Clinical Scholarship

Nurses’ Body Size and Public Confidence in Abilityto Provide Health EducationMary Hicks, Laura L. McDermott, Nicole Rouhana, Melissa Schmidt, Megan Wood Seymour,Tina Sullivan

Purpose: To replicate research about confidence level in receiving health teaching from eitheran overweight or a weight-appropriate RN.

Methods: A quasi-experimental post-test only design was used. Participants were randomlyassigned to be shown images of a nurse, either overweight or weight-appropriate, thenasked to rate their confidence in health teaching received from that nurse. Descriptivestatistics, t test for independent samples, and covariate analyses were performed.

Results: A significant difference in confidence p=0.000 was noted between participants whoviewed the image of a weight-appropriate nurse and participants who viewed the image ofan overweight nurse.

Conclusions: Weight-appropriate nurses may inspire more confidence in their teaching. Fur-ther study is indicated to explore the implications of these findings for practice.

Clinical Relevance: Nurses need to be conscious of clients’ perceptions of weight whenplanning teaching interventions.

[Key words: patient education, health education, nurse-patient relations, obesity,quantitative methodology]

JOURNAL OF NURSING SCHOLARSHIP, 2008; 40:4, 349–354. C©2008 SIGMA THETA TAU INTERNATIONAL.

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Obesity and overweight, with all their attendanthealth consequences, have reached epidemic levelsin the United States (Chang, Liou, Sheu, & Chen,

2004; Daniels, 2006; Rogge, Greenwald, & Golden, 2004;Tricas-Sauras, 2006). Approximately 65% of Americans areoverweight, defined as having a body mass index (BMI) be-tween 25 and 29.9; obese, defined as having a BMI between30 and 39.9; or morbidly obese, defined as having a BMIover 40, and these figures show at least a two-fold increaseover the last 30 years (Daniels, 2006). This is not a uniquelyAmerican issue, however, and few countries are unaffectedby this epidemic (Green, 2006). In addition, in a recent sur-vey of 760 nurses Miller, Alpert, and Cross (2008) foundthat 54% were overweight or obese, with a mean BMI of27.2. Although a variety of theories exist about the causesof this increase, including genetics, environment, evolution,diet, and lifestyle, there is little doubt about the conse-quences. Being over one’s ideal BMI has been linked con-clusively to significant increases in risk for diabetes, heartdisease, dyslipidemia, arthritis, sleep apnea, gallstones, andmany cancers, including breast, colon, uterus, pancreas, andkidney. Obesity is now considered the leading preventablecause of morbidity and mortality (Daniels, 2006; Roggeet al., 2004).

Educating patients about their health has long beenamong the primary roles and responsibilities of profes-sional nursing (Borchardt, 2000; Clarke, 1991; Connolly,Gulanick, Keough, & Holm, 1997; O’Connor, 2002). Giventhe significant increase in rates of obesity and the healthrisks associated with being obese, teaching about diet, ex-ercise, and healthy lifestyles is, and will continue to be, thefocus of a lot of the patient education in which nurses en-gage. However, many nurses may feel uncomfortable ad-dressing this topic with patients because of the sensitivenature of the subject. One study indicated that while 93%

Mary Hicks, RN, MS, Zeta Iota, Teaching Assistant, Binghamton University,Binghamton, NY; Laura L. McDermott, MS, RN, FNP, Zeta Iota, Clinical In-structor, Binghamton University, Binghamton, NY; Nicole Rouhana, MS,CNM, FNP-C, Zeta Iota, Clinical Assistant Professor, Stony Brook Uni-versity School of Nursing, Stony Brook, NY; Melissa Schmidt, RN, MS,Assistant Professor, Tompkins Cortland Community College, Dryden, NY;Megan Wood Seymour, RN, MS, Zeta Iota, Doctoral Student, BinghamtonUniversity, Binghamton, NY; Tina Sullivan, RN, MS, FNP-C, Omicron Rho,Assistant Professor, Hartwick College, Oneonta, NY. This project was sup-ported in part by Nursing 606: Advanced Research Practicum, Doctoralprogram in Rural Nursing, Decker School of Nursing, Binghamton Univer-sity, NY. Correspondence to Ms. Seymour, 24 Vine St., Binghamton, NY13903. E-mail: mwood5@binghamton.edu

Accepted for publication July 21, 2008.

