Patient Management: Their Journey of Change

by Douglas Sutton, EdD, ARNP, NP-C; Deborah A. Raines, PhD, RN, ANEF; and Natalie Murphy, MSN, FNP-BC

Introduction

Weight reduction is the most obvious—and often most celebrated—outcome that results following bariatric surgery. As clinicians, we must be reminded that for our patients this physical metamorphosis has been many years in the making. While we often begin our assessment of the client by determining the number of days, months,or years postoperative a client is, we forget that the decision to seek information about bariatric surgery, and then to ultimately undergo a weight loss procedure, takes months and years for most people. This article focuses on both the presurgical decision-making period as well as the postsurgical experience of 14 patients who underwent Roux-en-Y gastric bypass surgery and shared their story as part of a larger, descriptive, qualitative study focused on women who chose to undergo a surgical weight loss intervention. While the change after surgery was captivating, dramatic, and life altering, this article will also focus on understanding the journey of change and its impact on those who undergo bariatric surgery.

As part of a larger study on the lived experiences of women who have undergone a surgical weight loss intervention, we noted a dominant, strong, postsurgical theme that we simply referred to as change. Because qualitative research attempts to bring understanding to the experiences of the participants, it became clear that this experience was dramatic and a life-altering change, and it was associated with a complete physical metamorphosis that one subject referred to as her “meltdown.” In keeping with the norms of qualitative research, the research team situated the results within a body of literature that follows the Results section in this article.

Research Question
This paper describes the phenomenon of change as experienced by women who have undergone bariatric surgery and is derived from the following research question: “How has your life changed as a result of having bariatric surgery?”

Study Design and Methods
The study proposal was approved by our university’s IRB; following completion of the informed consent procedures, a research assistant contacted participants to schedule the interviews. The interviews were conducted by phone and were audiotaped with the participants knowledge and assent. The same research assistant conducted all the interviews to increase the consistency in the interview format and process. The goal of the research was to illustrate and understand the individual experiences of the participants. As a result of data analysis, the phenomenon of change emerged from interviews conducted with women who underwent a surgical intervention to manage their obesity.

Purposeful sampling was used to identify individuals who had undergone a surgical weight loss intervention. A semi-structured interview was conducted using an interview guide. The interview consisted of open-ended questions to allow participants to fully explain the thoughts and decisions leading to their surgery, as well as their experiences following surgery. This article reports the findings related to change experienced by participants. Data were collected and analyzed over a four-month period in mid-2008.

The research assistant/ interviewer was a registered nurse enrolled in a doctoral program. The research assistant had no experience with bariatric patients; therefore, the potential introduction of bias in the data collection process was minimized. The interviewer’s use of field notes during the interview enhanced the reproducibility of the data. The audiotaped interviews were converted to text transcripts by a paid transcriptionist and generated over 300 typed pages of data. As each transcript was ready, the researchers read the transcript and compared it to the audio file for accuracy and to minimize transcription errors.

Data collection and preliminary analysis was done concurrently, allowing identification of coding, validation of the emerging codes with participants, and gathering of additional information for verification, relevance, and saturation. Data was considered saturated by dense categories that made sense and with no new data emerging. These criteria were achieved after 11 participants shared their experiences. No new data emerged in the last three interviews; therefore, data gathering was terminated.

The transcripts were analyzed for common themes as appropriate for phenomenological inquiry.[1] Words, statements, and paragraphs were extracted that expressed the change these women experienced. Themes were exemplified by quotes that provide a rich description of the meaning. Initially, each member of the research team analyzed the data using a common organizing structure. Then the team came together to share and discuss the individual analysis, to identify common findings and to verify the meaning of the data. This process enhanced the trustworthiness and reproducibility of the findings and verified that the themes identified reflected the participant’s experiences and captured the meanings. An audit trail was established through the field notes maintained by the interviewer during the interviews and notations by all researchers during the transcription, coding, and organizing of the data in the analysis process.

Assumptions
This study was based on the following assumptions:
1.    Participants were honest in their responses to interview questions.
2.    Participants were comfortable with answering interview questions regarding bariatric surgery and their lived experience.
3.    Participants did not intentionally withhold aspects of their experiences with bariatric surgery.
4.    Some participants were more articulate than others.

Delimitations
The following delimitations should be considered when interpreting results of this study:
1.    This study sample included only women.
2.    Participants were required to be beyond two years postsurgical.

Limitations
The following limitations should be considered when interpreting results of this study:
1.    There was a possibility that participants’ recall of life experiences after bariatric surgery were influenced by subsequent events or limited memory.
2.    Study results are not intended to be generalizable to the general population.
3.    Research team members’ beliefs and experiences might have influenced data analysis and conclusions.

Results

Change was a consistent theme among all 14 women who had bariatric surgery between 1995 and 2006. All participants were beyond the two-year anniversary of their surgical intervention, with 80 percent of the sample beyond their fifth year, thereby allowing adequate time for reflection and integration of the meaning of the experience. The participants ranged in age from 28 to 63 years and were educated, having all completed high school and taken or completed college level coursework. The amount of weight lost following surgery ranged from a high of 167 pounds to a low of 72 pounds.

