a ripple effect of increasing the already overburdened stress level of the nurses.  However, I believe the costs and risks associated with the hospital assuming a strong position in support of a healthy nursing population far outweigh the opposite risks presented by an overweight and unhealthy nursing staff. 

For those loving a challenge, the medical institution could offer organized Fitness Challenges.  I think it’s fair to say everyone wants to be a winner.  Instead of the winner being the fastest or strongest etc, etc, the winner could be the person that most improves their performance over a pre-established set of time.  Some of the skills that could be a part of the challenge could be jumping rope, running at a particular aerobic rate for 30 minutes or more, push-ups, lunges with dumbbells, and even sit ups/crunches.  The winner of this challenge could design a day outdoor walking/hiking excursion amongst nature in which they are the ‘trainer’ for the day.  My personal favorite is a good old-fashioned dance-a-thon.  Dancing is a great way to keep in shape and have a great time.  If a dance-a-thon doesn’t work for a particular health care facility, then perhaps, free dance lessons one day per week ‘on campus’, available for all nursing shifts.

The hospital could section off a portion of every day (pre-established to provide class offerings encompassing all shifts) for group yoga in their physical therapy room.  These sessions could be offered within an hour before the start of each nursing shift.  The gentle exercise is healthy and therapeutic in nature, the body and soul will receive a work out simultaneously.  Aqua aerobics could be offered three times per week, despite the above mentioned challenges associated with the upkeep of a pool.  Several personal trainers could be hired by the hospital to lead individual work out sessions in the physical therapy rooms.  This will not only save the nurse money from gym memberships and personal trainers, but the flexibility to squeeze in a work out during lunch, or even before/after work.  The trainers could also set up group aerobic classes, kick boxing, belly dancing or knockout ballet lessons for those preferring group motivating exercise classes.  Who wouldn’t love an exercise bike in the nurses’ lounge to work off some stress during a lunch break?

Medical institutions could further this cause by ensuring there are adequate storage facilities for nurses to park/lock/store their bicycles.  Walk-a-thons for charity should be promoted by the hospital.  Parking lots could be strategically located far enough away to ensure a several minute walk into the health care facility.  However, security should be on hand to ensure continued employee safety.  Stairwells could be brightly lit and painted in bright and inviting colors or even filled with murals to welcome nurses to taking the stairs instead of elevators.

At the end of the day, exercise that addresses both the physical needs and emotional needs associated with our nursing population doesn’t have to be as bleak, unexciting and dreary as my personal workouts appear to be.  Washing windows may not be appealing, but gardening most likely is.  The hospital could host a beautify your neighborhood day with floral and tree plantings (donated by a local nursery) in locations within walking distance of the hospital.  Given this particular population has very unique physical and emotional needs associated with their chosen profession, I believe the medical institutions; themselves can offer practical, enjoyable solutions that nurture not only the body with exercise, but the spirit through camaraderie and friendship, all within the confines of the busy life associated with our study group.  The key to addressing these needs is to simply get nurses moving, in any fun way possible.

Addressing the Psychological Need Deficiency:
Our biggest problem aside from focusing on the preventative and rehabilitative care for the physical risks associated with nursing work is that of addressing the unique psychological needs associated with nursing professionals.  If an amazingly disproportionate number of nurses have a tendency to be overweight, based on our theory of emotional tendencies how can we begin to change their negative emotional response into a positive foray?  There is no one solution to counter this epidemic but there are multiple possibilities to be explored. 