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of nurses acknowledge the importance of interventions tar-geting obesity, 76% reported that they do not routinelydiscuss the topic with their patients (Miller et al., 2008).There is considerable evidence that social stigma is attachedto being obese, and that nurses are as likely both to ex-perience and to project these opinions as are the rest ofthe population (Chang et al., 2004; Daniels, 2006; Roggeet al., 2004; Tricas-Sauras, 2006; Wright, 1998). In ad-dition, a certain amount of controversy exists regardingwhether nurses have a responsibility to serve as role mod-els of healthy behaviors (Borchardt, 2000; Clarke, 1991;Connolly et al., 1997; Dunkley & Ward, 2005; Durrett &Goog, 1983; Eliopoulos & Lagana, 1999; Frost, Jorgensen,& Hounsgaard, 2006; Gomez, 1999; Narayanasamy &Narayanasamy, 2006; O’Connor, 2002; Rush, Kee, & Rice,2005; Swaffield, 1986).

Literature that indicates the effect of a nurse’s weighton the confidence patients have in receiving health teachingfrom that nurse is sparse. If nurses are to be an effective partof the effort to reduce obesity, more must be known aboutthe perceptions of potential clients. In addition, replicationis an important link in the synthesis and verification of newknowledge (Fahs, Morgan, & Kalman, 2003). In this study,therefore, we replicate a previous study in which investiga-tors examined the relationship between a nurse’s body sizeand perceived confidence in health teaching received fromthat nurse (Wells, Lever, & Austin, 2006).

Background

A large body of research literature indicates the healthconsequences of obesity, but there are also psychosocial con-sequences. Many obese people report feeling stigmatizedbecause of their weight, and also report incidents in whichthey experienced discrimination and even humiliation be-cause of their weight (Daniels, 2006; Rogge et al., 2004).Obesity has also been linked to low self-esteem, poor self-image, depression, and social isolation (Chang et al., 2004;Daniels, 2006). Even more significant for nurses, health-care providers often share the same negative attitudes to-ward obese people as does society in general (Daniels, 2006;Tricas-Sauras, 2006; Wright, 1998).

The average American nurse is a woman in her midto late 40s, an age at which 28% of women are overweightand 37% are obese (Daniels, 2006). Overweight nurses havereported feeling uncomfortable providing education aboutweight loss to their clients (Wright, 1998); and have alsoreported that obese patients do not trust them regardinghealth teaching and are unable to perceive them as role mod-els (Frost et al., 2006). Conversely, other researchers havefound that nurses who were engaged in healthy lifestylesthemselves were more comfortable teaching clients aboutthese topics (Dunkley & Ward, 2005). Borchardt (2000) ex-pressed the belief that nurses with healthy lifestyle habits willteach patients with more confidence; and O’Connor (2002)emphasized the responsibility of nurse leaders to present

positive and healthy role models to the rest of the nurs-ing workforce. In another study, critical-care nurses whopracticed healthy habits believed that they were good rolemodels for patients (Connolly et al., 1997).

The degree to which nurses are actually seen by patientsas role models, or ought to see themselves in that way is,however, somewhat controversial. Nurses may place thisresponsibility on themselves, or believe that society expectsit (Rush et al., 2005). One commentator noted that, “ad-vocates of health promotion need to demonstrate credibil-ity with users,” (Narayanasamy & Narayanasamy, 2006,p. 538), by refraining from unhealthy habits, such as smok-ing, and modeling positive ones, such as healthy diet andexercise, while others have also questioned the credibility ofobese nurses (Durrett & Good, 1983).

