The nursing industry has embraced the Internet as a viable education tool.

According to Barbara R. Grumet, BA, JD, executive director of the National League for Nursing Accrediting Commission (NLNAC), online and distance education programs must meet the same requirements as traditional programs. “We do not have separate standards for online or distance education programs,” she adds.

Recently, however, online education came under scrutiny during a tussle between the California Board of Registered Nursing (BRN) and Excelsior College.

Online pre-licensure program

Excelsior College is a New York-based online program that is accredited by NLNAC. Its associate degree in nursing program is the only accredited RN pre-licensure program in the nation that can be completed at a distance, according to Bill Stewart, director of communications at Excelsior.

The program is designed for those with backgrounds in health care, including licensed vocational nurses (LVN) and emergency medical technicians (EMT).

“[These] are working adults for whom going back to school full-time or even part-time is not possible,” Stewart says. “We provide them with an opportunity to learn and demonstrate that they have particular skills and knowledge in a variety of subject matter.”

In December 2002, the BRN initiated discussions with Excelsior College regarding minimum education requirements for RN licensure in California. The BRN was concerned that Excelsior graduates lacked the sufficient supervised clinical practice to meet California standards.

Since Excelsior is an assessment-based program, it doesn’t provide instruction in the theory and practice of nursing. Rather, each graduate has to demonstrate his/her knowledge of nursing theory and the application of nursing principles through a series of seven written examinations, which are the equivalent of end-of-semester exams for the subjects covered, according to Stewart.

Excelsior students are then required to take and pass its Clinical Performance Nursing Examination (CPNE), a weekend course involving only medical-surgical and pediatrics areas of practice. The BRN’s education/licensing committee claims that a two and a half day examination falls short of the required 405-450 hours of supervised clinical practice required of LVNs. Also, California law states that schools must teach five different areas of practice: pediatric, medical-surgical, geriatrics, psychiatric and obstetrical/gynecology.

Vicki Bermudez, RN, California Nurses Association’s liaison to the BRN, says Excelsior students are unable to fulfill the additional requirement for clinical practice.

“There are some problems associated with students caring for patients and demonstrating their clinical skills on patients here in California when they are not licensed in California and they’re not enrolled in an approved program,” Bermudez says.

She adds that some employers are not convinced LVNs, without having any clinical experience as RN students, are able function as RNs after a short weekend examination.

In response to the BRN’s concerns, Excelsior submitted a plan for 135 hours of clinical experience through the Cal State University “open university” program. The proposal was rejected by the BRN for not meeting the state’s minimum training guidelines for RN graduates.

“What the BRN is trying to do is hold the Excelsior College to the same standards of education for all the programs,” Bermudez says.

Stewart says Excelsior College is trying to work with the BRN to resolve the matter. “There appears to be a reliance on their part that the traditional path to a nursing degree is the only one that could yield qualified graduates,” he says. “Yes, we are an innovative program, but we’re not unproven. We’re not new and we’re not unestablished. We’ve been around for 30 years.”

Distance education programs

Although online education is commonplace, colleges like Excelsior that offer pre-licensure education exclusively online are extremely rare.

“The majority of our programs offer some sort of online education, as part of, or in addition to their traditional programs,” Grumet says. “For example, one-third of our master’s degree programs, and 25 percent of our baccalaureate programs, offer multiple courses in their existing programs online.”

Frequently, the course content in the online degree programs is similar to those offered in campus settings. The only difference is that nurses are able to complete their degrees at home and at their own pace.

“Probably the most common areas where distance [education] has been used for registered nurses are the RN-to-BSN programs,” Bermudez says. “At that point, they are acquiring additional knowledge to apply to their RN practice.”

Professionals are often motivated to pursue an RN-to-BSN program to improve their marketability and to keep pace with continuing education requirements.

Cal State Fullerton’s (CSUF) distance RN-to-BSN program combines interactive video conferencing and online course work. The lessons are broadcast from Fullerton to approximately 14 healthcare sites across the state. Students attend for about five hours a week, and the remainder of their work is in online discussion boards, online assignments and assigned readings.

A lead faculty member will broadcast from Fullerton and part-time faculty members are present in off-sites to conduct group sessions and answer questions.

There are approximately 190 students enrolled in the Fullerton program, according to Jo-Anne Andre, RN, MSN, director of the nursing distance education program at CSUF.

She says employers surveyed by CSUF are pleased with its distance nursing program.

“Their reactions are extremely positive,” she says. “They mention the increase in students’ critical thinking abilities … increase in students’ leadership skills … and the ability to communicate more clearly on an individual level and in a group.”

Some hospitals are now offering their own in-house distance learning programs. In early 2002, Catholic Healthcare West partnered with Holy Names College in Oakland to offer a distance RN-to-BSN program for the facility’s RNs. The program includes funds provided by Blue Cross to reduce tuition costs. In two years, graduates of the teleconference and online program receive a bachelor’s of science in nursing. Currently, there are 20 nurses in the program at Northridge Hospital Medical Center’s site.

“We’re very education focused here, so we push our nurses to do this,” says Angel Cotten, nurse recruiter at Northridge. Among the 750 nurses at Northridge hospital, approximately 45 percent have a BSN.

According to Cotten, the hospital offers students favorable loans and up to $3,000 in tuition reimbursement.

“In this fast pace environment where time is of the essence, our program is fantastic,” Cotten says. “It is such a new thing and it’s being embraced and taken advantage of nicely.”

Classes are held in the hospital’s conference room two days, every other week. The hospital also offers an online specialty program sponsored by the American Association of Critical-Care Nurses. “Critical care education is a very complex and complicated process,” Cotten says, “[we offer it in-house to] anybody that wants to make the transition into this field.”

She feels there are no differences between the quality of graduates from her hospital’s distance program and BSN nurses from traditional programs.

Cotten adds that the hospital is still in the discussion stage regarding a possible LVN-to-RN program that could be implemented in 2004.

Reluctance about online ADN programs

CSUF’s Andre says that although some employers have fully embraced the distance educational mode, others are still hesitant, especially when it comes to pre-licensure, associate’s degree programs.

“I think that the dilemma with associate’s degrees is that they need to do all of their clinical preparation during their associate’s degree. It’s easier, by far, to offer an RN-to-BSN degree online because all their clinical [preparation has] already been completed in their associate’s degree program,” she says. “So it’s very difficult to offer that type of program without the clinical being done either through simulation, which is better than non-simulation, but not as good as being with actual patients.”

Andre says she has heard of some facilities that are hesitant about online ADN programs because employers “are not certain of the degree of clinical experience that they’ve received.”

For this article, CGM contacted a number of other healthcare facilities and recruiters that declined comment on the subject.

Latest Update

On Dec. 5, the California Board of Registered Nursing concluded that the current Excelsior College curriculum does not meet California’s educational standards. The BRN issued requirements that Excelsior College graduates will have to meet in order to get approval for RN licensure. The ruling will not affect previous graduates of the program or students who were enrolled prior to Dec. 6, 2003.