Change was physical and psychological as well as intrapersonal and interpersonal. The first to occur, and the most obvious, was the physical change in body size related to the rapid and dramatic weight loss that occurs during the first months following surgery.

The quote that cited the initial weight loss experience as a meltdown was the following: “It’s such a major physical change…to lose a hundred pounds in a couple of months. It’s like losing another person literally; it was a major meltdown.”

The weight loss lead to a physical change in appearance, which leads to interpersonal change or a change in the way others acted and reacted to the women. Most of the changes in their interpersonal relationships were positive, such as the following: strangers opening doors for the patient, someone complimenting the patient, being offered help at the Home Depot, and being able to play kickball with their children. However, one participant described a negative reaction from her husband related to her changing appearance.

“He [her husband] was not enthusiastic about my weight loss and the change in my body. He got progressively angry about the whole thing. When anybody who would look at me or compliment me, he really didn’t like it.”

Participants frequently mentioned the intrapersonal process of change following their surgery. Initially, many of the women experienced periods of sobbing and often questioned what they had done: “I was sobbing and wondering what had I done…I was a fat person in a thin body.” The dramatic, transformative nature of the change was a common experience for all participants and was repeatedly mentioned such as in the following examples:

“It transformed my life.”
“It’s a major life change.”
“I had to come to terms with the change…I call it my re-birthday.”
“It’s different than any other life-changing event…Weight loss surgery is a huge life-changing event.”

Ultimately, psychological change occurs as the individual recognizes and adapts to the change in self, as reflected in the following quotes:

“It took about 1 to 2 years for my mind to catch up to the physical change in my body.”
“Change means learning new habits, exercising, and changing the way I look at things; now I see possibilities.”
“You need to change your mindset because the physical changes are dramatic.”

Overall, the change resulting from weight loss surgery was viewed positively. However, it was a process that requires ongoing support from others as the individual adapts to the change, both internally and externally. One participant nicely captured the magnitude of her metamorphosis following weight loss surgery when she gave the following observation: “It’s a viable option if you are prepared to change everything about your life.”

Behavioral Change Literature Review
This section develops a theoretical model that will attempt to explore change in persons who undergo bariatric surgery. The personal decision to undergo a rapid metamorphosis is as much cognitive as is the anatomical change performed by the surgeon. Therefore, it is incumbent for persons involved in the presurgical and postsurgical care of persons who undergo a surgical weight loss intervention to understand the process of change, particularly as it relates to change from a prior behavior pattern to a new behavior pattern. The process begins with an event often referred to as the “trigger” of change.[2,3,4] The nature, duration, and endpoint of the trigger to change may take several different forms. For example, Fox et al believed that change in one’s behavior occurs only after the significance of change is understood.[5] Taylor suggested that the trigger may actually be the result of a more subtle culmination of long-term dissatisfaction with current behavior, while Lyon suggested that a trigger occurs in stages.[6,7] After listening to the stories of these participants, it becomes clear that the extent of the change is not realized until well after the trigger has been reached.
The experience of change is the subject of many concepts and theories that are predominantly grounded in a behaviorist orientation to learning a new behavior.[8-11] In terms of how such learning is accomplished, Fox et al stated that learning could be implicit, and/or reactive, and/or deliberate.[5] What has not been discussed is that learning can be exhilarating and sustaining in and of itself.

Alternatively, the constructivist orientation to learning a new behavior contributes the added element of something referred to as perspective transformation, which is something that changes an entire perspective or vision of the individual and seems to play an essential role in ensuring that an individual sustains the change in behavior long after the trigger event. Therefore, the constructivist view of learning a new behavior is typified in transformative learning theory.[4,12]

The behaviorist orientation to learning is grounded in the belief that learning is evidenced by a change in behavior.[13] Behaviorists believe that if a new behavioral pattern is repeated often enough, it will eventually become automatic. In comparison, the constructivist view reflects a more philosophical view of learning that is founded on the supposition that, by reflecting on our experiences, we construct a new and personal understanding of the world in which we live.[10] Each of us generates our own rules and mental models, which we then use to make sense of our experiences. Therefore, the constructivist orientation introduces the added element of a learned and valued adaptation of our internal representation of the world, in learning.

Behaviorist theoretical frameworks have traditionally informed many of the intended behavior change initiatives in current practice and, as such, their significance cannot be ignored or diminished.[14] These frameworks range from classic change theory through stage theories like Prochaska’s transtheoretical model of change,[11] Ajzen and Fishbein’s theory[8] of planned behavior, and Bandura’s social cognitive theory,[15] with his emphasis on the role of self-efficacy beliefs.[9] These and other theories and concepts—developed in light of the need to address health behavior change in particular—contribute to the current conceptualization of behavior change and maintenance.[14] However, while behavior change theories can explain how a change in behavior may be initiated, they fall well short of explaining the basis for sustaining the change into the future.[16,17] What they do is to “explain behavior and suggest ways to achieve behavior change,” which does not necessarily extend to sustaining the new behavior, particularly when environmental and personal factors are in a state of flux.[18] This theoretical challenge remains in spite of extensive empirical studies on behavior change.

