Words are powerful. They inspire us to act, to change, to make the world a better place. Today, may I choose mine carefully.
— Me
The only thing I know that is more powerful than words is the work of the great profession I belong to. Today, I firmly state that I believe the work of nursing is some of the most critical for individuals, families, communities, and countries around the globe. This week I want to pay tribute to a nursing organization that believes it is in its final stages, but really this organization has merely sparked the beginning of a movement… a movement of evidence as to the importance of the work of my profession.
In 2005 the Robert Wood Johnson Foundation decided to take action on evidence about the importance of nursing found during the I.O.M.’s quest to stamp out health care errors and begin supporting the investigation of the importance of what nurses do. Out of the discovery of the ‘To Err is Human’ project, the INQRI was born. Lead by Dr. Mary Naylor, Dr. Mark Pauly, and Dr. Lori Melichar, the program was designed to investigate evidence of the importance of the nursing profession, to link everyday actions by bedside nurses to the improvement of patient outcomes, and to strengthen healthcare through interdisciplinary research. What the program did, in retrospect, was even more profound. By funding 40 different interdisciplinary research teams investigating the importance of nursing actions for patients, the program has laid the groundwork for future nurse scientists everywhere to learn from and act upon.
One of the Most Important Trips of My Life
Just prior to nurses week I had the greatest privileged of my nursing career, when I was invited to sit and drink in the important lessons learned from the INQRI program at their final meeting in Washing D.C. April 26th and 27th. Check out the highlights of the entire INQRI program at their blog. Being present at this event changed me, through broadening my outlook on nursing research and giving me much to ponder about the questions left unanswered even in my own practice. I could go on for paragraphs about what learned, but I will summarize in a few short bullets:
- The work of nursing within healthcare is critical and is increasing as time progresses.
- Nursing needs more evidence. This evidence needs to be immediately usable to all practitioners at all levels of the profession and not just highly scholarly or theoretical.
- The INQRI program funded over 40 projects that used robust measures and truly interdisciplinary teams to measure the impact of nursing. Results from these research projects will continue to be published and impact nursing, healthcare, and patients for years to come.
- Interdisciplinary teams are critical to moving beyond ideas of a single profession’s scope of practice, keeping the patient and outcomes the center of everything, and they are key to pushing valuable evidence out to more than only the nursing profession.
- Nursing needs to emphasize the importance of engaging in research to all levels of practice, and not just the academic institutions or persons with the highest degrees within the profession.
- Nursing research is difficult because it involves real people, multiple factors within the profession such as staffing, time, technology, and an ever changing healthcare system, small amounts of funding,… but still research needs to be done and we must find a way to overcome barriers.
- By simply developing and executing the INQRI program for six years much important information was learned about measuring interventions, working with multiple sites, engaging patients and nurses at all levels, and dealing with and overcoming barriers.
- What nurses do matters, and to prove that and be heard, we must have more evidence.
- There are still gaps in knowledge about the impact of what nurses do and the impact of our practice on patients.
This week I want to say to all of the nurses who have given days, weeks, years to this profession and to your patients… THANK YOU! I also want to say thank you to the Robert Wood Johnson Foundation for placing a priority on the health of people and for putting your faith in nursing as a critical part of that priority. Finally, I want to say thank you not only to Dr. Naylor, Dr. Pauly, and Dr. Melichar for giving years of time and effort into strengthening the nursing profession and improving health outcomes, but also to the numerous people behind the scenes who made the INQRI a success and brought information and knowledge to an entire profession, people like Heather Kelly and the many teams of funded researchers, bedside nurses, and patients who made this new knowledge possible. Without each of you, nursing would not be at this great door of hope and opportunity that you have opened.
To all nurses everywhere, I challenge you as the INQRI program is ending, that you do not let the spirit of this program die. The INQRI has opened the door to stronger evidence and now we must walk through it, no matter where we are or at what level we practice. We must be the change we want to see for our patients and change begins with sound evidence.
Goodbye to one of the greatest programs in nursing history.
Hello to a new dawning of scientific curiosity and inquiry, or rather INQRI, in nursing.
Happy Nurses Week to all who made both possible.