In response, Excelsior stated that the college will not encourage persons seeking to practice as RNs in California to enroll in their ADN program, and will not recommend their students take Nursing Concepts 1 & 2, either as practice tests or for credit.

Students who enrolled at Excelsior College on or after Dec. 6, 2003, and wish to practice in California must meet the following requirements:

1. Must be an LVN.
2. Must have 8 units or 360 hours of supervised clinical experience through a California approved program. Required clinical areas include advanced medical surgical nursing, psychiatric nursing and geriatrics.
3. The practicums may be provided through the “open university” option throughout California State University System, California Community College System or through Independent College System.
4. Must comply with LVN to RN requirements under California law, Business and Professions Code Section 2736.6 and California Code of Regulations, Title 16, Section 1429.

“Women should be obscene and not heard.”
Groucho Marx

In February 1999, the Journal of the American Medical Association published a study titled “Sexual Dysfunction in the United States.” In it, researchers Edward Laumann, PhD, Anthony Paik, MA, and Raymond Rosen, PhD, analyzed data of the 1,749 female and 1,410 male participants in the National Health and Social Life Survey (NHSLS).

The results were-as reported in the national media-shocking. According to the researchers, 43 percent of women and 31 percent of men reported some level of sexual dysfunction in their lives, leading researchers to conclude that it was an important “public health concern.”

From the beginning, however, there were concerns with the often-cited research that seemed to generate minor attention. For the purposes of the study, “sexual dysfunction” encompassed symptoms that were biological, psychological and psychosocial, and the definition of “sex” was limited to male-female intercourse.

The researchers also excluded respondents who were not sexually active with at least one partner during the prior 12-month period of the study (more than 11 percent of survey participants). By the researchers’ own admission, they expected these exclusions to bias their findings for men downward and those for women upward.

Bizarrely, in the study’s repeated references to the impact of “traumatic sexual events” on adult sexual behavior, the researchers first mentioned same-sex activity and its affect on men and women, respectively. Although statistics about male-female sexual assault, rape and incest are by far the most prevalent in the United States, they received secondary placement within report text. Only in the final three paragraphs of the report did the researchers note that, for women, adult-child contact or forced sex is “generally perpetrated by men.”

The pink scapegoat

In American society and others, men are considered the arbiters of sexuality. It is also generally accepted that men think about and want sex more frequently than women. It’s no surprise then that the corporate media concluded that the JAMA report suggested a female problem. Not-so-subtle variations of this included insinuations that women wanted too much, worked too much and were not doing their duty. The dysfunction label belonged to them.

One of the more recent examples of this bias came from Phil McGraw, PhD, the mass-marketed “woman friendly” psychologist. In a December 2003 telecast, McGraw cited the JAMA study and described the problem as couples being either “too tired or too grumpy to have sex,” language that does not actually reflect the published findings. He characterized the situation as “practically an American epidemic.”

McGraw brought on three couples to illustrate his point. In minutes it was clear, from his perspective, this problem had its roots in female behavior and that females were primarily responsible for fixing it.

Couple number one, married with four young children, had experienced very limited sex in the last few years. The mother clearly stated up front that, with her kids constantly at her, “The last thing I want is for my husband to start grabbing me.” To the careful listener, this statement might suggest some insensitive if not crude behavior on the part of her spouse. She went on to add that she wanted to be “touched” and “kissed” and for her hand to be held. She felt that sex could be an outgrowth of that type of behavior, hardly outrageous demands to be asked of a loving spouse.

In response, her husband made remarks like, “I never signed up for a sexless marriage.” He also admitted that he found his wife’s nursing breasts disgusting, which would be a problem since the couple had four small kids in the house. “I still kind of cringe about it,” he squealed.

Incredibly, McGraw admonished the mother for not “carving out time for yourself” (with the goal of giving her husband more sexual access). He did not retract his admonition when he learned just moments later that the husband had not been helping with the children or maintaining the house until just the “past couple of weeks.”

McGraw engaged in even greater blame-game distortion with the next two couples. The second wife simply asked for intimacy that didn’t always end up with intercourse (a request deemed unreasonable by the two men flanking her). The last couple, amazingly, had McGraw charging the woman with lowering her husband’s sperm count (through stress and pressure), and consequently his self-esteem, by wanting too much sex from him in her desire to become pregnant.

Who defines “sex”?

In a study designed to measure sexual activity and satisfaction within a large population, it would seem that some consideration be given to the range of sexual behaviors between men and women. The JAMA study, however, defined sex strictly as male-female coitus, potentially slanting the findings, as well as their interpretation, to an overtly male perspective.

Shere Hite, PhD, renowned author of The Hite Report and The Hite Report on the Family, says that women’s sexuality is not so simplistic.

“Women are more excited by seducing and being seduced, teasing and playing, creating sexual tension and desire, than by a focus mainly on orgasm,” she writes in the essay “What is a Woman’s Sexual Nature?” Hite claims that women’s sexual arousal, unlike men, does not necessarily end with orgasm, and that coitus can be considered a part of the arousal process itself or even foreplay by some women.

In a recent interview for Australian radio, Leonore Tiefer, PhD, an author and faculty member of the New York University School of Medicine, challenged the discussion about female sexual dysfunction altogether.

“Increase your blood flow, or increase the sensitivity of the tip of your clitoris or the right side of your labia-all of it is genital, genital, genital,” she said. While conceding that genital sensation is clearly part of sexual activity, Tiefer emphasized that it is “far from the whole story.”

“If you don’t have high, intense, regular, routine, reliable levels of genital experience,” Tiefer said, “then the pharmaceutical industry I think wants you to believe that you have a problem, a medical problem, and that you ought to be taking something to jack up your genital function.”

Certified sex therapist Carol Livingston, ARNP, PhD, has been in practice for over 20 years. She believes that many women are just beginning to understand what their sexuality is all about, largely due to arcane societal rules that have traditionally discouraged women from sexual exploration and discovery.

“When women tell me that they don’t know what they want, I say that’s an unacceptable answer,” Livingston says. “I use the example of going to dinner. You have particular tastes, what you like and what you don’t like. You don’t let your partner order the whole meal for you.”

Hite’s research also suggests that female sexual discovery is still in its infancy. In The Hite Report, she found that many women were actively creating new forms of sexual exchange for themselves. These often included female orgasm via clitoral stimulation, but did not obsessively focus on size or duration of penile erection as the sine qua non for having sex with a man.

Defining dysfunction

“There are two ways to go about understanding women’s sexual problems,” Tiefer says. “One is to ask doctors and one is to ask women.”

According to Tiefer, physicians will generally conclude that men and women experience the same range of problems relating to arousal, orgasm or pain. “But if you ask women,” she says, “their problems are that they’re too tired, or that their partner doesn’t want it in the same way as they do, or at the same time as they do, or that they’re not getting along very well with their partner.”

Letitia Anne Peplau, PhD, is skeptical about the reports of women’s so-called sexual dysfunction. “There’s no question that many American women are dissatisfied with their sex lives,” the UCLA professor says. “Women who are quietly angry at their partner, who worry that they are too fat or unattractive, who feel compelled to have sex to avoid conflict, or whose partners are clumsy or inconsiderate may all report sexual problems.”