The added value of looking at an intended behavior change from the constructivist perspective becomes evident when the elements of behavior change theory are viewed parallel to those of transformative learning theory. Figure 1 illustrates such a comparison. This illustration is represented linearly only for purposes of clarity and does not mean to imply that behavior change follows an unwavering pattern.

This comparison highlights some common elements of the behaviorist and constructivist orientations to behavior change. The first of these is a trigger that precipitates behavior change. The significance of such an event or circumstance in behavior change is well established and extensively explored in the literature.[2-4] A trigger is not always a sudden episodic event but can in fact occur imperceptibly over a period of time.[19-21] For the bariatric surgical client, this gradual trigger recognition may be the culmination of months and years of contemplation that ultimately results in the decision to undergo bariatric surgery.

Second, common to both orientations is an intention to change the behavior. In behavior change theory, the theory of reasoned action and the transtheoretical model of change emphasize that individual performance of a given behavior is determined by a person’s intention to perform that behavior.[8,11] In transformative learning theory, Cranton described a phase where individuals would “explore options for new behaviors and build competence for new roles.”[22] This stage is often recognized in the presurgical candidate when he or she is exploring the various types of bariatric surgical procedures, or when he or she compares bariatric surgery to another form of structured weight loss. As the person builds the knowledge, he or she is gaining competence in the decision-making process.

The third common element preceding change in behavior in both orientations is the plan to change behavior. Sometimes, the line between intention and planning is blurred. However, Prochaska et al[11] described a distinct phase of “preparation,” while Mezirow[4] pointed out a stage in the transformation process that he described as “planning a course of action.” From the viewpoint of the bariatric surgical patient, this may be the point where the personal decision is made to pursue a surgical intervention as a means of treatment for morbid obesity.

Subsequent to when the trigger, intention, and plan to change a behavior have all occurred, there appears the distinctive difference between the behavioral perspective and the constructivist perspective, which is referred to as the perspective transformation, and is a critical component of transformative learning theory. This difference is represented only in the constructivist theory. It is important that clinicians understand that perspective transformation occurs in the following three stages: 1) becoming critically aware of how and why our assumptions have come to restrict the way we perceive, understand, and feel about our world; 2) changing the framework of old habits with an expectation to make possible a more inclusive, discriminating, and integrating perspective; and 3) making choices or otherwise acting upon this new understanding.[4] Perspective transformation allows for a shift in an individual’s mindset, whereby according to Mezirow’s theory,[4] once an individual has moved forward to a new meaning perspective, he or she does not return to perspectives of the past. For this reason, perspective transformation offers a means of conceptualizing behavior change that is sustained over the long term. Since this study was inclusive of persons who had undergone bariatric surgery two or more years prior, it is important to understand the differences between the two theoretical frameworks. This understanding provides clarity when reading their words of change.

Discussion/Conclusion

It is clear that measuring or evaluating change in persons who have undergone a surgical weight loss intervention is both personal and complex. While the obvious physical changes are celebrated, it is the change that occurs cognitively that will sustain the new and emerging person who is undergoing transformation. As researchers who have studied this population on several prior occasions it is troublesome that cognitive change is not as well nurtured and measured as the physical change.[23-27] It is often much easier to collect weight, blood pressure, blood sugar, and cholesterol measurements than it is to evaluate the mental state of a person who is undergoing or has undergone a complex surgical procedure that has altered all previous facets of their daily life. However, it is incumbent that research efforts focus on the entire person and not simply the biophysical metamorphosis.

No theory can explain all of the personal variables that an individual experiences after undergoing bariatric surgery. It is frustrating for both healthcare professionals, as well as for the individual person who undergoes bariatric surgery, when initial efforts to achieve long-term lifestyle changes to sustain and maintain weight loss suddenly and unfortunately do not persist. Internal and external factors impact an individual in explicit ways, whereas theoretical frameworks offer a more flexible approach for applying abstract concepts of theory to real circumstances. When healthcare professionals become familiar with behavior change theories, clinicians gain access to tools that facilitate creative solutions to personal circumstances. Clinicians can use a theoretical framework to formulate questions and generate interventions that will help them identify factors that may mitigate failure. Behavior change theory is not reserved only for academics and researchers, but instead can be applied to problems clinicians face every day. The abstract nature of theory helps clinicians to understand the factors underlying real situations and to reconceptualize solutions.

Nursing is a discipline of knowledge and a field of professional practice grounded in caring. Nursing makes a unique contribution because of its focus on nurturing the wholeness of persons and environment through caring. Caring in nursing is a mutual human process in which the nurse responds to the needs of the person. In order to foster the complex change that is required of an obese person who undergoes bariatric surgery, all caregivers should listen with authentic presence to the specific needs of each person, and competent professional care should be available to facilitate this most wonderful and celebrated journey of change.

Acknowledgement

The authors would like to acknowledge the National Association of Bariatric Nursing and the Florida Atlantic University Iota Xi Chapter of Sigma Theta Tau for their financial support of this research project.

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Category: Original Research, Past Articles