Other authors disagree, however, debating the appro-priateness of nurses being held responsible for being healthyrole models (Eliopoulos & Lagana, 1999). Clarke (1991)concluded that effective patient teaching has more to dowith who the nurse is, than what health behaviors he orshe performs, and that personal integrity, self-awareness,warmth, empathy, respect, and genuineness are more im-portant in establishing patients’ trust in the nurse’s teachingthan is outward appearance. There is also a concern that atleast some of the unhealthy behaviors practiced by nursesare related to job stress, and that the added burden of beingexpected to be a role model for patients will only add to thatstress (Gomez, 1999; Swaffield, 1986; Zahourek, 1981).

After reviewing this body of literature, the central ques-tion is this: What do patients actually think about nurses’body sizes, and does it have any influence on their perceptionof confidence in a nurse’s ability to teach them about healthylifestyles? The original study by Wells and colleagues (2006)showed a relationship between body size of the nurse in theimage and confidence level among participants. By replicat-ing this study utilizing the same images of nurses and visualanalogue scales, the small body of knowledge related to thisquestion was augmented.

Methods

For this replication study we used a quasi-experimentalpost-test only design to evaluate respondents’ level of con-fidence in the ability of an overweight or normal-weightnurse to provide health education. A beta analysis with amedium beta effect, alpha level of 0.05, and a power levelof .80 were used to calculate the required minimum sam-ple size of 135 participants (Cohen, 1988). Inclusion cri-teria consisted of English-speaking adults, defined as aged18 years and over. Participants could be of either gender,and while disabled participants and pregnant women werenot specifically sought, neither were they excluded. Permis-sion to conduct the study was obtained from the researchreview committee at a large public university in upstate NewYork before data collection began.

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Table 1. Demographics

n %

Age ≤25 years 135 90

Gender Male 78 52Female 65 43.3Missing data 7 4.7

Educ. Level HS Diploma/GED 98 65.3Assoc. degree 12 8Bachelor’s degree 24 16Master’s degree 10 6.7Doctoral degree 1 0.7Missing data 5 3.3

Residence Suburban 74 49.3Urban 53 35.3Rural 20 30.3Missing data 3 2

The university’s ethnically diverse student body consistsof over 14,000 students enrolled in baccalaureate, master’s,and doctoral degree programs. The university campus is lo-cated in a metropolitan area, with a small urban center sur-rounded by suburban and rural areas. Therefore, students,faculty, and staff of the university live in rural, suburban, orurban areas. Data collection occurred in two common areason the university campus on March 17, 2008, from 12:30to 2:30 pm, a time known to have a high volume of foottraffic. Participants were approached by the researchers onthe sidewalk or in the university union as they were walk-ing by. Participants had no prior knowledge of this study;no public notification was given that this study was to beconducted on campus.

The resulting convenience sample of 150 participantsconsisted of university students (89%, n=134), faculty andstaff members (6%, n=9), and visitors (5%, n=7). Agesranged from 18 to 65 years, but the majority (almost 75%),were 21 years or younger. Less than 14% of the samplereported being a healthcare provider in any capacity. How-ever, 55% reported having received some kind of healthcareinformation regarding diet or exercise in the past. Additionaldemographic data are shown in Table 1.

The instrument consisted of two pictures that were cre-ated on MyVirtualModel.com during a previous study in2006 by Wells, Lever, and Austin. The two pictures con-sisted of a Caucasian woman dressed in a white pantsuitand white shoes. One picture depicted a weight-appropriatewoman, approximate dress size 10/12 and the other pic-ture, depicted an overweight woman, approximate dress size20/22. A visual analog scale (VAS) was created and placednext to the pictures on the same page.