Face it, every day nurses confront suffering, grief and death, dissimilar to the majority of the population.  Some of their tasks are mundane, unrewarding, and by most standards, distasteful, degrading and disgusting.  Most will not be able to rid themselves of the inappropriate transfer of these hefty psychological burdens without some professional assistance.  Quite frankly, the nurse practitioner needs help in developing a strategic method for ensuring the patient/nurse psychological boundary is not compromised.  Mental wellness counselors should be readily accessible to the nursing population through a work-based, early intervention strategy which provides appropriate, timely, professional and confidential counseling and referral services for staff (and their families) in order to assist them to identify and resolve professional, personal, health or work-related issues.  Private counseling services should be offered through the Employee Assistance Program, while group therapy should be offered as well.  Whether group therapy or individual therapy, these services should begin by establishing a trust relationship between the nurse and the counselor.  Collectively, the counselor in conjunction with the nurse practitioner, efforts should be made to build a strategy for tackling the unique emotional risk associated with their chosen occupation.  As these strategies succeed the nurse should be encouraged to relish in his or her own successes.  Mental health experts should help the nurses develop skills toward processing ambivalence, dealing with resistance, negotiating agreement and dealing with denial. (Catlin 253)

Some less mainstream therapies for addressing the psychological stress overload could be humor therapy.  “Experts say a good laugh relaxes tense muscles, speeds more oxygen into your system and lowers your blood pressure, lowers serum corstisol levels, increases the amount of activated T lymphocytes, increases the number and activity of natural killer cells, and increases the number of T cells that have helper/suppresser receptors.” ("Stress the Silent Killer”)  Nurse lounge televisions should be programmed with DVD’s of comedic sitcoms and filled with funny books.  Is it possible to rig the television to turn on only when someone is peddling an exercise bike?  Winners of the Fitness Challenges should receive complimentary tickets to comedy clubs.  Monthly, and encompassing all shift, local, new and talent budding comedians could be asked to volunteer their entertainment skills to perform comedic sets in house for the nursing population, as a light way to deal with the emotional burden of their roles. 
Music therapy falls under the category of having the ability to regulate emotions associated with stress, managing tension, thus facilitating relaxation and as such should be viable solution to helping nurses cope with their psychological stressors.  Music therapy can:

("Stress Management: Music Therapy for Stress & Anxiety")
Given the helpful nature of music therapy, a relatively easy solution is to play relaxing, peaceful music throughout the hospital corridor and at the nursing stations.  Perhaps a music therapist could be on staff to help employees in a group setting use music as a way to recognize their stress with the ultimate goal of developing newfound skills for relaxation through this unique therapy. 
Color therapy is a holistic therapy associated closely with moods and emotions and includes rainbow healing, color breathing, visualization and meditation, and illumination therapy to name a few.  The theory uses the body’s own sensitivity to color to identify and correct any imbalances in the body’s internal energy patterns that might lead to emotional or physical illness.  (Greenfield) This particular therapy could be offered on an individualized basis on the hospital campus free to all nursing staff. 
Art therapy is helpful to those individuals who have trouble identifying and putting words to their inner most feelings.  The premise for this particular therapy is the creativity helps people begin to understand themselves.  Generally the clinician, who is a psychotherapist or trained art therapist, instructs the ‘patient’ to express how they are feeling that day, that hour, or that particular minute.  The next step is for the artist to explain what their creation means, allowing the individual to externalize their problems or concerns, making the problem easier to deal with, and setting free negative emotions.  A secondary benefit is by the simple act of producing a piece of art, it provides people with a sense of control and self-esteem. (Hutson 20)

We should give consideration to massage therapy.  In a 2007,  twelve week study of emergency room nurses, it was determined between 60 and 65 percent of the nursing staff suffered quantitative measures from extreme anxiety due to stress.  During the course of this particular study, nurses were provided two, fifteen minute massages per week for twelve weeks, by a qualified therapist who sprayed aromatherapy mist above the heads of the study participants and then massaged their shoulders, midback, neck, scalp forehead and temples, wile they listened to relaxing music on headphones.  The number of staff feeling stressed fell to eight percent.  (Cooke 1695)  While this appears to be the first study of this nature, it appears to have positive measurable impact and could be another option in addressing the psychological need deficiency of nurses.  Another thought is not only to provide nurses with massage therapy, but to train them in massage therapy as well.  It could be a very physical manner in which nurses may rid themselves, in a rather passive aggressive manner, of their aggression as they work the frustrations out of another’s back or neck.  The physical exertion allows the nurses to vent their frustrations in a positive manner, rather than in a negative manner such as ingesting unnecessary calories.  A side benefit is it provides the nurses with a method of increasing their own exercise. 

