Higher education institutions (HEIs) are tasked with equipping newly qualified midwives with the skills, knowledge and understanding they need to care for pregnant women. This includes being able to demonstrate all of the 6Cs in their practice: caring, compassion, competence, communication, courage and commitment (Department of Health, 2012).
Using obesity (defined as having a body mass index (BMI) ≥ 30 kg/m2) as a case study, this article presents a series of teaching techniques aimed at enhancing the teaching of the 6Cs in pre-registration midwifery education. In particular, we will use four of the 6Cs—caring, compassion, communication and courage—to frame this article, on the basis that evidence suggests that improvements in these key areas could have a significant impact on improving women's experience of maternity services (Deery and Wray, 2009; Phelan et al, 2015). The case study of obesity was selected to demonstrate the value of teaching innovations in the 6Cs for two reasons. Firstly, because obesity has been identified as one of the most significant current issues facing midwifery (Royal College of Midwives, 2013); despite this, obesity training for health professionals has been found to be inadequate (Fillingham et al, 2014). Secondly, because there is a growing body of concerning evidence to suggest that health-care students and professionals (including midwives) may hold negative, even discriminatory attitudes towards obesity, seeing the condition as a sign of lack of self-control (Schmied et al, 2011; Keyworth et al, 2013). Not surprisingly, research suggests that the lived experience of receiving maternity care when obese is far from positive (Deery and Wray, 2009; Furber and McGowan, 2011). Phelan et al (2015), in their review on obesity stigma, outline how individuals are affected by negative attitudes towards weight. This includes individuals feeling devalued and stereotyped which, in turn, threatens their sense of identity and self-worth. It is the apparent lack of professional principles—including caring, compassion, communication and courage—which makes these findings of particular concern.
This case study is part of a larger programme of work on obesity management training for pre-registration education that is currently being carried out at the Centre for Maternal and Child Health Research at City University London. This article builds on previous work (Olander and Scamell, 2016) where the current focus is to reflect on this work in an effort to move the discussion from a largely academic debate towards a set of tangible practice recommendations based on transformative learning (Mezirow, 1997). In this article, we look at caring, compassion, communication and courage in relation to obesity education with the aim of suggesting practical steps (not yet evaluated) that can be considered when teaching student midwives about obesity and obesity management. The overall objective is to provide practical ways to avoid perpetuating the stigmatising attitudes that currently undermine the success of obesity management in maternity services, and in the NHS more widely (Phelan et al, 2015), and thereby help to improve the quality of care for individuals living with obesity.
The article will be divided into four discrete learning activities. Each learning activity can be completed using a variety of approaches. Table 1 provides a summary of how the different activities described could be organised.
| Exercise | Learning environment | Individual or group task |
|---|---|---|
| Creating a caring environment (C1: caring) | Face-to-face |
Small group task |
| Bariatric simulation (C2: compassion) | Face-to-face | Small group task |
| Word game (C3: communication) | Face-to-face |
Small group task |
| Reflection on own weight (C4: courage) | Face-to-face |
Individual task |
C1: Caring and obesity—creating a caring environment
As care is described as ‘our core business and that of our organisations’ (Department of Health, 2012: 13), creating a weight-sensitive environment is paramount when providing woman-centred care to pregnant women with obesity. Phelan et al (2015) suggest that individuals with obesity can suffer from threats to their identity caused by stereotyping and stigmatising attitudes and actions of health professionals. This includes not considering the woman's individual circumstances; recent research suggests that antenatal care providers may need to work in partnership with women to provide weight-related care (Olander et al, 2015).
Research with midwives suggests that there is an underlying sense of discomfort in caring for pregnant women with obesity, with some midwives regarding it as a burden (Schmied et al, 2011). In addition to creating a positive and caring psychosocial environment, the physical environment is also important, to ensure the best quality of care for women with high BMI. Having furniture positioned in such a way that allows women of all sizes to move around freely in the clinical space, or having appropriate equipment to hand, should be considered carefully when creating a non-stigmatising caring environment (Phelan et al, 2015). A physical environment where furniture and medical equipment is appropriate for women with obesity will make them feel more welcome (DeJoy et al, 2016).
Providing students with a learning opportunity where they can consider the importance of a weight-sensitive clinical environment encourages insight into the significance of physical space when caring for this client group. The learning activity should be designed to enable students to think proactively about the contribution they can make towards creating a caring environment. Using interior design tools (either virtual or hard-copy), students can be encouraged to design their own clinical space where every element of the space, including position and size of furniture and examination equipment, must demonstrate attention to weight-sensitivity. This activity can be used to stimulate discussion and reflection on how placement areas could be adapted to ensure a less stigmatising clinical space for obese women. Thinking about these seemingly benign, smaller details can enable the most significant learning and enhance caring.