I have been debating as to whether I was going to write about this subject that has been on my mind for a while. I believe I will proverbial ‘step in it’ with this post, but I wanted to find out what others think. This is not an ‘old guard’ post where I have an opinion because I want other nurses to have to complete exactly what I have had to. I love nursing and the patients I serve, even when the days are rough and the patients too many. To change as healthcare is changing, nursing education needs to beef up, not dumb down, curriculum…
Removing Clinical and Hours from RN-BSN Programs to Make them More Marketable
This post stems out of a conversation with a highly regarded person evaluating our RN-BSN program. This person advised our program to drop all clinical to make it more ‘marketable’. I was shocked…
I proudly work for an RN-BSN program that requires clinical. We do this because our general experience in working with our amazing nursing students is that they have only had acute care experience (which is critical and a great starting place to build other knowledge on). Let me emphasize that the majority of them are very bright and capable acute care nurses and I learn from them daily. However, one of the goals of our program is to push the envelope in their thinking… exposing them primary care, public health, and areas where they have not practice previously. In turn, we like for them to reflect on how these new areas, access, disparities, etc. affect the patients they see every day in their own acute care practice.
We also strive to expand their knowledge base, teaching them about how health affects not only individuals, but families, communities, and the like. Many of our nurses (who are students) do not know how or even where to palpate for lymph nodes, test consolidation in lungs, or how to map out a liver boarder. Will they use these skills daily in practice?… Perhaps not, but they do use them. I had a student just last month, during health assessment class, pick up a pneumonia in an ICU patient that others had missed because he could test for consolidation. I have had many students pick up on other critical findings, simply by expanding and completing full assessments that they learned in their RN-BSN program. In the acute care setting in particular, it is rare for other providers to even asses a patient, they simply look at the nurse’s notes and tests to make decisions. As inpatient care becomes more complex and patients continue to be more ill, why would we CUT health assessment clinical from RN-BSN programs?
Our nurses have also had little exposure to community health and administration/leadership areas. Do associate or diploma degree students learn how to write up a community assessment, spend time in community health centers and health departments, learn vaccination schedules and mass vaccination protocols, learn about community resources, WIC clinics, STD counseling and testing, food purification systems, the importance of epidemiology, large scale school nursing management, and the like? Further, in the administration and leadership course I teach I find that students have been little exposed to communication styles, interviewing, hiring, firing, and managing committee meetings, budgeting, finance, and service projects/leadership within their communities. Can these things simply be learned from reading and writing assignments, or should they be observed, practiced, and implemented in a ‘practice’ setting? (I know it sounds like I am asking rhetorical questions here, but I honestly want to know.)
In addition, many of my students want to go on to graduate school. Several graduate clinical programs require a separate health assessment course with clinical, as they should. Several BSN prepared nurses come into our RN-BSN program each year simply to take health assessment with us for graduate school. While I love having these students… this is ridiculous. Why should students have to take additional coursework beyond what they had in their BSN to get into school? Why did their original BSN program fail them in this way?
Who would have thought that we would make a move to remove clinical from RN-BSN programs simply to get more people into them and through them. Again I ask, isn’t the point/argument of a BSN degree to be more educated and prepared? Does cutting clinical help or hurt those students? The most popular courses in our program, based on qualitative and quantitative data from the students, are our three courses with a required clinical portion based entirely on the students feedback and learning in clinical!
More than 80% of our students go on to either graduate education, move up in career clinically or into administration, or move out into the community to provide care within a year of graduation. Why on earth would we leave them ill-prepared simply to make a program marketable? Wouldn’t we be doing them a great disservice, or their patients? Most all of our students work and manage families along with clinical requirements well, finding clinical to be a new outlet of exposure to worlds of practice and nursing that breathe new life and excitement into their personal nursing practice. The biggest obstacle for them in planning clinical and school work is often their current employer, not home life demands.
The Problem
The problem, I think, is that there are no clearly defined differences from accrediting bodies or research in what should be required within BSN education. AACN only accredits BSN level programs and higher, thus their clearly written standards, do not help RN-BSN programs much with what clinical and classroom portions need to be included. Many programs argue that their RN-BSN students have had plenty of clinical in their places of work (mostly acute care) and do not need any more. I would argue with this ill-laid premise. They have had much clinical, but need more, nursing is a clinical practice after all.
