Characterisation of vaping liquids used in vaping devices across four countries: results from an analysis of selected vaping liquids reported by users in the 2016 ITC Four Country Smoking and Vaping Survey.

OBJECTIVES: This study presents an analysis of vaping products (VPs) purchased in the USA, Canada, England and Australia and assesses whether differences in regulations were associated with differences in the chemical composition of the VPs. METHODS: April-September 2017, a total of 234 VP refill liquids and prefilled cartridges were purchased in convenience samples of retail locations in each country. Products were chosen from brands and styles most commonly reported by current VP users in the 2016 ITC Four Country Smoking and Vaping Survey. All products were tested for nicotine, tobacco-specific nitrosamines (TSNAs), minor tobacco alkaloids, organic acids and flavouring chemicals. RESULTS: Consistent with the laws in Canada and Australia at the time of product purchase, nicotine was not detected in any of the VPs (n=10 in Canada; n=15 in Australia). US liquids (n=54) had a mean nicotine concentration of 16.2 mg/mL, (range=0.0-58.6) and English liquids (n=166) had a mean concentration of 11.9 mg/mL ((range=0.0-31.2) F(3244)=12.32, p<0.001). About 5% of English samples exceeded the UK's 20 mg/mL nicotine limit. Substantial country differences were observed in levels ofTSNAs, with the USA being higher than elsewhere. Of all products tested, 18.8% contained at least one organic acid. Liquids purchased in England contained far more identifiable flavouring chemicals than those in the other countries. CONCLUSIONS: VP composition, particularly with respect to nicotine and flavouring, varies by country, likely reflecting both marketplace preferences and country-specific regulations. There are differences between nicotine levels claimed on the package and actual levels, particularly in England.

Prevalence of Telehealth in Nursing: Implications for Regulation and Education in the Era of Value-Based Care.

Value-based care theoretically catalyzes the business case for telehealth. Hence, the purpose of this study was to define the proportion of a statewide nursing workforce who self-reported telehealth or telephonic nursing as their primary work setting in a U.S. state undergoing rapid transitions to value-based care. We conducted a secondary analysis of a 2017 statewide nurse relicensure survey (n = 10,851), overall response rate 99%. The focus of the analysis was registered nurses who reported that they were currently working in Vermont or serving residents of the state (n = 8,457). Analysis was limited to descriptive statistics. We found that 18.4% of respondents (n = 1,556) reported their employment status as "telehealth/ working as a telephonic nurse." Responding to a different question, 17.2% (n = 1,458) defined "telehealth/telephonic" as their primary work setting. Thus, nearly one fifth of nurses practicing in the state were employed in telehealth, a role for which there is scant preparation in nursing education. The multistate practice of roughly one third of these nurses highlights the importance of the Enhanced Nurse Licensure Compact and raises questions about global telenurse practice. Taken as a whole, these findings have profound implications for health care policy development and implementation, ongoing workforce development and analyses, nursing regulation, education, and continuing education. New and renewed skills are needed to provide safe, effective, culturally relevant telehealth, and virtual care.

Reducing Preventable Hospitalizations With Two Models of Transitional Care.