C2: Compassion and obesity—bariatric simulation
Compassion is defined by the Department of Health (2012: 13) as ‘how care is given through relationships based on empathy, respect and dignity… [or] intelligent kindness’. Evidence which suggests that the negative attitudes of health professionals towards weight can have a detrimental impact on the way they care for patients is not consistent with this definition (Keyworth et al, 2013; Phelan et al, 2015). Midwives, for example, have been found to have high levels of intolerance of pregnant women with obesity (Schmied et al, 2011); this may erode the potential for compassionate care when working with this client group. Helping students become aware of their own views and attitudes towards pregnant women with obesity should be an essential component of all pre-registration obesity training. One way to do this is to create a learning exercise around compassion and obesity.
Drawing from the inspiration provided by the ‘Whose shoes’ change campaign (Phillips, 2015), the activity described here aims to unsettle any feelings of intolerance by developing a more compassionate approach through empathy.
The use of bariatric suits is well-established as a means for developing students' skills in physically handling women with obesity. The suit's ability to expose prejudice, however, is less developed. Using bariatric suits to encourage students to reflect on their emotional reactions to obesity—from the perspective of both the pregnant woman and the midwife—may help students to challenge their own attitudes towards obese women. To ensure effective learning, the environment should be suitably prepared; for example, using seats with fixed armrests, birthing stools, birthing balls and so on. This preparation will reinforce the learning from the environment exercise described above.
During the activity, the task facilitator can make observations on the emotional reactions of all the students involved in the exercise, and these observations can be used to frame a debrief discussion that should take place at the end of this part of the task. Students should be encouraged to reflect on how it felt to be faced with chairs that were too small, and any other equipment that is clearly not designed for use by people with obesity (Phelan et al, 2015).
In the authors' experience, this innovative use of the bariatric suit is not only highly evaluated by students, it provides a genuine opportunity to experience the health-care environment from an obese woman's perspective. The emotional reactions are often in the realm of great amusement—always a useful devise for maintaining student attention and interest in the learning. But such reactions have a more sinister side, which can be fully explored in the structured debriefing session. Questions that can be posed to the group during structured feedback sessions should include:
Drawing historical comparisons of social groups that have previously been stereotyped and categorised as ‘clowns’—for example, specific ethnic groups (Boskin and Dorinson, 1985) or people with disabilities (Adelson, 2005)—can be helpful to add a cross-cultural comparison that draws attention to the social construction of current attitudes towards obesity. The insight this kind of reflection provides is a powerful tool for unpicking why compassion can be so confined within this area of maternity care; moreover, it offers a vivid illustration of why unempathetic attitudes towards women with high BMI should never be accepted in maternity services.
C3: Communication and obesity—word games
Communication is described as being ‘the key to a good workplace with benefits for those in our care and staff alike’ (Department of Health, 2012: 13). Crucial to this are the words we choose when talking about body weight (Berg, 1998). Evidence shows that pregnant women with obesity consistently report poor communication regarding their weight by health professionals (Heslehurst et al, 2015; Lavender and Smith, 2016), suggesting that it is important for student midwives to reflect on the language they use when discussing weight with pregnant women with obesity.
One activity to help students with this is a simple word-association game with the purpose of encouraging student reflection on deep-seated and rarely acknowledged prejudices that may influence language choice and communication around obesity. The word the students could be working with in this activity may be ‘obesity’. The game could involve either a chain association process or a simpler brainstorming approach. The objective of the former would be to create a word chain that every student must take turns in recalling. If a student forgets any of the words in the chain, they are out of the game. The game would come to an end when only one student is left participating. For example, the first student in the group would repeat the word ‘obesity’ and add their word(s)—‘body fat’; the second student must then repeat the words ‘obesity, body fat’ and then add their own word(s)—‘adipose tissue’, and so on. An advantage of opting for this word chain approach is that it offers more scope for creating a less formal learning environment through the creation of a learning game and thereby potentially increasing the impact of the learning (Cowan, 1974). The disadvantage of this approach is that it only really works in the face-to-face teaching context.
In the brainstorming approach to this word association activity, each contribution made by every student would be an association from the original word, ‘obesity’. The task would be to build a word association mind map around ‘obesity’. All associated words suggested should be captured on either a virtual word cloud or mind map. The brainstorm approach has more flexibility in how it can be achieved.
The idea behind the word game examples described here is not to elicit contemplation or reflection in the first instance; the reflection comes later. It is hoped that this initial activity will help to expose some of the taken-for-granted understandings and feelings associated with the language of obesity, enabling the students to reflect on the normative nature of this language. If the games are played to strict time limits, the spontaneity of the thought processes captured in the exercise is likely to be strengthened.