Peplau believes that issues such as these are more appropriately framed in the context of interpersonal relationships and their inherent social circumstances. “I think we must be very careful not to confuse these sexual problems with medical conditions that might warrant the term ‘dysfunction,’” she says.

Joy Davidson, PhD, a certified sex therapist in Seattle, says that many of her female clients arrive in her office concerned about their libido. In a course of a few sessions, Davidson often discovers that libido isn’t the issue, but that the client has a poorly educated lover.

“It’s not uncommon for couples who have been married 10 years to come into therapy. And when we wind up talking about the specifics of their sex life, their foreplay, etceteras, I’ll find that the man has never even heard of the G-spot,” she says.

Echoing both Peplau and Hite’s observations, Davidson says the lack of desire expressed by her female clients is usually tied to satisfaction with their relationships. And without receiving the same encouragement for sexual exploration that men receive during formative years, many of her female clients are more likely to experience their sexuality as a specific function of their relationship, as opposed to it being an element of their own innate desire.

“The idea that a woman is in and of herself an embodiment of strong sexuality has a negative connotation in the traditional culture,” she notes.

Changing the paradigm

As Carol Livingston says, there needs to be both better and more consistent communication between women and men about sexual issues. There is also a need to stem the amount of media misinformation that continues to circulate throughout society, reinforcing stereotypes and creating confusion.

In January 2004, Men’s Health, a popular national magazine, released promotional collateral that, among other indignities, included an inset titled “Her Sex Calendar.” With the opening line, “A woman’s sex drive is driven by her monthly cycle,” the feature went on to encourage male readers to time the follicular, ovulatory and luteal phases of their female companions, so as to know when to solicit the “lustiest” or most “aggressive” sex of the month.

From conservative sources, it’s not unusual to find simplistic gender role discussion and blatantly sexist notions about male and female sexual behavior. Themarriagebed.com, one of countless similar sites, counsels married women to keep their sexual focus entirely on satisfying the needs of their husbands, as did the Laura Doyle book The Surrendered Wife. A representative piece of advice from the Web site says, “When a man constantly feels a strong need for release, it is very hard for him to focus on the other very important aspects of intimacy.”

On the flip side, contemporary media programming is promoting images of women as sexual aggressors and even predators. No less distorted than starving bodies with ballooned breasts, these images are as inaccurate and insulting to most women as the tranquilized, know-nothing wife of the 1950s, and seem to equate the social and economic progress of women with the mere privilege of copying male stereotypes.

“Many [women] may feel revulsion at images pushed on them and behaviors they are told they ‘must have to be sexy and desirable,’” Hite observes.

In either extreme, the Marx wisecrack “women should be obscene and not heard” seems to apply. Women’s diverse sexuality still takes a backseat to men’s, making informed discussions about sexual needs, sexual dysfunction and strategies for change particularly difficult.

When Bill Clinton fired Jocelyn Elders, the surgeon general of the United States, for simply mentioning masturbation, it was a clear signal that America was hardly the sexually sophisticated nation it imagined itself to be. But, if Elders is any example, it may be up to women to lead a healthy dialogue about sex and sexuality, one that is fair to both women and men and creates the possibility for more mutually fulfilling relationships.

I began a career as a cancer genetics nurse two years ago, after being in the nursing profession for 20 years. My natural interest in hereditary cancer syndromes (there appears to be a high incidence rate in my family), combined with my love of new challenges made this an excellent fit.

Communicating the complicated principles of hereditary (family) cancer syndromes to people requires skill and sensitivity. I help put patients’ cancer risks into perspective and explain strategies for detecting cancer at an earlier and more treatable stage (surveillance), or reducing their cancer risk with prophylactic surgery (i.e. mastectomy, hysterectomy, oophorectomy) or medication (i.e. tamoxifen).

Our clinical team consists of myself, a secretary and a medical geneticist. We accept about 350 new referrals per year in addition to seeing about 240 patients annually in a region of approximately 1.5 million people.

In all cases, the family history of cancer is the most important part of the assessment. To meet the criteria of the clinic, the history must include three individuals in the same bloodline, from at least two generations, diagnosed with cancers associated with a cancer syndrome, with one of these individuals diagnosed under age 55. There are over 50 familial cancer syndromes that are associated with an increased risk for developing malignancies. The most common cancer syndromes I counsel for include hereditary breast and ovarian cancer, hereditary colorectal cancer syndromes and hereditary prostate cancer.

Going to work

Using a patient-completed family history questionnaire, I draw a four-generation family tree (pedigree) noting the details of any cancer diagnoses (including primary site, age at diagnosis and age at death), along with the age and cause of death for all family members. I try to confirm the cancer diagnoses by using additional information from pathology reports, operating room records and medical death certificates. All of this is done by mail before the patient’s first visit. The geneticist and I then review the pedigree in order to establish a likely diagnosis and identify key areas of the family history that need to be enlarged upon. We then discuss whether genetic testing would be helpful for this family and who would be the most appropriate individual to test.

During the first clinic visit, I review the pedigree with the patient and ask additional information about personal health history and cancer surveillance behaviors. We then discuss the cancer syndrome in detail, their personal cancer risks, who else in the family may be at increased risk, as well as surveillance and prevention strategies. For those individuals who are eligible for genetic testing we discuss the advantages and disadvantages of this choice.

Sometimes, the extensive interview uncovers other inherited disorders and medical problems that we bring to the attention of the patient and their family physician for consultation with other specialists.

Disclosing probability

Presenting the results of genetic testing is the most challenging aspect of my practice. It is a very vulnerable time for patients. I need to carefully gauge the psychological impact of the results. In situations where the patient experiences significant depression or sense of helplessness, referral to a psychosocial specialist may be arranged.

For people who already have cancer, the finding of a mutation can bring a sense of relief or closure. They now have an explanation for their own cancer diagnoses and a means for empowering other relatives to potentially avoid the same fate.

Genetic testing does not always identify a gene mutation. In many families the genetic cause of the hereditary cancer syndrome remains unknown. Receiving a non-conclusive test result can be very disappointing. Whatever the outcome, I encourage my patients to keep me updated on their family.

Defining the field

Genetic counseling, as a profession, became established in 1970 when one university began offering a Masters of Science degree in genetic counseling. In the late 1970s, the American Board of Medical Genetics offered certification examinations to these graduates.

There is no separate certification examination for nurses in genetic counseling in Canada and the United States. Nurses in Canada who wish to certify in genetics can take the Canadian Association of Genetic Counselors (CAGC) examination. Nurses in the United States can submit a portfolio to the International Society of Nurses in Genetics (ISONG).

The CAGC, the governing and certification body for genetic counselors in Canada, will continue to evaluate individual nurses’ experiences in genetics counselling and education to determine their eligibility to write their certification exam for the next two exam cycles only (2004 and 2007).

ISONG grants the Genetic Clinical Nurse (GCN) and the Advanced Practice Nurse in Genetics (APNG) designations through a process of professional practice portfolio review.