The VAS is a way in which researchers can obtain inter-val level data on participants’ perceptions of a phenomenonand has been shown to have a high level of validity for mea-

suring self-reported measures of perception (Gift, 1989).The VAS is 10 centimeters long, which is a standard length(Gift), thus the potential interval data range is 0 to 10 cm.The VAS instructions are for participants to: “Please indi-cate on this scale, by placing a line across or through theexisting solid line, indicating how confident you would feelin receiving diet and exercise education from this nurse.”

Each picture with the vertical VAS was transferred intoa Microsoft R© Word document and printed in color onheavy-weight, semi-glossy, 81/2 by 11 inch paper. Printingwas chosen instead of color photocopies in order to pre-serve the integrity of each picture and VAS because pho-tocopies are subject to image distortion (Gift, 1989). Noformal psychometric testing has been done with this instru-ment because it has been used in only one previous study.However, visual analogue scales have been used extensivelyto measure perceptions and other subjective phenomena,such as the construct measured in this study (Gift).

Each instrument was stapled inside a manila folder op-posite a demographics form. The demographics form wasfor obtaining data regarding age, gender, primary residence,educational level, height, and weight. Self-reported heightand weight were used to calculate body mass index (BMI)during data analysis.

All respondents were informed that participation wasvoluntary. Respondents were assured of the confidentialityand anonymity of their responses. Consent to participatewas obtained verbally and also implied by the respondentfilling out the instrument and demographic form. A copyof the informed consent form was available to participantswho requested it. Confidentiality was maintained becauseno identifiable information was collected. The completedinstruments and demographic forms were coded and keptin a locked file cabinet within a locked office suite on theuniversity campus. The database was kept on one computerwhich required password access.

Data collection consisted of asking potential respon-dents if they would like to participate in a short nursingresearch study. Each person indicating a willingness to par-ticipate in the study was provided with a manila folder,as described above, containing the demographics form, oneof the two nurse pictures, instructions, and consent. Par-ticipants were instructed to complete the forms accordingto the written instructions provided inside each folder. Re-searchers were available for any questions participants had.Folders were shuffled prior to dispersal, ensuring randomdistribution of the nurse pictures.

Before data entry and analysis, all VAS measurementswere checked by one researcher and verified by a second re-searcher to ensure accuracy of measurements. In the event ofimproper VAS marking or measurement disagreement it waspreviously decided that each case would be discussed indi-vidually as a group until consensus was reached. For exam-ple, 13 participants marked the VAS with an “X” instead ofa horizontal line, two participants left their VAS unmarked,and one participant circled the anchor, full confidence,

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instead of marking the vertical VAS. In each instance, groupdiscussion resulted in the decisions to use the intersection orcenter of the “X” as the intended mark, discard unmarkedVAS, and to use 10 cm as the intended measurement for theone participant who circled the anchor. There were no casesin which agreement could not be reached.

Each participant’s BMI was calculated, based on self-reported height in feet and inches and weight in pounds,using SPSS. First, heights which were reported in feet andinches were converted to inches only. Then BMI was calcu-lated using the following formula: Weight in pounds/[Heightin inches]2 × 703=BMI (Centers for Disease Control andPrevention, 2007).

All data were entered into SPSS 16.0 for Windows soft-ware. Frequencies were obtained to establish a descriptionof the participants as a whole. Independent t tests were con-ducted to evaluate the hypothesis that participants are moreconfident in receiving diet and exercise counseling from anormal-weight nurse than from an overweight nurse. Addi-tional analyses were run with covariates of BMI level andplace of primary residence.

Findings

Demographic comparisons of the two groups, one view-ing the normal-weight nurse and the other viewing the over-weight nurse, were nearly identical. Male and female par-ticipants were equally distributed, with 40 male and 32female participants viewing the normal-weight nurse, and38 male and 33 female participants viewing the overweightnurse. In each group the majority (68% for the normal-weight nurse viewing and 62% for the overweight nurseviewing) reported high school or general equivalency diplo-mas as the highest level of education received. In each group8% reported holding an associate degree, while 13% of thegroup who viewed the normal-weight nurse and 19% of thegroup who viewed the overweight nurse reported holdingbaccalaureate degrees. An even percentage in each group,6.7%, reported having master’s degrees, and one doctoraldegree was reported in the group that viewed the normal-weight nurse, but none were reported in the group thatviewed the overweight nurse. Primary residence of the par-ticipants again showed a high level of consistency betweengroups.