Perhaps hospitals and medical institutions could offer group Life Coaching.  Life coaches aren’t necessarily there to promote bigger and better careers, but rather to focus on creating better employees within the given confines of the employee’s current role.  It provides a group venue for nurses to vent their frustrations, while allowing them opportunity to empower themselves and find creative solutions to the unique challenges of their vocation. 

As statistics have proven, if only in our clinical study population, it is evident more nurses are female.  Given this statistic, it would be prudent to offer a group therapy aimed at the female nursing demographic.  Feminist therapy focuses on “empowering women and helping them discover how to break free from traditional molds that may be blocking growth and development.” (Gerrig 35)  This particularly therapy focuses on strengthening women in their communication skills, ability to be assertive, help with self-esteem and relationships.  Perhaps this therapy would be particularly beneficial with the ability for nurses to avoid and or manage the transference and countertransference consequences of their given profession. 

Lastly, I would like to see hospital service providers offer on-site workshops specifically targeted to addressing the transference and countertransference issues of both male and female nurses.  As an additional incentive, these particular workshops should be designed in a manner that not only addresses the ramifications of the nursing occupation, but could be utilized as a source of fulfilling continuing educational requirements for nurses. 

While there does not seem to be one particular method preferred to address the psychological deficiencies of nurses, there are clearly multiple options that should be part of the ‘employee benefit packet’. 

It’s sad to realize one of our medical institution’s most valued asset, nurses, are a danger to themselves.  It is clear from our clinical study; nurses have higher trending patterns toward overweight and obesity as a result of significant and unique workplace psychological stressors.  Given the nature of the nursing occupation, it is highly unlikely these stressors will relieve themselves without proper intervention.  Medical institutions and nurses must take a proactive approach toward dealing with the stressors particularly common amongst their fellow practitioners.  If the nursing population does not take charge of these individualized threats, there will seemingly continue to be a repeat cycle of negative behavioral patterns, self-exhibited by excess weight gain.  Despite the evidence associated with our case study population, these destructive patterns can truly be negated through a variety of methods that encourages behavior modification and addresses the psychological need deficiency.  Nurse, please, heal thyself.  For we, the infirmed, and the weak, desperately need you. 

APPENDIX A:  Interview with Janee’ Pugnale

On Sunday, October 28, 2007, I had pre-arranged a conference call with Janee’ Pugnale, a 13 year career Neonatal Intensive Care Nurse at Duke University Hospital in an effort to discuss her perception of the work place stressors amongst nursing professionals.  The goal of my conversation was to personalize the nursing stress experience and in turn extract Ms. Pugnale’s own clinical perception of the response to stress amongst her colleagues.

Ms. Pugnale was introduced to me via a friend who had shared Weight Watchers Meetings with her.  Although I had never spoken with Ms. Pugnale prior to October 28th, I found her to be intelligent, witty, and forthcoming with her personal observations relating to my subject matter.  I began the discussion by explaining in brief to Ms. Pugnale the premise of my paper and my theory for curbing this trend amongst her professional associates.  At the conclusion of my synopsis of the paper, Ms. Pugnale freely admitted to “having more than a few pounds to lose.”  Rather candidly she defined those ‘few pound’ as approximately 50 pounds over the appropriate height for weight ratio for a five foot 2 inch woman.  She quickly volunteers that ‘Normal range’ is 104-132.