Overall I believe that nurses bring special skills to the role of the genetic counselor. Our unique knowledge and experience in providing family centered health care enriches the genetic counseling process in our communities.

In order to comply with California’s new nurse-to-patient ratios, many hospitals are using nurse registries to meet their staffing needs in the near term. That means increased activity for several local businesses.

“Hospitals are calling more often for nurses,” says Sonny Park, administrator and president of Nurses Internet Staffing Services Inc., based in Commerce, Calif. Park has witnessed a 20 percent business increase since January. Nurses Internet Staffing Services employs approximately 300 nurses and provides staffing services to more than 35 hospitals in Los Angeles and Bakersfield, including all the Tenet hospitals.

“There’s more demand than supply,” he says. “We ask the nurses to work more [hours] but they can only work so much.”

In the business for five years, Park says meeting hospitals demands has always been a challenge, even before the new regulations began implementation on Jan. 1. “We always have a shortage of quality nurses,” he says.

Nursefinders, a nurse registry employing more than 10,000 RNs, LVNs and LPNs, has a long history of serving hospitals such as Kaiser, Highland Hospital and UCLA Medical Center. Amy Goetz, divisional vice president, says her company has experienced a 40 percent increase in staffing requests.

Like Park’s company, 24/7 Pro Care Inc. in Los Angeles estimates a 20 percent increase in business from Southern California hospitals in 2004. It tries to meet the demand by increasing recruitment efforts.

Barbara Nelson, chief nursing executive at Sutter Roseville Medical Center in Roseville, Calif., agrees that registry nurses are in high demand.

“Statewide, California hospitals currently are operating with a more than 15 percent RN vacancy rate-meaning that more than one out of every six nursing positions is vacant,” she says. “Registry and traveling nurses are used to fill the gap.”

However, not all registries have benefited significantly from the new law. Smaller companies like Adelphi Nursing Agency in Moreno Valley, Calif. and Dallas-based Medical Contracting Services Inc. have seen only slight increases in hospital demands.

“In some ways, [the ratios] have helped us, but we’re a smaller company,” says Stephanie Miller, sales manager of Medical Contracting Services Inc., which provides services to several California hospitals. “We’re not as big as some of our competitors. There are more temporary openings for agencies like ours to fill, but if we don’t have a contract with that hospital, we’re not able to fill them.”

Adelphi Nursing Agency serves many hospitals in the Inland Empire area but office manager, Ade Akande, says the demand hasn’t been great since the implementations.

“A lot of these facilities have nurses that work practically 24-hours-a-day because they can only have a limited amount of registry staff,” she says. She believes that some hospitals limit the number of registry nurses by opting to keep nurses on for longer hours.

Gloria Abaeze, an RN who works for a nurse registry in the Los Angeles area, says that she has been called in more often for work since the ratio implementation. “The demand is high, but the workload is high, too,” she says. “You just have to be ready for it.”

Registry nurse Von Lewis, RN, agrees. “Overall, it has added some workload and taken away some workload,” she says. For example, Lewis notes that the amount of certified nursing assistants in her area has decreased, and as an RN, she now must assume many of the CNA duties. However, she still believes the new nurse ratios are a positive step, despite the fact that many hospitals will continue to depend on nurse registries for their temporary staffing needs.

Deborah Burger, RN, president of the California Nurses Association, feels that in the short-term, registry nurses are helpful in meeting immediate staffing needs. “I appreciate having travel and registry nurses [who can] come in and help pick up the slack when there’s an obvious need,” she says.

Burger doesn’t believe registry nurses are good solutions for hospitals in the long run. She would like to see more resources directed at recruitment and retention of permanent staff nurses.

The Indian Association of Occupational Health Nursing is an India’s registered, voluntary and non-profit making organization.
It is our great pleasure in informing you that we have started help line services to our nurses, who likes to seek a job in the United States or its protectorate. Our organization will help and prepare them for the examination tests and job assistance.

As you may aware that in India we are facing a major problems like unemployment, population, education, poverty etc. and Indian nurses are very hard working, peace loving but economically backward so unable to fulfill your requirement. We are looking forward for full sponsorship to the education as well as immigration procedures. We have decided to get tie up with US based companies or groups and solve the immigration problems of our nurses. We invite you and all please come forward and be one of our sponsor on board of sponsors / donors.

You can send your comments and join with us. For all correspondence you can contact to IAOHN head office and on favor of “IAOHN”. Waiting for your hopeful & positive feedback. Your motivation will help us to success our project in future and fulfill our objective “We Serve For Nurses By Nurses”.

Is it Depression?

Skilled nursing home professionals should be aware of the symptoms of a common malady among residents-major depression. It is manifested as a depressed mood or loss of interest in previously enjoyed activities, plus any five or more of the following symptoms, lasting for at least two weeks:

• Weight loss or gain
• Insomnia or hypersomnia
• Psychomotor retardation or agitation
• Decreased energy
• Guilt feelings
• Inability to concentrate
• Thoughts of suicide

When depression is present, these symptoms almost always produce social impairment that is not related to substance abuse or bereavement. The many complications inherent in assessing, managing, and preventing depression are further complicated when they occur in the skilled nursing home setting with its own set of physical, emotional, and environmental variables.

Skilled nursing home caregivers must be able to recognize depressive symptoms so they can make a referral to the psychologist or psychiatrist. The evaluating professional will then assess them and do a root-cause analysis and diagnosis, so that not only the symptom, but the cause can be treated.

Physical conditions such as hypothyroidism, cardiovascular disease, pulmonary pathology, anemia, and stroke can all cause depressive symptoms that, if not recognized, may lead to profound physical effects.

If a resident has had a heart attack, treatment of his/her post-recovery depression can be almost as important as treatment of the heart itself because of the inhibiting effect depression can have on the recovery process. However, skilled nursing home workers don’t pay the same attention to these very important risk factors of depression.

There are some common triggers for depression in long-term care which makes its population particularly vulnerable. They include chronic illnesses and losses. Consequently, residents with more severe cases should be monitored for depressive symptoms.

Sadness is a normal response to uncomfortable changes. However, referral for an evaluation must be made when the symptoms become serious, not transitional and go from normal mood variations to a chronic persistent state that lasts for months.

The skilled nursing home professional should be aware that medication side effects from many drugs such as long-acting benzodiazepines, steroids, non-steroidal anti-inflammatories, digitalis, cardiac antiarrhythmics, antihypertensive medications, seizure medications, beta blockers and antihistamines can mimic depressive symptoms.

Mental status is another possible trigger. A patient who is chronically confused should be evaluated to be sure that the confusion is not being misdiagnosed as dementia. This is common in Alzheimer’s or stroke-related dementia, hypertension, and with diabetes related depressive symptoms.

Apathy is common in individuals with dementia; however, it is a cognitive problem, not a mood dysfunction and is not equivalent to depression. Distinguishing apathy from depression has important treatment implications because these disorders respond to different interventions.