Data analysis was conducted using SPSS 16.0 for Win-dows software. An independent t test was conducted todetermine if nurses’ body size had any effect on partici-pants’ level of confidence in their ability to provide ed-ucation on diet and exercise. The test was significant,t (133)=3.74, p=0.00, indicating that people felt less confi-dence in the overweight nurse’s ability to provide educationon diet and exercise. Levine’s test for equality of variancewas significant, and the results for equal variance not as-sumed are reported. These findings are consistent with theoriginal study results reported by Wells et al. (2006; seeTable 2).

Table 2. Comparison of VAS Confidence Scores and t TestResults Between Original and Current Study

Viewed Overweight Viewed Normal-weightnurse nurse

Mean (SD) Mean (SD) p

Original Study(Wells et al., 2006) 5.1 (3.00)a 8.4 (1.5)b .00Current Study(Hicks et al., 2008) 5.8 (2.86)c 7.3 (2.0)d .00

Note. VAS data range is 0 to 10. an = 45; bn = 45; cn = 75; dn =73.

Data were then analyzed further to determine if anycorrelation was present between an individual’s BMI andlevel of confidence in nurses’ ability to provide educationon diet and exercise. Pearson’s r was calculated, which wasnot statistically significant (r=−.074, p=.369), indicatingno correlation between individuals’ BMI and reported con-fidence level. BMI was recoded into categorical level data,with the categories low, normal, overweight, and obese, andan analysis of covariance (ANCOVA) was performed withBMI and figure viewed as covariants. While figure viewed, aswith the t test, did have a significant influence on confidencelevel (F=7.836, df=1, p=.006), neither BMI (F=1.362,df=3, p=.257) nor the interaction of figure viewed and BMI(F=1.070, df=3, p=.364) had statistical significance. Anal-yses were also performed examining potential relationshipsbetween demographic variables of gender, place of primaryresidence, and age, with the dependent variable of confi-dence level, and none were found to be significant. Theseanalyses support the hypothesis that the observed differ-ence in confidence level between groups was explained bywhich image, normal weight or overweight, the respondentsviewed, and not by other factors.

Discussion

Replication studies are important and often not used innursing research. They are important because nursing prac-tice cannot be altered based on a single study, and deliberatereplication offers the benefit of establishing the credibilityof research findings in addition to extending generalizabilityof results (Polit & Beck, 2004). The results of the currentstudy are interesting not only because they are consistentwith those of the original study, but also because they in-dicate a phenomena that could have serious implicationsfor the success of health promotion in general. A review ofthe literature did not reveal any additional studies suitablefor comparison. However, if patients feel less confident re-ceiving diet and exercise education from overweight nurses,this has the potential to have significant effects on patients’success in following diet and exercise recommendations.

Several approaches to patient education recommendeliciting and understanding patients’ preexisting represen-tations of illness before giving any new information. This

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provides an opportunity for providers and patients to iden-tify gaps, confusion, and misconceptions, the end resultbeing patient education that is highly individualized andmore likely to be accepted as intelligible, plausible, and pro-ductive (Donovan et al., 2007). Therefore, it is imperativethat nurses make every effort to understand patients andespecially perceptions and expectations patients bring withthem.