I was delighted to realize not only did I have the opportunity to interview a practicing clinician, but one who unwittingly supported my theory, if only by the numbers reflected on her scale.  Rather candidly, I started by asking Ms. Pugnale why she thought perhaps she was overweight?  Without hesitation, she states ‘the chronic stress’.  With further prompting from me she began to explain the stressors related to her job and those of her fellow associates.  She states that particularly in the NICU, one is dealing with intensely sick patients (usually premature babies).  Similar to my case study, it is ‘intensive care’. 

By sheer nature of the verbiage ‘intensive care’ one can glean the intensity of the atmosphere.  Ms. Pugnale went on to say it is almost crushing when the patient declines in health or dies.  In some ways, she feels that nurses take on the same pain the family and or sick person bears.  She says a nurse invests so much of themselves into the care of the patient and suffers extreme emotional defeat when a patient can not be healed.  She says that at least once a week, tears are shed by someone amongst this particular department.  She furthers her claims by stating the nurse ultimately feels responsible for the well-being and survival of every patient within their care and suffers emotions in a roller-coaster fashion.

I asked Ms. Pugnale if there are undue demands placed on them by the hospital administration, nursing administration, managed healthcare system, as well as by the supply or lack thereof of professional nurses.  In addition, I was curious to know if she had experienced the sense of a lack of respect for their individual contribution amidst the medical community and particularly in comparison to physicians.  Ms. Pugnale states that it is “sad and pathetic” what managed healthcare has done to care.  Her perception is everything is about rushing the patient through care, in some instances discharging them before they are really healthy.  She feels administration has zero respect for the recommendations of the nursing professionals.

Secondly, she feels the hospital administration and nursing administration places undue stress on the nursing staff by ‘shorting’ the shift and asking nurses to work double shifts.  “It’s no wonder we go through a drive through exhausted and hungry, woof it down, and then tumble into bed, sometimes without taking off our work clothes”.  I asked her how many times per week did she exhibit this type of behavior.  She states that at least 4 times per week she eats from a drive through, in her car, on the way home after a horrendous day on her feet, attempting to meet the needs of her tiny patients and their families.  It should be noted that she would agree there is a consensus amongst her colleges, they are seriously overworked and there seems to be no immediate end in site.
Sadly, it isn’t the stress that causes the overweight and obesity; instead it is their response to the stress that creates the issues of overweight and obesity.  I asked Ms. Pugnale what she eats during her shifts at the hospital.  She states, families are always dropping off ‘goodies’, such as candies, cookies, banana walnut bread, and even brownies.  Since there rarely is an opportunity to relax and go down to the cafeteria, quite often, she and her colleagues eat the sweets, drink a sugary soda, or purchase something from the visitor’s lounge vending machine located on their floor.  She states it is pretty rare for a patient’s family to send fruit.  Given the choice between fruit and sweets, she states her hand will reach for the sweets first.  I asked her why she doesn’t choose the fruit over the sweet….she states she believes the sweet meets her mood of the moment more than the fruit does.  She does realize the amount of extra calories she absorbs from this type of eating but during time of emotional crisis “frankly, I don’t care. I just want to feel better.”

We addressed the concerns surrounding the lack of physical exercise.  She says nurses are on their feet most of the day, tending to their sickly charges.  At the end of the 8-16 hour shift, there is no thought toward going to exercise; instead the only thought is of putting one’s hurting feet up and escaping by entertaining mindless dribble through the television.  She says most nurses don’t want to be needed for just a little while, so they watch television and snack on finger foods (not usually vegetables).  I asked Ms. Pugnale what she thought could/would help her with her ongoing quest for healthfulness as a nursing professional.  She states “remove the stress, delivery meals to my home, keep me off my feet for 8-16 hours per day and perhaps I would have the energy and enthusiasm to work toward a healthy future.”

On Thursday, November 1, 2007, I spoke with Ms. Pugnale again to thank her for her time with me earlier in the week.  I took the opportunity to ask her if she had any further observations to offer me at this time.  She states that she has been so busy and stressed at work that quite honestly she hasn’t had a second to rethink our conversation.  Sadly, case in point.



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