Differential Diagnosis

In older patients, the presentation of depression is often nonspecific–confusion, loss of appetite, anorexia, weight loss, or fatigue. There is apt to be a sense of loss. Some realize they’ve lost their independence and understand they’re near the end of life. These emotions factor into it.

In older adults, depression often doesn’t look like sadness, and so it is harder to identify than in younger people. This is especially so for people who have cognitive impairment.

Because these individuals often can’t articulate their feelings, one has to look at changes in their behavior, such as more agitation, wandering, hitting, biting, and acting-out. It’s a complex situation requiring that the skilled nursing home population receive skillful individualization in its assessments..

One of the Resident Assessment Protocol issues in the skilled nursing home is mood state. But physical functions, nutrition, and hydration are clinically linked to depression, so it should be considered as a possible cause of changes in such status as weight loss or activity level.

Apathy, certain medications, lethargy due to medical illnesses, adverse drug reactions, and self-destructive dementia-related behaviors can mimic depression. Therefore, before concluding that someone is depressed, it is important that skilled nursing home professionals rule out these other possible reasons for any non-specific symptoms.

Failure to thrive, a term historically used to portray children who don’t grow at the expected rate, is increasingly being used in the elderly care center to describe older adults who begin to decline for no clear reason.

Most skilled nursing home workers have known at least one of them the resident who seems to have “just given up” or lost the will to live, typically showing signs such as weight loss, decreased appetite, poor nutrition, and inactivity.

Signs of failure to thrive in nursing home residents can be very subtle, including things like depression or withdrawal, less engagement in the events around them, a change in mental status, or decreased pleasure in activities they used to enjoy.

Although there are noticeable changes in those experiencing failure to thrive, people who see them every day might not be able to see them. The changes are often hard to notice because they are so gradual. Their life begins unraveling, they become disengaged, and they experience emotional and mental drift.

Thorough Assessment

What can be done to help people in the elderly care center who show the marked decline typical of failure to thrive?

The first step is a comprehensive initial assessment that includes an evaluation of physical and psychological health, functional ability, and social and environmental factors-a thorough check of all the systems to make sure everything is functioning as it should.

After taking a detailed health history, the doctor will look at any existing chronic health conditions or medical problems and look for recent changes in disease management.

For instance, diabetic patients might not be keeping their blood sugar under control, or patients with hypertension might be forgetting their blood pressure medications.

The next part of the process is to look for relatively simple problems – such as urinary tract or respiratory infections – that are having negative effects on the patient. A problem with teeth or oral health, for example, can cause eating or appetite changes.

The doctor will also want to assess the patient’s emotional state and wellbeing, asking about any changes in sleep and eating habits or signs of depression – is the patient having any thoughts of suicide, or thoughts that make death seem appealing?

Finally, the doctor will perform a more in-depth evaluation of any problem areas, followed by a plan of action that might include physical or occupational therapy, nutritional supplementation, new medication, or fine-tuning the dosage and timing of current medications to minimize side effects.

Finding the root cause of failure to thrive might not be possible; the causes and effects are often intertwined. Depression can be a cause and a consequence of failure to thrive and the same could be said of virtually any of the symptoms.

Syndromes Point to Adverse Outcome

Physicians should evaluate patients in each of these areas.

• Impaired physical function. “Activities of daily living,” or ADLs, consist of everyday tasks such as eating, bathing, moving around in one’s environment, and dressing.

  Patients who have trouble with these activities will likely have a difficult time maintaining their independence. Physicians have a number of simple tests that they can ask the patient to perform in order to assess physical status.

• Malnutrition. Many medical conditions that are common among the elderly – and, unfortunately, the medications used to treat them – can result in poor nutrition among older adults.

  To discern the causes of malnutrition, physicians can discuss dietary habits with patients and run a number of laboratory tests to assess conditions such as dehydration, electrolyte imbalances or loss of muscle mass.

• Depression. Depression is one of the more common psychiatric conditions of older persons in the elderly care center. It exists often in response to physical, mental or emotional issues that accompany aging. We don’t use psychotherapy or anti-depressants as effectively as we should in the geriatric population.

  A significant percentage of the time, there’s a role depression is playing in their behavior.” There are numerous tests and questionnaires that doctors can use to evaluate a patient’s state of mind, and a number of highly effective medications to help alleviate the condition.

• Cognitive impairment. In addition to physical health problems, many situations can have an impact on the status of a patient’s mental function: Information on the patient’s social network, relationships, family support, living situation, financial resources, abuse, neglect, and recent loss are important aspects of the assessment.

After considering reversible causes of failure to thrive, the doctor will want to look for more serious illnesses like cancer or thyroid disease.

Older residents might not recognize the decline themselves or dismiss the concerns of family members or staff. If an individual has been well functioning and something changes, the elderly care center worker might have to point it out to him/her and s/he might deny it or disagree. The caregiver might have to be assertive, explaining that there’s been a noticeable change and need to find the cause.

Doctors should give positive feedback to ailing elderly care center residents and reassure them that it might be possible to help them feel better.

Failure to thrive is often a decision point. One looks for reversible causes. If there are none, it might be time to change expectations about this patient and move from therapeutic to palliative care.

The Gene, Immune and Stem Cell Therapy (GISCT) program at the CHLA Saban Research Institute focuses on hematopoietic stem cell (HSC) biology; development, function and diseases of the immune system; B lymphocyte function, erythropoiesis and gene therapy for hemoglobinopathies. The program has also analyzed graft-versus-host disease and immunologic reconstitution, xenotransplantation immunobiology, development of methods for gene therapy using HSC, and trans-differentiation of hematopoietic and embryonic stem cells.

Human hematopoietic stem cells

One of the principal stem cell investigators at CHLA is Dr. Gay M.Crooks, attending physician at the Division of Research Immunology/Bone Marrow Transplant.Her research interest lies in the basic biology of human HSC and progenitors.

“For more than 15 years, we’ve been studying different aspects of bone marrow stem cells,” Crooks says. Physicians in the division provide medical management of patients with diseases treatable by hematopoietic stem cell transplantation (HSCT), including all aspects of pre- and post-transplant care.

The HSCT program is one of the largest, most highly regarded pediatric programs in the world. Physicians are refining techniques of HSCT to benefit children who lack a suitable family donor, including the use of unrelated donor bone marrow or umbilical cord blood, treated to remove T cells. The program, established in 1983, currently performs 45 to 55 bone marrow transplants per year, according to CHLA.

HSC can be isolated from bone marrow, umbilical cord blood and peripheral blood. “[These] stem cells are much better understood and they’re the ones that are used essentially in bone marrow transplantation,” Crooks says. “We use them clinically, as well as study them in basic biology. A great deal has been discovered over the years and continues to be.”

According to Crooks, recent research suggests that HSC, also known as adult stem cells, are able to produce more than just blood. This represents a potentially revolutionary breakthrough in medicine. “Over the last three or four years, people have been wondering whether bone marrow stem cells (HSC) might also make other tissues like liver, brain muscle and so on,” she says

The researchers at CHLA consist primarily of physician scientists who work in the lab and also provide clinical care to bone marrow transplant patients. Crooks says the knowledge they gain in the lab helps doctors with treatment plans. For example, physicians can learn how to manipulate the immune system after transplantation to help speed patient recovery.