Part of this exploration and individualization of careshould include discussion of patients’ perceptions, experi-ences, and cultural views related to obesity. In mainstreamAmerican culture, obese people are widely stigmatized, andreport a variety of negative effects on their lives and interper-sonal interactions related to this stigma (Puhl & Brownell,2003; Rogge et al., 2004). Nurses must also take care toexplore their own negative perceptions related to obesity,as well as their discomfort with the topic as a whole, be-cause this has the potential to influence interactions withpatients. In planning nursing interventions, including pa-tient education, nurses need to be aware that both they andtheir patients may have experiences and expectations thatcould negatively affect the efficacy of these interventions ifnot fully examined and corrected.

Several limitations were present within this study. First,many respondents specifically stated that they had difficultydetermining their confidence in the nurse pictured becausethey did not know how qualified that nurse was. Manyasked questions such as, “Does this nurse know a lot aboutdiet and exercise?” This is interesting in light of findings in-dicating that respondents felt more confident receiving dietand exercise information from the nurse pictured as havingnormal weight. Perhaps, despite the confidence level theyultimately indicated, they would have liked to have consid-ered other characteristics of the nurse that were importantto them in making that decision.

A second limitation is that the nurses pictured wereboth female. Because of an ever growing number of men inthe nursing profession, it might have been appropriate toinclude pictures of male as well as female nurses. Althoughthis may lead to a confounding variable of perceptions ofgender-appropriate roles or gender superiority, it is worthconsidering prior to future research.

A third limitation is the small amount of demographicdata collected about the participants. Upon review, it wouldhave been helpful to have additional socioeconomic datasuch as income level, ethnicity, and occupation. Researchhas shown that members of different racial and socioeco-nomic groups may have varying perceptions of weight andobesity (Nies, Cook, & Hepworth, 1999). Although the im-plications of these differences in perception on confidencein nurses and their teaching is unknown, without collectingthis data, this issue could not be investigated and cannot beadded to the body of knowledge. Certainly, revision of thedemographic form to collect this data is an easy solutionthat could potentially yield valuable data in the future.

Additional important considerations for future researchinclude addressing the lack of variation in participant age,

BMI, and place of primary residence. Obtaining a moredemographically diversified sample would enhance general-izability of the results. Also, as opposed to using a measure-ment/verification procedure for determining VAS scores, itwould be prudent to have two independent measurements.This would allow establishing inter-rater reliability with aPearson product-moment correlation coefficient.

Conclusions

This study allowed us to validate the results of a previ-ous study which showed that members of the public had sig-nificantly higher confidence in the ability of normal-weightnurses to provide education about diet and exercise as com-pared to overweight nurses. Given the epidemic of obesityin the US and the crucial role nurses play in providinghealth education, studies such as this have important impli-cations for designing and implementing effective teachinginterventions.

Clinical Resources

• Weight-control Information Network (WIN). http://www.win.niddk.nih.gov/

• U.S. Department of Agriculture (USDA), My Pyra-mid. http://www.mypyramid.gov/

• American Heart Association, resources for health-care professionals. http://www.americanheart.org/presenter.jhtml?identifier=3052043

References

Borchardt, G.L. (2000). Role models for health promotion: The challengefor nurses. Nursing Forum, 35(3), 29–32.

Centers for Disease Control and Prevention. (2007). Body mass index:Adult BMI calculator. Retrieved March 17, 2008, from http://www.cdc.gov/nccdphp/dnpa/bmi/adult_BMI/about_adult_BMI.htm

Chang, Y.J., Liou, Y.M., Sheu, S.J., & Chen, M.Y. (2004). Unbearableweight: Young adult women’s experiences of being overweight. Journalof Nursing Research, 12(2), 153–159.

Clarke, A.C. (1991). Nurses as role models and health educators. Journalof Advanced Nursing, 16, 1178–1184.

Cohen, J. (1988). Statistical analysis for the behavioral sciences (2nd ed.).Hillsdale, NJ: Lawrence Erlbaum Associates.

Connolly, M.A., Gulanick, M., Keogh, V., & Holm, K. (1997). Healthpractices of critical care nurses: Are these nurses good role models forpatients? American Journal of Critical Care, 6(4), 261–266.