PURPOSE: Transitional care is an emerging model of health care designed to decrease preventable adverse events and associated utilization of health care through temporary follow-up after hospital discharge. This study describes the approaches and outcomes of two distinct transitional care programs serving different populations: one is provided by master's-prepared clinical nurse specialists (CNS) with a chronic disease self-management focus, another by physicians specializing in palliative care (PPCs). Existing research has shown that transitional care programs with intensive follow-up reduce hospitalizations, emergency department (ED) visits, and costs. Few studies, however, have included side-by-side descriptions of the efficacy of transitional care programs varying by healthcare providers or program focus. DESIGN: This is a retrospective cohort study comparing the number of ED visits and hospitalizations in the 120 days before and after the intervention for patients enrolled in each transitional care program. Each program included post-hospitalization home visits, but included differences in program focus (chronic disease vs. palliative), assessment and interventions, and population (rural vs. urban). Data from participants in the CNS program (September 2014 to December 2014) were analyzed (n = 98). The average age of participants was 69 years and 65% were female. Data were collected from patients from the PPC program from September 2014 to April 2015 (n = 71). Thirty participants died within 120 days after the intervention and were excluded; the remaining 41 were included in the analysis. Participants had an average age of 81 years and 63% were female. METHODS: For the CNS program, a secondary analysis of existing data was performed. For the PPC program, a review of patient charts was done to collect data on encounters. A Wilcoxon matched-pairs signed-rank test was performed to test for significance. FINDINGS: Patients in the CNS intervention had significantly fewer ED visits (p < .005) and hospitalizations (p < .005) in the 4 months after the intervention than in the 4 months before the intervention. Patients in the PPC program had a nonsignificant reduction in ED visits (p = .327) and a significant reduction in hospitalizations postintervention (p = .03). CONCLUSIONS: Both transitional programs have value in decreasing rehospitalizations. The CNS intervention also significantly reduced ED visits for their target population. Further study with randomized controlled trials is needed to allow for a better understanding of the healthcare workforce best fitted to enhance transitional care outcomes. Future study to examine the cost savings of each of the interventions is also needed. CLINICAL RELEVANCE: Transitional care programs have the potential to prevent unnecessary utilization of health care at the critical periods of transition that leave patients vulnerable to adverse events and poor outcomes.

Teaching Electronic Health Record Communication Skills.

This pilot study investigated nurse practitioner students' communication skills when utilizing the electronic health record during history taking. The nurse practitioner students (n = 16) were videotaped utilizing the electronic health record while taking health histories with standardized patients. The students were videotaped during two separate sessions during one semester. Two observers recorded the time spent (1) typing and talking, (2) typing only, and (3) looking at the computer without talking. Total history taking time, computer placement, and communication skills were also recorded. During the formative session, mean history taking time was 11.4 minutes, with 3.5 minutes engaged with the computer (30.6% of visit). During the evaluative session, mean history taking time was 12.4 minutes, with 2.95 minutes engaged with the computer (24% of visit). The percentage of time individuals spent changed over the two visits: typing and talking, -3.1% (P = .3); typing only, +12.8% (P = .038); and looking at the computer, -9.6% (P = .039). This study demonstrated that time spent engaged with the computer during a patient encounter does decrease with student practice and education. Therefore, students benefit from instruction on electronic health record-specific communication skills, and use of a simple mnemonic to reinforce this is suggested.

Characteristics of Informal Caregivers and Social Participation of People With Dementia.

BACKGROUND AND OBJECTIVES: Social participation is associated with increased quality of life and well-being but declines following the onset of dementia. Informal caregivers may facilitate social participation among people with dementia. This study aims to identify characteristics of informal caregivers associated with social participation of people with dementia in valued activities. RESEARCH DESIGN AND METHODS: This cross-sectional study used data from the 2011, 2015, and 2017 National Health and Aging Trends Study (NHATS) and the National Study of Caregiving. NHATS respondents with possible or probable dementia and an informal caregiver were included (N = 1,060). Respondents were asked whether they participated in each of 5 social activities during the past month. Valued activities were considered somewhat or very important. Survey-weighted logistic regression models were computed to identify characteristics of primary informal caregivers associated with participation of people with dementia in social activities. RESULTS: Social participation of people with dementia was not independently associated with sociodemographic variables or relationship to the primary caregiver (spouse/partner, adult child, or other relative/nonrelative). Social participation of primary caregivers was associated with increased participation of people with dementia in the same activity for visiting friends/family (odds ratio [OR] = 1.88, p = .016), attending religious services (OR = 4.82, p < .001), and volunteering (OR = 3.25, p = .015), whereas greater caregiver external support was associated with increased participation of people with dementia in organized activities (OR = 1.37, p = .022). DISCUSSION AND IMPLICATIONS: Assets of informal primary caregivers found to promote social participation of people with dementia include traveling to the person with dementia's home, being socially active themselves, and utilizing support services.

Tai Chi for older nurses: a workplace wellness pilot study.