“We learn a great deal from our patients that we can then bring back into the lab. And our lab work very much influence how we treat the patients,” she adds.

Expanding nurse role

Crooks says there are more than 50 healthcare professionals working in stem cell or related research at CHLA, among them Kathy Wilson, RN, Dominique De Clerck,
BSN, and Renna Killen, RN, BSN.

Killen is a clinical research nurse in charge of data management. “She is absolutely central to the collection of data and running of the clinical protocols for our various trials,” Crooks says. “She’s very much a part of the stem cell clinical that we do.”
“In addition, we have two of our outpatient coordinator nurses who are very involved with the care and the conduct of research patients outside the hospital,” Crooks says.

Wilson is the outpatient coordinator who handles patient studies necessary for bone marrow stem cell transplant. De Clerck, nurse coordinator for the matched, unrelated donor program, identifies stem cell donors for patients undergoing bone marrow transplant.

“The nurses are predominantly involved in the clinical, translational research,” Crooks explains. Most of CHLA’s outpatients participate in clinical trials. Nursing staff coordinate patient research, making sure all tests are completed and analyzed.

Crooks believes nurses are going to be at the hub of stem cell research trials. “There’s nothing to stop nurses from being part of the development of these trials,” she says.

“There’s no reason it has to be MDs or PhDs. The basic biology is going to be mainly the people in the labs, but we won’t know how useful they are until we get these cells into the clinic and then anybody caring for patients with these disorders will be on the frontline.”

Embryonic stem cells

The newer, controversial embryonic stem cell research has received widespread support, as well as criticism. Currently, funding is available for only 78 existing stem cell lines. According to the National Institutes of Health (NIH), however, as of April 18, 2003, there are only 11 human embryonic stem cell lines that federally supported researchers can purchase.

At CHLA, researchers have been using only two of the cell lines approved by federal regulations. Crooks says that the government restrictions came at an early stage of the research, limiting the expansiveness of the studies.

Recently, a Johns Hopkins University medical ethics panel raised questions about the existing lines approved by the Bush administration. The sanctioned cell lines were initially grown on mouse cells and could potentially leave human immune systems vulnerable to animal viruses. The panel stated that safer stem cells are currently available, but are not eligible for federal funding.

Future of stem cell research

According to the NIH, more analysis is needed for both embryonic stem cell and HSC research. A 2001 study by the agency verifies the impossibility of predicting which stem cells will best meet the needs of basic research and clinical applications.

Crooks agrees with the NIH, saying that both embryonic stem cell lines and HSC research are just beginning. “It’s very much up in the air at the moment as to how either
embryonic stem cell lines or bone marrow adults stem cells are going to be useful therapeutically,” she observes.

For the immediate future, Crooks predicts that scientists will focus on the essential biology of the two types of stem cells and their application in tissue renewal, tissue engineering or tissue transplantation.

“Stem cells are being studied for their potential to make other tissue. In the future, they will impact lots of other disease processes, like liver disease, CNS (central nervous system) disease, muscle disease and certainly cardiac disease,” Crooks says.

The Debate Heats Up

In November 1998, scientists successfully isolated and cultured human embryonic stem cells-sparking a flurry of debate. These cells have the potential to generate muscle cells, nerve cells, heart cells and blood cells. Approximately 128 million Americans suffering from disabling diseases could experience dramatic benefit from continued research.

Conservative groups maintain that embryonic stem cell research is unacceptable since it leads to the death of donor embryos. On Aug. 9, 2001, President Bush limited funding for the research, in spite of its life-saving potential.

“Research on embryonic stem cells raises profound ethical questions, because extracting the stem cell destroys the embryo, and thus destroys its potential for life,” Bush said in a televised speech.

On April 28, 2004, in a bipartisan effort, more than 200 members of the House of Representatives petitioned President Bush to reconsider the restrictions on stem cell research. “Stem cell research is vital and has great potential to help victims of debilitating diseases like cancer, heart disease, diabetes, Parkinson’s, Alzheimer’s, multiple sclerosis and many others,” Rep. Lois Capps says. “Federal funding is essential to the success of this type of research, but, sadly, the current policy that restricts stem cell research is having an extremely adverse effect.”

Great Britain and other European nations are moving forward with fewer restrictions and more funding for embryonic stem cell research. In December 2002, the Australian parliament passed a bill allowing scientists to harvest stem cells from human embryos for research purposes. However, scientists are not permitted to create new embryos or foster any work related to human cloning.

“The only reason I haven’t gotten seriously hurt is that I’m lucky,” says DePalma, a registered nurse at the University of California Davis Medical Center.

Although hospital officials at UC Davis contend that current safety measures are effective, including a campus police force, security guards in the emergency room and monitored video cameras, DePalma says she didn’t feel safe. “It’s a pressure cooker,” she warns.

After leaving the ER in September 2003, DePalma transferred to an intensive care unit. “It’s more controlled,” she says. “We’re six floors up and behind locked doors. We’re not dealing with people walking in off the street.”

For her colleagues who remain in the ER, DePalma has fears. “It’s not a question of ‘if,’ but a question of ‘when’ someone will come in with a gun,” she says. “I hate to feel that something like that has to happen before anything is done.”

Workplace violence and the threat of violence are not only serious issues for nurses in California, but for nurses throughout the nation. According to the National Institute of Occupational Safety and Health (NIOSH), more than 9,000 nurses and healthcare workers are harmed on the job every day, many by verbal and physical assaults. But despite a long and sometimes harrowing history, the issue of workplace violence has often been shunted aside or ignored by hospitals, providers and legislators, taking a back seat to concerns about public relations, litigation and insurance rates.

It took brutal murders of hospital staff in the 1990s, along with some well-publicized sexual assaults and abductions, to swell an outcry demanding strategies to protect healthcare workers.

In 1995, California became the first state to require that hospitals assess overall safety, develop a security plan to protect patients, visitors and staff, and continually train ER personnel to deal with potential violence. The regulation, known as Health & Safety Code 1257.7, mandates that hospitals track incidents of aggressive and violent behavior.

The regulation may look good in print, but there are problems. It does not standardize specific criteria for hospital safety plans and no state agency is responsible for collecting the data generated. Consequently, like a bill with no funding, enforcement is unfeasible.

As for tracking incident reports and trends at the provider level, it’s hard to know who is doing what. While several hospital officials contacted for this article maintained that their institutions monitor incident/accident reports internally, they declined to disclose any of the information to Caregiver Mom.

While it is easy to appreciate the sensitivity of the information, the secrecy with which it is guarded doesn’t help engender confidence among those it is intended to protect. As for DePalma, she expresses little trust in the system that is supposedly working on her behalf. “People down there in the trenches know it’s bureaucratic idiocy that has nothing to do with safety,” she claims.