The BSN educational standards laid out by the NLN-AC build upon the ASN standards for sure, but are merely expansions on those in conceptual terms of student abilities. These same accrediting bodies have clearly laid out the need for nursing informatics and transcultural curriculum within BSN programs, and have laid out objectives for community health, population care, and administration and this is good. However, these guidelines do not require clinical for programs to meet accreditation standards. To my knowledge, there are no specific quantitative measures for RN-BSN students at program start and completion to see if students have gained knowledge in certain standardized areas, all testing for BSN students comparing national standards are geared toward pre-licensure measures of passing NCLEX. Likewise, standardized pre-licensure testing programs for both ASN and BSN students are identical.
This academic problem of defining the difference between associate/diploma and BSN education continues to bleed into practice. Until we clearly define a domain difference for our students, this problem will remain. It affects our nurses both in acute care and community health/primary care, because we cannot clearly articulate the difference in their knowledge base, employers do not see an added need nor do they delegate more activities to nursing which need to be delegated to nursing. Nurses both in acute care and beyond need to be released to more tasks that come under their scope of practice, like being able to order social work consults, diabetic education, foot care, etc., until we clearly define roles and educational foundations, nursing education will continue to be part of the problem for our bedside nurses regarding scope of practice.
I am enthusiastically all for all nurses returning to school! Life-long education is critical for nurses no matter their setting of nursing practice or education. I am fully aware of how difficult it is to schedule school with working, family, and life. I have done it myself now in four different nursing degrees and I do not want in any way to belittle the difficulty in continuing education for any of my students. Continuing one’s education is a difficult path, but one that benefits both nurse and patient. To help emphasize the importance of life-long learning, nursing educators must clearly articulate what skills and knowledge are gained at every level of education and the accrediting bodies must hold programs accountable for this.
However we move forward, it must be deliberate, clear, and evidenced based… and for GOODNESS SAKE… don’t cut the clinical from your RN-BSN program simply to be more ‘marketable’.
I haven’t posted in a while. I hate to use the excuse that life is busy, but … life has been overwhelmingly busy. My children, family, several jobs, and the future have been dominating my time. I also have had to make changes to the blog, since wordpress was not supporting my template well. There have been a few rough-draft posts written, but none of them have yet made the cut to post. However, something happened today that I felt compelled to share.
Kids Basketball and Nursing
Today I was literally moved to tears watching a bunch of 7 to 9-year-old kids play basketball. I was there to support my youngest daughter in her cheerleading endeavors, another post entirely, and was unavoidably drawn into the excitement on the court. The two teams of kids I observed have played each other several times, with the point of the league being to expose kids to good sportsman-like conduct, rules of the game, teamwork, and expose them to exercise.
Today, something magical happened. One team had obviously been advised by their coach prior to the game that one of the players had not yet ‘scored’ during any of the previous 5 games. His kids were listening, more than listening, they made it their mission to help this player succeed at scoring. Today was game 6 and close to the end of these little ones’ basketball season. Every single time this team took the ball to their end of the court to score, every player, no matter their age, gender, or talent, sought out the player who had not scored and passed him the ball, encouraging him to ‘shoot it’. Time after time I watched these kids, who played with utter joy and no trace of resentment, work to provide this child with the opportunity to shoot the ball. Every time they went down the court their eyes sought him out. They moved to pass him the ball and then they verbally cheered him on. Sometimes he did not catch their pass and the ball moved out-of-bounds to the other team, sometimes he passed it off, and many times he shot, improving each time, but never making the score. None of the children showed any sign of resentment, tantrum, or bitterness. They continued to play with happiness, smiling and laughing as they bounded up and down the court.
Now, it is at this point many people roll their eyes and would comment that these kids are not really learning the true meaning of sports, competition, being the best, etc., and that this team was creating false sense of relevancy for this player. I beg to differ. What I observed was a miracle of human kindness, humanity, encouragement, learning, team work, and joy. The coach never reminded or encouraged any of his players to take on the cause of this one child. The children took this on themselves. They worked hard to provide opportunity to learn, not unfair advantage.
Observing all of this I wondered… how often do we miss this chance within the nursing profession? More importantly, how many times have I exhibited this same encouragement, teamwork, and opportunity with sheer joy, pleasure, and happiness? The world in general, and nursing specifically, could stand to watch a few kids basketball games like this. I am better, and thankful, for having observed this true miracle. May we as nurses play with sheer joy and advocate for our members, their opportunities to learn, and for true teamwork.
Translation of EBP: Why creating nurse scientists is the way to improve patient outcomes.
Brief Overview: You can read the below verbal explosion or you can know this… I basically say what is contained in the bullets below then provide links.