PURPOSE: The purpose of this pilot study was to assess the feasibility of a Tai Chi workplace wellness program as a cost effective way of improving physical and mental health, reducing work related stress, and improving work productivity among older nurses in a hospital setting Design A randomized control trial of two groups (control and Tai Chi group). DESIGN: A randomized control trial of two groups (control and Tai Chi group). SETTINGS: Northeastern academic medical center. SUBJECTS: A convenience sample of eleven female nurses (mean age 54.4 years). INTERVENTION: The Tai Chi group (n = 6) was asked to attend Tai Chi classes once a week offered at their worksite and to practice on their own for 10 minutes each day at least 4 days per week for 15 weeks. Controls (n = 5) received no intervention. MEASURES: SF-36 Health Survey, Nursing Stress Scale (NSS), Perceived Stress Scale (PSS), Sit-and-Reach test, Functional Reach test, the Work Limitations Questionnaire, workplace injury and unscheduled time off. ANALYSIS: The two study groups were compared descriptively and changes across time in the intervention versus control were compared. RESULTS: The Tai Chi group took no unscheduled time-off hours, whereas, the control group was absent 49 hours during the study period. There was also a 3% increase in work productivity and significant improvement in functional reach (p=0.03) compared to the control group. Other outcomes were not statistically significant. CONCLUSION: This pilot study demonstrates the feasibility of Tai Chi with older female workers as a cost effective wellness option in the workplace; thus encouraging replication with a larger sample. Methodological implications were also addressed.

Education and employment characteristics of nurse preceptors.

BACKGROUND: Nurse preceptors are vital linchpins, supporting the transition of new graduates to practicing registered nurses (RNs). This research clarifies similarities and differences among preceptors and nonpreceptors in an established statewide preceptor program. METHODS: A secondary analysis of relicensure data from all nurses working in Vermont hospitals in two years (2005 and 2009) was undertaken. RESULTS: There were no statistical differences by basic degree type, highest degree, RN experience, years in the current job, job satisfaction, and intention to leave. Statistically significant differences that persisted over time included: (1) being less likely to be employed per diem; (2) work site population density; and (3) being more likely to be enrolled in nursing education programs. CONCLUSION: Given the lack of obvious identifiers, organizations would benefit from a systemized approach to preceptor identification and development. Regulators, who hold the clear social and legal mandate for patient safety, must also be an enabling force toward change.

Advanced Practice Registered Nurse supply in a small state: trends to inform policy.

This study is a contribution to the small existing pool of state level research on Advanced Practice Registered Nurse (APRN) workforce supply. Data from four biennial surveys of Vermont APRNs from 2003, 2005, 2007, and 2009 (n = 1,538) were analyzed to produce descriptive statistics of one small state's APRN demographic, educational, employment, job satisfaction, intention to leave, and practice-setting characteristics. Survey results were then used to identify patterns or trends that existed in the data. There was a marked shift in the employment settings and a decrease time worked as an APRN, despite an aging APRN workforce. There was an increase in the aggregate education level of APRNs; however, the percentage educated at the doctoral level remained flat at 2%. Overall, APRNs were a satisfied segment of the health workforce; however, those intending to leave for dissatisfaction voiced more concern about job stress and less concern about salary and benefits over time. Implications for workforce planning and public policy are discussed.

Practical nurses' health and safety in nursing homes.

PURPOSE: Practical nurses (PNs) rated their general and emotional health and their employers' attention to their health and safety. These components were examined in relationship to work setting and intention to leave for the purpose of exploring workforce issues involving these important care providers of frail elders. DESIGN/METHODS: A relicensure survey mailed to all PNs in one rural state included the Minimum Data Set for nurse workforce supply plus questions from the Health and Retirement Survey. Data were analyzed using Kruskal-Wallis nonparametric ANOVA, t-test, and chi-square tests. RESULTS: Of the state's working PNs, 813 responded, (71%) and 34% (n=269) reported nursing home employment. Overall, age and work role were not significantly associated with self-rated general health (p=0.14 and p=0.12). Males reported poorer general (p=0.09) and emotional (p=0.004) health. PNs working in nursing homes rated their general and emotional health lower than PNs in other settings (p<0.001). Of the PNs in nursing homes, 28% reported they were likely to leave their position within one year, versus 19% in other work settings (p=0.003). PNs with higher evaluations of their employer safety practices were less likely to leave. IMPLICATIONS: Understanding PNs perceived general/emotional health and perceptions of workplace health/safety efforts can inform interventions to reduce turnover.