Credibility factor

Even if facilities are observing the monitoring guidelines of code 1257.7, no one can be certain that the information collected is accurately characterizing what’s really happening in the workplace. For example, many nursing professionals say that it is commonplace for incidents as serious as assault to go entirely unreported. Some professionals may feel too embarrassed or shamed to come forward, or may work in environments that discourage tenacious reporting. Whatever the situation, the gap between recorded numbers and actual experience has a wide potential.

Still others minimize jobsite danger altogether, saying that it all comes with the territory. But in a profession that already carries significant risks of infection and on-the-job injury, such dismissive positions seem hardly credible.

“Things are better, but it’s still a violent environment,” says Darlene Bradley, RN, PhDc, MSN, director of emergency trauma services at the UC Irvine Medical Center and president of the Emergency Nurses Association, California chapter.

Although it’s possible that code 1257.7 may have helped lower incidence rates, Bradley believes much more can be done to establish uniform standards for security and training.

“Politically, the issue has been taken care of, but that doesn’t mean it’s resolved,” says Tricia Hunter, RN, MN, executive director of the American Nurses Association, California chapter. Hunter helped craft the workplace safety legislation when she served in the state assembly in the early 1990s.

But without funding for enforcement, legislation efficacy is hard to measure.

Violence defined

While professionals in the health sector comprise about 11 percent of the total U.S. workforce, they experience almost 25 percent of all workplace violence. More than half of all healthcare workers may be affected, according to a joint report by the International Labor Organization, the International Council of Nurses and the World Health Organization.

Most physical confrontations involve hitting, shoving, scratching and/or biting, accompanied by verbal abuse. Alcohol and drug involvement can complicate and exacerbate violent behavior. Even if staff are not seriously injured, the experience can be emotionally disturbing and even traumatic. While homicide is rare, it does occur and the potential is always a looming threat.

Given the amount of contact with patients, families and the general public — and because most are female — nurses are frequent targets of assault. One survey published in the Journal of Emergency Nursing in 2000 found that 82 percent of nurses had been assaulted during their careers. Incredibly, only 3.6 percent of the nurses surveyed for the study said they felt safe at work.

Research suggests that of all nursing professionals, those working in emergency departments are at the greatest risk for workplace violence. In these highly charged environments, patients and their family members and friends often face life-and-death situations, and emotions can run high. Fevers and certain medications can contribute to out-of-control behavior. Add to this mix the volume of foot traffic that passes through a typical ED on any given day and it’s easy to understand an escalated risk exposure.

Psychiatric units, which are increasingly becoming temporary holding places for the homeless, chronically mentally ill, are also considered high-risk areas. Nurses who work closely with Alzheimer’s and other dementia patients report an elevated incidence of assaults. Aggressive and/or hostile behavior is a common symptom of neurological degeneration and it poses an added challenge to primary caregivers.

Bigger than California

Across the country, professionals, consultants and lawmakers are re-evaluating the need for mandated safety plans, and considering stiffer penalties for those who assault healthcare workers on the job.

“The assault rate is still as high now as it was when I started this work 20 years ago,” says Marilyn Lanza, DNSc, ARNP, CS, FAAN, a nurse researcher at the Veterans Hospital in Bedford, Mass. “There have been some beginning efforts of legislation, but the problem is ongoing.”

Massachusetts currently requires its hospitals to adhere to workplace violence prevention protocols established by the International Association for Healthcare Security & Safety.

Mary Johnson, PhD, associate professor at Rush University’s College of Nursing in Chicago, says that understanding the different ideologies of violence is essential to prevention programs. The aggressive behavior of patients with psychopathic disorders is very different from those who are bipolar or suffering from dementia, she observes. But regardless of the particular patient group or clinical specialty, Johnson believes that workplace violence has not been given adequate study. “It’s a real problem,” she says.

At the federal level, the Occupational Safety and Health Administration (OSHA) has developed guidelines for improving security in healthcare settings. Unfortunately, implementation of the OSHA guidelines remains voluntary, again raising legitimate concerns about their regulatory impact.

Bradley of the Emergency Nurses Association says her organization has developed a position paper that is currently awaiting board approval. The paper proposes universal safety standards, such as the use of alarm systems in hospitals, well-trained security staff and barriers where necessary and appropriate (such as bulletproof glass). The draft paper also calls for legislation that would mandate the use of metal detectors and other stringent safety controls in medical facilities.

The ENA supports more nurse involvement in safety policy development. It also recommends more thorough follow-up and resources for victims of violence, who can suffer from post-traumatic stress and depression.

Emphasizing education

It is well known that education and training are key factors in any successful safety plan. California law requires violence prevention training for ER staff. OSHA’s national guidelines recommend training for personnel throughout hospitals, although no specific standard has been established.

Bradley attributes staff training to mitigating some potentially serious occurrences at UC Irvine. “Most incidents occur because the staff failed to recognize things like pacing, speaking in a loud voice, clenching hands into a fist, or behaving in ways that are generally inappropriate,” she says.

Bradley adds, however, that the institution does not have a set curriculum or competency measurement for its safety training.

Marlene Nadler-Moodie, MSN, APRN, CNS, president of the American Psychiatric Nurses Association, California chapter, says she feels safe working in the psychiatric unit at a San Diego facility because of the intense training staff members undergo. It’s not uncommon, however, for nurses outside the unit to interact with psych patients as well, especially in the emergency department. These nurses do not benefit from the same training programs as Nadler-Moodie and her staff.

“Money is tighter and staffing is shorter,” says Nadler-Moodie, who observes that safety training and implementation is often one of the first things to suffer during funding shortfalls.

DePalma of UC Davis says that when she first started in nursing, she did not understand the appropriate protocol when confronted with a violent patient. She says that she and her colleagues were amazed when they saw an older nurse contact police and file charges following an assault. “We all thought, ‘Gee, I didn’t know we could do that,’” she remembers.

Safety plans in action

“Larger hospital systems, such as Kaiser Permanente, are taking a more systematic approach to beefing up security,” says Phil Hoffman, director of security and investigations for Kaiser Permanente’s national facilities services. “Because of our size, we can roll out best practices.”

With 28 hospitals statewide, Kaiser Permanente has threat management teams that help evaluate each incident reported and how it could have been prevented.

All new buildings must meet certain structural requirements, such as built-in locations for security cameras and silent alarm systems. And according to Hoffman, employees receive extensive safety training.

It may be necessary to install bulletproof glass at certain locations, Hoffman says. However, he quickly adds, “The more barriers you put between you and the patient, the less contact you have, and that can be even more frustrating.”

Though he declined to provide specific numbers for Kaiser, Hoffman says the security measures are working. “We’re seeing a downward trend within the organization,” he says. “We will see an aberration once in a while, but we’re not seeing any unusual collective increases.”

In some instances, hospitals collaborate with law enforcement to develop security measures. At Los Angeles County-University of Southern California Medical Center, where in 1993 a physician was shot to death, county police officers are on site at all times, according to Capt. Hector Lemus, a member of the LAPD.

Lemus says that hospital security guards conduct weapons screening at all entrances and that security cameras are used throughout the campus, as are alarm systems. Employees receive training in conflict resolution and strategies for de-escalating hostile behavior. Most calls for assistance, according to Lemus, come from the psychiatric unit and the emergency department.