Daniels, J. (2006). Obesity: America’s epidemic. American Journal of Nurs-ing, 106(1), 40–49.

Donovan, H., Ward, S., Song, M.K., Heidrich, S., Gunnarsdottir, S.,& Phillips, C. (2007). An update on the representational approachto patient education. Journal of Nursing Scholarship, 39(3), 259–265.

Dunkley, S., & Ward, M. (2005). Debate: Should nurses be role modelsfor health? Nursing Times, 101(8), 21.

Durrett, B., & Good, P. (1983). The fat nurse. Nursing Focus, 5(2), 4.Eliopoulos, C., & Lagana, L. (1999). Should nurses be responsible for

modeling positive health behaviors? American Nurse, 31(4), 4.Fahs, P.S., Morgan, L.L., & Kalman, M. (2003). A call for replication.

Journal of Nursing Scholarship, 35(1), 67–72.

Journal of Nursing Scholarship Fourth Quarter 2008 353

Nurses’ Body Size

Frost, H., Jorgensen, M, & Hounsgaard, L. (2006). Nurses’ obesity—A private matter or a professional issue? Danish Journal of Nursing,106(24), 50–52.

Gift, A.G. (1989). Visual analogue scales: Measurement of subjective phe-nomena. Nursing Research, 38(5), 286–288.

Gomez, D. (1999). Caring for others means caring for ourselves. AmericanNurse, 31(4), 5.

Green, H. (2006). Global obesity: Nestle initiatives in nutrition, health,and wellness. Nutrition Reviews, 64(2), S62-S64.

Miller, S.K., Alpert, P.T., & Cross, C.L. (2008). Overweight and obesityin nurses, advanced practice nurses, and nurse educators. Journal of theAmerican Academy of Nurse Practitioners, 20(5), 259–265.

Narayanasamy, A., & Narayanasamy, M. (2006). Communicating healthpromotion in nursing. British Journal of Nursing, 15(10), 538–539.

Nies, M.A., Cook, T.H., & Hepworth, J.T. (1999). Measures of body sizebased on height, weight, and reported ideal weight: Conceptual distinc-tions and empirical demonstrations. Journal of Nursing Measurement,7(1), 21–34.

O’Connor, M. (2002). Nurse leader: Heal thyself. Nursing AdministrationQuarterly, 26(2), 69–79.

Polit, D., & Beck, C. (2004). Nursing research principles and methods (7thed.). Philadelphia: Lippincott Williams & Wilkins.

Puhl, R.M., & Brownell, K.D. (2003). Psychosocial origins of obesitystigma: Toward changing a powerful and pervasive bias. The Inter-national Association for the Study of Obesity: Obesity Reviews, 4, 213–227.

Rogge, M.M., Greenwald, M., & Golden, A. (2004). Obesity, stigma,and civilized oppression. Advances in Nursing Science, 27(4), 301–315.

Rush, K.L., Kee, C.C., & Rice M. (2005). Nurses as imperfect role modelsfor health promotion. Western Journal of Nursing Research, 27(2), 166–187.

Swaffield, L. (1986). Fit to nurse? Lampada, 8, 8–9, 11, 24–25.Tricas-Sauras, S. (2006). Psychosocial strategies for obesity. Journal of

Advanced Nursing, 53(2), 265–266.Wells, M., Lever, D., & Austin, E.N. (2006). The effect of the nurse’s body

size on client confidence in the nurse’s ability to provide health educationon diet and exercise. Unpublished manuscript, State University of NewYork, Binghamton.

Wright, J. (1998). Female nurses’ perceptions of acceptable female bodysize: An exploratory study. Journal of Clinical Nursing, 7, 307–315.

Zahourek, R.P. (1981). Even “people helpers” need help: Stress and addic-tive behaviors in nursing. National Student Nurses Association, 28(3),30–33.

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