Knowledge and perceptions of quality systems among Vermont laboratorians.

OBJECTIVES: This article reports on a survey of medical laboratorians' knowledge of quality systems in their workplace and their perceptions about the effect of job function, education and training, professional credentials, and experience on the overall quality of testing and results. METHODS: The Medical Laboratory Workforce Survey was designed and conducted in Vermont in 2005. Surveys were distributed to all laboratorians working in Clinical Laboratory Improvement Amendments-regulated laboratories throughout Vermont. Results were analyzed for statistical significance using the Fisher's exact test for overall group comparisons. RESULTS: Laboratorians perceived that they were generally knowledgeable about the quality systems in place in their laboratories (96% considered themselves familiar with quality assurance [OA] measures in their laboratory), but meeting quality objectives and perceptions of factors that impact quality measures in the laboratory were variably influenced by the laboratorians' years of experience, professional credentials, organization type, and job title. Almost half (47%) of laboratorians said they did not have a role in deciding the QA measures, whereas 77% felt they had a significant impact on meeting the QA objectives. CONCLUSIONS: Not all laboratorians feel that they play a significant role in assuring quality or influencing quality measures used in the laboratory. All laboratorians should be encouraged to take an active approach to influence quality systems in the laboratory to ensure the highest quality health care possible.

Registered nurses' perceptions of health and safety related to their intention to leave.

This study examined perceptions of general and emotional health among a statewide sample of nurses, and their assessment of employers' workplace health and safety initiatives. These variables and demographic data were then used to model predictors of intention to leave their work positions. A survey was mailed to all registered nurses in one state. Fifty-three percent responded (n = 3,955). Findings suggested marked differences in perception of emotional health by age, with younger nurses reporting less positive perceptions of their emotional health. Perceptions of employers' safety and health initiatives varied by age, setting, and work role. Predictors of intention to leave included lower perceived emotional health among younger nurses and employer safety initiatives for both age groups. This exploratory study suggests a relationship among employer health and safety practices, nurses' emotional health, and intention to leave. Implications for occupational health nurses are detailed.

Comparison of the Relative Abuse Liability of Electronic Cigarette Aerosol Extracts and Nicotine Alone in Adolescent Rats: A Behavioral Economic Analysis.

Background: Characterizing the determinants of the abuse liability of electronic cigarettes (ECs) in adolescents is needed to inform product regulation by the United States Food and Drug Administration (FDA). We recently reported that Vuse Menthol EC aerosol extract containing nicotine and a range of non-nicotine constituents (e.g., menthol, propylene glycol) had reduced aversive effects compared to nicotine alone in adolescent rats, whereas Aroma E-Juice EC aerosol extract did not. The current study used a behavioral economic approach to compare the relative abuse liability of these EC extracts and nicotine alone in an i.v. self-administration (SA) model in adolescents. Methods: Adolescents were tested for the SA of EC extracts prepared using an ethanol (ETOH) solvent or nicotine and saline, with and without 4% ETOH (i.e., the same concentration in the EC extracts) in 23 h/day sessions. Results. Although acquisition of SA was faster for nicotine + ETOH compared to all other formulations, the elasticity of demand for all nicotine-containing formulations was similar. Conclusions: EC aerosol extracts did not have greater abuse liability than nicotine alone in adolescents. These data suggest that nicotine may be the primary determinant of the abuse liability of these ECs in youth, at least in terms of the primary reinforcing effects of ECs mediated within the central nervous system.

Retaining an aging nurse workforce: perceptions of human resource practices.