Lemus says gang violence has been a periodic concern at the facility. If there’s any reason to suspect a patient may be in danger of retaliatory action by a gang member or even a domestic partner, the hospital uses a “John Doe protocol” to maintain confidentiality of patient identity and location, offering added security for both patients and staff.

Speaking for standards

Security officials say one important step toward improved workplace safety is more consistent reporting. Regardless of whether or not physical harm has occurred or whether formal charges are filed, staff need to officially document all real and potential threats.

It’s time once again for New Year’s resolutions. Posted on top of many lists is the desire to stop smoking.

Although it is well known that lung cancer, heart disease, stroke, cervical cancer and other life-threatening illness are linked to this habit, millions continue to smoke. Oddly enough, many smokers are healthcare professionals.

As reported in the November issue of CGM, a Thomas Jefferson University study found last year that 13.5 percent of nursing students and 3.3 percent of medical students smoke. It suggests even health professionals are susceptible to the lure of tobacco.

Dr. Frederic Grannis, a thoracic surgeon and lung cancer specialist at City of Hope Cancer Center in Los Angeles, remembers smoking as a physician, and believes he wasn’t a good role model for his patients and colleagues at the time.

“I personally feel that I let down a standard,” he says. “And I feel that I did the right thing by quitting, not just for my own personal health, but also to set an example for the general public health.”

Unfortunately, the 60-year-old says the addiction is common among professionals of his generation. “When I was in training, most of the thoracic surgeons I worked with smoked,” he says. “Almost all have stopped since then, but there have been some very prominent thoracic surgeons who died of lung cancer.”

Grannis now spends time each year giving a two-hour smoking cessation course for medical students at Western University of Health Sciences in Pomona, Calif. In addition, he gives talks on lung cancer and tobacco control and cessation throughout the year. He also set up a Web site (www.smokinglungs.com) with facts and images about lung cancer as well as information on smoking cessation.

As Grannis says, “If you’re smoking, how can you then tell others not to smoke?”

The bad news

The catalog of risks associated with smoking continues to grow, now extending to prostate cancer and even multiple sclerosis.

Researchers in Norway and Harvard University found the risk for multiple sclerosis to be almost three times higher for male smokers and two times higher for female smokers. The study, published in last October’s issue of Neurology, found most of the people in the group with multiple sclerosis were current or past smokers.

Meanwhile, doctors in Seattle discovered recently that men who smoke have a 40 percent greater risk of developing prostate cancer. Janet Stanford, MD, of the Fred Hutchinson Cancer Research Center led the study, which found worsening health risks for those who smoked more over a longer period of time.

Smoking-related lung disease may actually kill more people than previously thought. London researchers reported that chronic obstructive pulmonary disease (COPD) kills two-thirds more people than previously estimated. Smoking is responsible for about 90 percent of COPD. The World Health Organization had estimated that COPD, which can include emphysema and chronic bronchitis, kills 2.9 million people yearly. The London study now suggests that figure may underestimate the problem.

Meanwhile, tobacco companies spend more than $11 billion a year in advertising to retain and grow their customer base. Even as recently as November 2003, Gareth Davis, the chief executive of Imperial Tobacco, Britain’s largest tobacco company, claimed that he was not sure that smoking caused lung cancer.

Closer to home, two tobacco companies sued California in April 2003 to stop state-sponsored anti-tobacco ads on television. Lorillard Tobacco and R.J. Reynolds Tobacco claim the ads produced by the State Department of Health Services damage their reputations and violate their constitutional rights.

Grannis says the ads help save lives. “In states like California, where we spend a much higher percentage of money on anti-tobacco messages, we’re doing a lot better than other states,” he notes. “The incidence of lung cancer in the state of California is down by 19 percent.”

Sacramento federal Judge Lawrence Karlton threw out the lawsuit in July 2003 and denied the tobacco companies’ request to stop the ads.

The good news

Quitting smoking can be difficult. Results from the U.S. Surgeon General reports have equated aspects of tobacco addiction with those of heroin and cocaine addiction.

But no matter how hard it may seem, thousands quit every year. The Centers for Disease Control and Prevention (CDC) says the percentage of adult American smokers declined from 25 percent in 1993 to 22.8 percent in 2001.

David Stamps of Laconia, NH, is one such adult. He tried to quit several times during his 30 years of smoking, but it wasn’t until his mother deteriorated from COPD, that he was finally able to kick the habit.

“It took 10 years and it was very painful as each year she became weaker and weaker,” he says of his mother’s illness. “COPD is not like turning out the light, which many think when they start smoking, but a long, slow, agonizing process.”

He turned to the American Lung Association’s Freedom From Smoking program for help. Then went on to facilitate the workshop for five years and even set up a Web site to help smokers and those who live with them. “I wanted my site to be inspirational and factual, so as to build self-awareness and motivation in smokers,” he says.

Visitors to www.smokehelp.org can find everything from the advertising tactics used by tobacco companies to graphic visual aids of what happens in smokers’ lungs to useful advice for quitting. But perhaps most importantly, the site encourages visitors to ask Stamps anything about quitting tobacco. He proves to be an especially compelling source of information.

Finding help

For those who can’t quit smoking through counseling alone, Dr. Grannis recommends nicotine replacement products, which are now available over the counter. The products require careful use to be effective.

If counseling and nicotine replacement are not enough, Grannis suggests that smokers talk to their doctors about bupropion, a prescription drug used as an antidepressant that has also been shown to reduce smoking cravings.

No matter what method is selected, the important thing is to stay committed to quitting. “My experience as a teacher is that the only predictor of success was the personal effort made,” Stamps says.

Grannis agrees, adding that as powerful an addiction as smoking can be, it is possible to stop once you make the commitment to quit. “Once you make that decision,” he says, “it’s almost a guaranteed success, as long as you keep trying.”

An estimated 46.5 million adults in the United States smoke cigarettes. This behavior will cause death or disability for half of all regular users, according to the CDC. “It’s an average of 14 years potential life loss for adult smokers,” says Joel London from CDC media relations.

Smoking-related illness cost more than $75 billion in medical expenditures and another $80 billion in lost productivity from 1995-1999.

Anti-Smoking Resources

American Lung Association of California-Includes information on the Freedom From Smoking program. www.californialung.org, (510) 638-LUNG.

The California Smokers’ Helpline-A free service offering information, self-help materials and counseling in English, Spanish, Korean, Vietnamese, Mandarin and Cantonese. www.californiasmokershelpline.org, (800) NO-BUTTS.

Tobacco Information and Prevention Source-The CDC-sponsored Web site includes exclusive resources on smoking cessation. www.cdc.gov/tobacco/index.htm.

American Cancer Society-Learn more about the health risks of smoking and about the best ways to give it up. www.cancer.org, (800) ACS-2345.

Tobacco Cessation Guideline-Contains the latest drug and counseling methods for smokers and for the clinicians who treat them (in English and Spanish). www.surgeongeneral.gov/tobacco.