- Research is sometimes far removed from bedside nurses
- Research is COOL!
- Research is about PATIENTS and not fame/fortune of researcher
- Research is critical to practice and there are big gaps that nurses need to fill
- Bedside nurses may be the most crucial link in research ideas, translation, and practice.
My Thoughts
Creating nurse scientists has been somewhat difficult for the profession of nursing. I can only guess as to why this has been, but unlike other fields of biology, chemistry, and the like, where employment is often found in seeking answers, solving mysteries, and in effect being ‘scientists’, nursing has traditionally and rightfully been a ‘hands on’ profession of action for patients to produce desired outcomes. (Forgive the brevity of the definition of nursing, it is quite complex, but one gets the idea.)
Often nurses are too busy keeping patients alive, preventing complications, and working over time to consider solving the larger problems of their patients or their profession. However, nothing could be more critical. I believe that the hard-working, nose to the grindstone, mentality has kept nurses from exploring the science of their practice and answering important patient/practice questions. Likewise, many nurses may not be empowered enough at the bedside, another post entirely, to solve problems, lacking support from administration. There is also some distant mystery in the idea of being a nurse scientist. Personally, I used to believe that I could never be a nurse scientist. They were the rock-star like icons I only read about, but were not present in my health care institution, my local universities, and certainly, I believed, not pushing medications with me at the bedside. (I still would love to get several autographs – so nurse scientists out there, send them in with your photos. 
Linda Aiken, Robin Newhouse, Bernadette Melnyk , etc.)
The Need for More Evidence:
Evidenced Based Practice (EBP) is more than the latest buzzword for the vernacular of health care facilities and nursing schools. It IS health care, and yet it is still emerging. For nurses, there are so many practice areas where we have not verified with research what we do. I recently worked with a group of RN-BSN students on identifying a problem within their working units that they would like to change and I am always encouraged by their resounding frustration at not being able to find any ‘research’ on the area they want to change. Topics like decreasing cost of medical care waste, pain medication dosage/timing in post-operative patients, non-pharmacological practices for comfort measures at the bedside, nurse managed out-patient protocols for stomatitis in oncology patients, direct admission of septic oncology patients from out-patient/office triage, music as an anxiety reliever in pediatric emergency room waiting, use of certain products as bedside cleansers in ICU patients, and so forth … pepper their projects but baffle their attempts to find printed, peer-reviewed, research. The students are thinking and ready, but it is important for them to find nothing on their topics. They must be aware that THEY must be the catalyst for evidence and change, and that interdisciplinary evidence, and pilot projects are needed to test their theories. Science is a mystery that continues to change and nurses are the critical detectives, the Perry Masons of health care and patients, with their outcomes at the center of the mystery.
Research is Personal
As much as science provides statistics and evidence, it also has unseen faces, lives, and effects. Numerous unidentifiable persons participate in research in hopes of improving their own lives or to help improve the lives of others. They believe in health care scientists and our ability to move health forward. Beyond the research awards, publications, funding, and all of the rest, they are central. They are the purpose, the catalyst, and the mechanism through which we will discover answers. This was never more clear to me than when I completed a recent study and saw first hand the hope and desire for improved health of participants. For the researcher, who remains professionally detached, we learn that research is about people. Who better than nurses, who know people/patients well, to seek answers to the most pressing questions our patients face? Often, nurses see the bigger gravity in what are considered ‘minor’ issues by others in health care and how they affect patients. Patients need evidence and nurses can help them get it.
Now Where?
Nurse researchers really were at the bedside with me, guiding theory, practice, and nursing. They were the ones who pushed for things like Primary Care nursing, improving patient relationships through listening and communication, and the like. The need for evidence is no less pressing and is indeed growing. Pulling in nurses at all levels of health care to help discover and translate evidence is needed. Building consortiums of nurse researchers to bring nursing out to smaller health centers and hospitals as the ANA is doing, or building hospitals that function with bringing nurses into evidenced based practice at every level, and actually empowering them to act/translate/search/implement as Johns Hopkins is doing are models that should be echoed throughout health care agencies.
Nursing Research Matters to Everyone
With the increase in age of patients, nurses, nursing faculty, the pending large influx of patients into the U.S. health care system, and the push to a preventive-team approach to health instead of acute care-reactionary medicine, the time is now to create more nurse scientists. Below are some links of importance to nursing science and highlights of nursing research being done.