The expected retirement of the largest cohort of nurses will push the RN workforce below projected need by 2020. The challenges of managing a nursing workforce with the majority of nurses over 45 years of age are now necessitating attention to polices for recruitment and retention of older nurses, particularly in rural areas. This convenience sample study employed a mailed survey to investigate perceptions of nurses in 12 institutions (four hospitals, seven home health agencies, and one nursing home serving a small rural state). The goal was to explore rural RNs' perceptions of intent to stay in their current position, with their organization, and employment as a nurse; organizational and unit-level culture regarding older nurses in the workplace; importance of specific human resource practices/policies to their own intention to stay; and extent to which these human resource practices/policies are currently done. The results indicate that although there are similarities across age cohorts, important differences exist that can be addressed to create career-span sensitive policies and practices. This study provides an indicator of progress or lack of progress in addressing older nurse recruitment and retention, and also offers guidance for differentiating policies and practices for younger and older nurses.

Non-nicotine constituents in e-cigarette aerosol extract attenuate nicotine's aversive effects in adolescent rats.

BACKGROUND: Development of preclinical methodology for evaluating the abuse liability of electronic cigarettes (ECs) in adolescents is urgently needed to inform FDA regulation of these products. We previously reported reduced aversive effects of EC liquids containing nicotine and a range of non-nicotine constituents (e.g., propylene glycol, minor tobacco alkaloids) compared to nicotine alone in adult rats as measured using intracranial self-stimulation. The goal of this study was to compare the aversive effects of nicotine alone and EC aerosol extracts in adolescent rats as measured using conditioned taste aversion (CTA), which can be conducted during the brief adolescent period. METHODS AND RESULTS: In Experiment 1, nicotine alone (1.0 or 1.5 mg/kg, s.c.) produced significant CTA in adolescent rats in a two-bottle procedure, thereby establishing a model to study the effects of EC extracts. At a nicotine dose of 1.0 mg/kg, CTA to Vuse Menthol EC extract, but not Aroma E-Juice EC extract, was attenuated compared to nicotine alone during repeated two-bottle CTA tests (Experiment 2a). At a nicotine dose of 0.5 mg/kg, CTA to Vuse Menthol EC extract did not differ from nicotine alone during the first two-bottle CTA test but extinguished more rapidly across repeated two-bottle tests (Experiment 2b). CONCLUSIONS: Non-nicotine constituents in Vuse Menthol EC extracts attenuated CTA in a two-bottle procedure in adolescents. This model may be useful for anticipating the abuse liability of ECs in adolescents and for modeling FDA-mandated changes in product standards for nicotine or other constituents in ECs.

Identification of flavouring chemicals and potential toxicants in e-cigarette products in Ontario, Canada.

OBJECTIVES: The current study examined constituents of e-cigarette products on the Canadian market, with a focus on the province of Ontario. METHODS: E-cigarettes were systematically purchased at 80 retail outlets across 4 cities in Ontario, Canada, in January-February 2015. Product constituents were identified using gas chromatography and mass spectrometry. Additionally, tobacco-specific nitrosamines (TSNAs) were quantified in tested products using liquid chromatography with tandem mass spectrometry. RESULTS: A total of 166 e-cigarette products were purchased, including disposable products (33%), refillable products (14%), and e-liquids (53%). Overall, e-cigarette products had an average of 6.2 (SD = 3.6) flavouring chemicals. E-cigarettes with sweet flavours (e.g., desserts, alcoholic drinks) had a significantly greater number of flavouring chemicals when compared with tobacco- and menthol-flavoured products (p < 0.05). Approximately one fifth (21%) of products contained flavouring chemicals with potential risk of inhalation toxicity (benzyl alcohol, benzaldehyde, vanillin). An additional 8 toxicants (e.g., acrolein, diacetyl) were detected in a total of 14 e-cigarette products. Measurable levels of TSNAs were detected in 70% of tested products. CONCLUSION: E-cigarettes purchased in Ontario, Canada, contained several constituents that may present excess risk, including some flavouring chemicals and carcinogenic nitrosamines. Further research is needed to determine whether the levels of these constituents have implications for the magnitude of risk to users. The findings reveal several policy gaps that may be addressed by developing regulatory product standards and labelling practices for e-cigarettes.