Feedback sessions are an essential component of the word games, as these will enable the students to explore the practice implications of the games. If we return to the word chain example, these words suggest a particular approach to obesity that is framed within a medicalised discourse. A preoccupation with the risks associated with obesity is argued by many to be over-simplistic, neglecting social structures and social inequalities as factors influencing health (Dumas et al, 2014). This reductionist approach to body weight implicit in the medicalised language can be discussed with students in a feedback exercise (again, either virtual or face-to-face) and a responsive reading list can be developed to deepen the students' understanding of the frames of reference and structures of assumptions through which they understand the issue of obesity. The example outlined here looks at just three or four seemingly benign words that can be associated with obesity. In being provided with the opportunity to identify this language, and then critically reflect on it with structured guided study, students will have a chance to explore the limitations and potential prejudices implicit in language choice, enabling them to develop a more sensitive and empathetic communication style.
As the care of women with complex health issues such as high BMI involves a multidisciplinary team, there is a danger that student midwives' training in this area could be undermined in practice. A unified approach to health professional training and communication could facilitate effective and sensitive use of language across the different professional groups involved in maternity services provision, but such recommendations are beyond the aims of this article.
C4: Courage and obesity—reflection on stigma
The fourth C is courage, and this applies to both teaching staff and student midwives. Courage is needed by teaching staff to tackle obesity as a form of stigma with their students. In particular, teaching obesity stigma demands the teacher to first be courageous about his or her own views and prejudices on what causes obesity, who becomes obese, and the care pregnant women with obesity require. Subsequently, it demands acknowledgement that pregnant women with obesity may not receive the same quality of woman-centred care as other pregnant women.
Similarly, courageous thinking should be encouraged in students. Broaching the topic of weight issues is recognised as being difficult when caring for pregnant women with obesity (Heslehurst et al, 2011). Lacking the confidence to discuss weight may be compounded and complicated by attitudes towards the student's own weight. Thus an initial task for the students can be to reflect on how they feel about their own body weight and the factors influencing their own weight. It is preferable for this task to be undertaken individually, as reflecting on this can evoke powerful emotional reactions. This reflective learning can be supported by face-to-face or online discussion based around the findings of the Foresight report (Butland et al, 2007), where students have the opportunity to explore the complex causes of obesity.
The aim of these tasks is for the student to recognise and be able to identify different factors such as how food habits, cultural expectations and peer groups influence individuals differently. For example, interrogating their own relationship to food and body weight, along with the findings of the Foresight report, may help students understand why weight is not everyone's priority or why some individuals find weight management difficult. Such insights may provide students with the necessary courage to tackle the topic in a way that can avoid stigma and incorporates a woman-centred approach to care. To further motivate students to be courageous and discuss weight with pregnant women, educators should remind them that many women expect midwives to tell them about all clinically important issues, including BMI (Olander et al, 2011), and that woman-centred care is something women want irrespective of weight status (Arden et al, 2014).
Discussion and authors' reflection
While little has been published on midwifery education with regard to obesity, inferences from the nursing literature suggest that it is likely to be of low quality (Fillingham et al, 2014), insufficient (Keyworth et al, 2013) and with little focus on how obesity is a stigmatised condition. Research into effective educational interventions for student midwives and nurses on weight management is urgently needed (Fillingham et al, 2014). The rapid expansion of this area of care within maternity services makes the current lack of evidence on how to teach weight management particularly worrying. In writing this article, we hope to have taken an initial step towards problematising the current pre-registration midwifery education provision on maternal obesity.
‘ The way in which academics and teachers view obesity is likely to influence how it is taught and, ultimately, how pregnant women with obesity are cared for ’
While the focus of this article has been on how student midwives might be enabled to think and talk about obesity in ways that are both caring and compassionate, we would also like to acknowledge that just as obesity discrimination is common among health professionals, it may also exist among academics tasked with teaching students about obesity. Although this research, as yet, has not been carried out, the issue of accountability of midwifery educators must also be highlighted. This means that an awareness of views and feelings about obesity and its causes is an essential prerequisite for teaching the subject, as well as placing this topic high on the research agenda. The proposition being made here is that the way in which academics and teachers view obesity is likely to influence how it is taught and, ultimately, how pregnant women with obesity are cared for.
Conclusion
By taking four of the 6Cs set out in the Department of Health's (2012) Compassion in Practice report, we have been able to present an educational case study of obesity. The literature around the quality of care for those living with obesity makes this a compelling case study for exploring how best to teach the tenets of compassion in practice. Through the application of innovative styles of learning that include creativity, spontaneity, inclusion and reflection, we suggest that it is possible to encourage woman-centred, empathetic care that is underpinned by courageous and sensitive communication. Through the practical suggestions in this article, we hope to encourage debate and strengthen the call for further research in this area of midwifery education.