Nursing science and EBP matter, for our patients.
- The NINR
- Nurse Researcher Hall of Fame at STTI
- Massage for blood pressure control (recent nursing research in the news)
- In home therapy improves disabled elder’s health outcomes (recent nursing research in the news)
- Vitamin C helps heart failure patients (recent nursing research in the news)
Those of you who attended and would like to have the handouts that some of the speakers were speaking of, they are attached with permission of the speaker here. These are PDF documents. If you would like to use these works please cite the authors appropriately.
Thanks!
Dr. Carole Eldredge DNP, RN, NEA-BC – “Administrator’s Dream or Nightmare?: Effective Use of Social Media in Clinical Settings”
Dr. Eldridge’s Handouts are as follows: Guide to formatting a social media policy, NCSB social media policy statement, ANA social media toolkit.
Dr. Terri Schmitt Ph.D., RN, FNP-BC – “Professionalism, Communication, and Collaboration: Use of Social Media in Nursing Curriculum for Student Self-Enhancement.”
Dr. Schmitt’s handouts are as follows: Social media integration for learning tip sheet, PDF of presentation
Rob Fraser MSN, RN – “From Theory to Pracice: understanding and Applying Concepts of Social Media” – His great handouts are on his blog at Nursing Ideas.
Teresa Heithaus MSN, RN-BC. Teresa spoke on Sunday and also with us. You should check out her blog, Nursing Staff Development Behind the Fire Wall.
Often, when I head to nursing conferences, I feel overwhelmed by my harried schedule, workload, logistics, and finances. However, once I arrive and become engaged I am excited, invigorated, and better informed about nursing. One particular nursing convention continues to stand out by the works of the organization behind it.
Sigma Theta Tau International Nursing Honor Society’s (STTI) biennial convention is currently taking place in Grapevine, Texas and I am once again privileged to be here as an attendee. Dr Karin Morin, current president, reminded attendees at the opening session of the amazing, ever expanding, and tireless work that the organization continues to pursue. STTI is the only international nursing organization. Likewise, it is the only nursing NGO for the United Nations, continues to expand partnerships to fund learning and mentoring academies like the maternal child and leadership cohorts, and has published over 24 timely text titles in the last biennium. They are not just setting goals, to fuel nursing scholarship, evidence based practice, and to improve the health of the world’s global citizens through nursing science, but they are achieving them.
Even as I type this, I am sitting in an intimate room with nurses from all countries and occupational settings preparing to hear a presentation on how to build sustainable nursing research teams that flourish. There is hardly an empty seat in the room. Such diversity, and yet oneness of purpose, is awe inspiring indeed. Part of me desires to bring more acute care and bedside nurses to such events and discussions. I am acutely aware right now that what is occurring here in this room is the way to inspire nurses and move the profession forward.
With such impressive activities and 469 chapters globally, one might ask… why aren’t all nurses members? Time, finances, lack of access to a chapter, and numerous other excuses may come to mind, but really, wouldn’t any of us like to be part of something bigger than ourselves, something that is changing nursing throughout the globe? I have found my STTI membership to be one of the most beneficial and cost effective nursing organization memberships that I posses. Community members are invited to join, but if you cannot find a local chapter then there is a virtual chapter that you can also access. I encourage you to consider joining and becoming involved. Perhaps I will see you in 2013 in Indianapolis.
Yes, the dissertation is done and approved, a couple of the kids’ birthdays are over, husband has gotten into a groove with the new business launch, and I finally have time to write… something. Below are updates and things I find interesting.
More Journal Club Fun
The journal club gang had another great time this last week, the first time since we have been together since last spring, sans one great member. There were great articles and discussion by all. The following were the articles we discussed:
1. Wade, G. & Kasper, N. (2006). Nursing students’ perceptions of instructor caring: An instrument based on Watson’s theory of transpersonal caring. Journal of Nursing Education, 45(5), 162-168.
This article focused on psychometric development about caring, but for the nurse educators in the group was an interesting concept to measure. Most instructors want to know if they appear ‘caring’ to their students, while not being overly indulgent or showing signs of lateral/horizontal violence or some of the authoritative ‘old guard’ mentality that can create negative feelings in students toward the nursing profession. The initial statistics on the 31 item questionnaire were interesting, but we wondered if it would change based on the day/situation/emotional state of the student? Check it out and let us know what you think.