Perceptions of an ideal career versus perceptions of six health careers.

OBJECTIVE: This study was intended to compare and contrast young adults' perceptions of an ideal career versus their perceptions of six health professions: medical laboratory science, nursing, pharmacy, physical therapy, radiation technology, and respiratory therapy. STUDY DESIGN: The study used a survey developed by May et al., which was modified and tested for application to the allied health workforce. The instrument measures 17 parallel items on a five-point Likert scale and has been assessed for reliability (coefficient a, 0.81-0.84) and content validity by a panel of experts. Analysis included descriptive statistics and paired t tests, with Bonferroni adjusted a significance set at p < 0.0028. POPULATION: The study used a convenience sample of 720 young adults aged 18 to 24 yrs who were recruited between January and September 2005 at job fairs and community events in one urban area and two adjacent rural communities in a northeastern U.S. state. FINDINGS: All six health professions were perceived as significantly less desirable (p < 0.001) than the ideal career in the areas of "being respected" and "working with high technology." "Care for people" was the third highest ranked attribute of an ideal career, and pharmacy and radiation technology were found to be statistically significantly lower in this area (p < 0.001). Only nurses were perceived as having job security that matched the ideal, with the other professions perceived as offering significantly less job security than the ideal (p < 0.001). CONCLUSIONS: Health care is increasingly dependent on highly collaborative multidisciplinary teams. Inaccurate perceptions of allied health occupations likely hamper the development of an adequate pipeline of new recruits to these professions, which has the potential to impact all health disciplines. This points to the importance of increased media/marketing portrayal of the positive aspects of careers in the allied health professions. Strategies to address this challenge and areas for further research are outlined.

A cross-disciplinary Statewide healthcare workforce analysis.

A statewide study was conducted to examine the healthcare workforce from the perspectives of the individual healthcare worker and employer as a basis for evidence-based workforce planning. The workforce minimum data set recommended by Colleagues in Caring was used to analyze job satisfaction, intention to leave current position, intention to leave profession, and reasons for such intentions in members of four professions (medical laboratorians, respiratory therapists, radiographers, and registered nurses) in a rural state. Statewide hospital vacancy and turnover rates for these disciplines also were analyzed. The study found that an aging workforce exists across these four healthcare disciplines. Despite relatively high satisfaction with their positions, a substantial proportion of this sample--over 20% for each profession--reported being "somewhat likely" or "very likely" to leave their position in the next 12 months. Top reasons for these intentions varied by profession and range from career mobility opportunities to job/organization dissatisfaction and stress. Nevertheless, vacancy and turnover rates in the hospital setting for all professions were comparatively modest. Implications for policy and research methods are detailed.

Is health care payment reform impacting nurses' work settings, roles, and education preparation?

This study explores nurses' work settings and educational preparation in the five years before passage of the Affordable Care Act (ACA) and five years after ACA passage, with the aim of identifying areas for nurse educators' attention. The study setting was one small state undergoing rapid transition away from fee-for-service service and thus provided the ideal laboratory to assess the impact of health reform on the nursing workforce. A secondary analysis of data gathered during relicensure compared the nursing workforce at an interval of one decade, with surveys in 2005 (n=4075; 65% response rate) and in 2015 (n=6723; 97% response rate). Findings demonstrated an increase in the proportion of nurses who reported working in ambulatory care and community settings (p=0.001). However, there was no associated decrease in the proportion of nurses who reported working in hospitals. Among respondents who reported employment in the ambulatory care/community settings in 2005, 34.3% had a BSN or higher, a proportion that increased to 41.2% in 2015 (p=0.010); nevertheless, the greatest proportional increase was among AD prepared nurses (34% to 48%). Although new nursing roles emerging as a result of health reform offer baccalaureate nurses the opportunity use the full complement of their knowledge and skills, these data suggest that BS prepared nurses are not fully accessing these opportunities. Implications for nursing education and further research are detailed.