2. Newhouse, R. et al. (2011). Advanced Practice Nurse Outcomes 1990-2008: A systematic review. Nursing Economic$. Available for free at https://www.nursingeconomics.net/ce/2013/article3001021.pdf
This landmark systematic review of RCTs of NP to physician outcomes is a must read for all nurses and patients. Likewise, it is an excellent example of a very well done systematic review, with charts, pictures, and excellent data. It would make a great example for a graduate research course.
3. Bonnel, W. (2008). Improving feedback to students in Online Courses. Nursing Education Perspectives, 29(5), 290-294
AND – Andresen, M. (2009). Asynchronous discussion forums: Success factors, outcomes, assessments and limitations. Educational Technology and Society, 12(1), 249-257.
These two articles reviewed the need for certain actions and characteristics of the faculty member in on-line learning, particularly as Bonnel points out, positive and energizing feedback to motivate students to self-improve. Detailed and timely feedback by nursing instructors were also cited as much needed by Andresen. Neither were really research, but had good points based in sound literature.
Be looking for our next update from the journal club coming in February!
Nursing Student Work
An excellent colleague who is finishing a certification as a nursing informaticist, has taken over the NUR3563 course I teach and is doing amazing things with it! She has wonderful insight, energy, and experience to take the course to the next level, which it so desperately needed. One of her RN-BSN students chose to do a multi-media project about how she saw Nursing Informatics. It is very well done, with much work/effort/learning evident throughout. You should check it out here.
She also continues to have the students blog and twitter, many with new found enthusiasm for use of technology. Keep looking for them on twitter.
Blog Updates
NURSING STUDENTS and NEW GRADUATES – Check out the New Nurse Survival Guide at BestNursingDegree.com. It looks very interactive and applicable.
I will post more soon. Thanks for reading and for supporting the profession of nursing! GO NURSES!
FYI – WordPress has jacked around with my theme and things are missing, etc. I am working to rectify that so be patient with me. I guess I should just pay for and code my own site. Lesson learned. Don’t be cheap .
On with the post.
So, several months back Rob Fraser of Nursing Ideas challenged me to post each month about nursing research and it’s application. Although, I read nursing research all of the time, I have been remiss for a while to post about it… so here… are my updates.
UPDATE 1: The journal club is still on!
Yes, nursing friends my previous post about my journal club is still going. We meet again in October and I will update you then. If you want to read my original post about how to start your own nursing journal club you can go HERE. I am contemplating starting a nursing journal club that meets once a month on twitter, but am not quite there yet time wise. Stay tuned…
UPDATE 2: Sigma Theta Tau International 41st Biennial Convention
A source for all things scholarly and nursing, there is a great convention coming up and it will be in Dallas (grapevine) this year. Check it out or sign up to come here. I have the privileged of speaking with the famous Rob Fraser, Carole Eldridge, and Teresa Heithaus about integration of technology and social media into nursing practice. There will be much research application there. Stay tuned for a report…
UPDATE 3: Research Article of the Day
You cannot access it yet, but mine came in the mail today and the entire issue is awesome, but one article in particular in the Sept/Oct issue of the Journal for Nurse Practitioners was on the top of my current interest list.
Bruney, T. (2011). Childhood obesity: Effects of micronutrients, supplements, genetics and oxidative stress. Journal for Nurse Practitioners. 7(8); 647-653.
Brief Overview: Obesity is a problem. Rates of obesity in children have tripled since 1980. WHO reports that 60% of disease burden for future will be chronic disease related to obesity. Obesity, based on current research, is not just an affect of the number of calories, but the quality of food. The article provides a good overview of research surrounding the effects of high fructose corn syrup, microflora of the gut, zinc and Vitamin D supplementation, antioxidants, nutrigenomics, and types of diets on obesity.
Take home for me: Our kids are getting more processed foods with little nutrients. We need more fresh foods and higher intake of fruits and vegetables as well as supplementation. It appears that once obesity is already a problem, that it may be difficult for Atlas to let go of the world, meaning it is more difficult to break out of the cycle of reactions in the body that occur because of obesity and cause one to stay obese. The author never comes out and says this, but after reading the research it makes one wonder. Nutrition, nutrition, nutrition…
So, even though I am still a research slacker, this post helps. Dissertation defense next week so back with more in October. Thanks for reading!