Protecting Nurses from Contact with Toxic Cancer Drugs

As the single largest group of oncology care providers, RNs face a disproportionate risk of exposure to hazardous drugs. It's up to nurse leaders to create and promote a culture of safety.

Nurses are often described as being on the "front lines" of healthcare, a phrase that evokes potentially dangerous fields like the military or law enforcement.

That description might seem overly dramatic until you stop to consider what registered nurses might encounter in the course of their workday (or night): Angry, emotional, and sometimes violent patients; risks of injury from needle-sticks or lifting too-heavy patients; the ever-present risk of illness; and the intimacy of caring for and comforting the sick and the dying in ways that few others do.

So it's no exaggeration to say that America's more than 3.1 million RNs are certainly on the front lines of healthcare. And it should come as no surprise that one particular group of nurses, oncology care providers, face a disproportionate risk of exposure to hazardous cancer drugs.

"We've known for about four decades that drugs that are used to treat cancer… are potentially harmful to those who handle them," says Christopher Friese, PhD, RN, FAAN, a University of Michigan School of Nursing assistant professor and member of U-M's Comprehensive Cancer Center and Institute for Healthcare Policy and Innovation.

Although the dangers are known to exist, experts aren't sure how much exposure is too much, and "there can be both short-term and long-term side effects," Friese told me.

In the short term, side effects might include headaches, nausea, rashes, and asthma. Exposure could also lead to long-term side effects such as miscarriage, difficulty conceiving, and unusual cancers, such as leukemia.

Dangers Known and Unknown
Whereas patients are only treated for a relatively short period of time, nurses are exposed continuously, sometime for years. Ambulatory clinics, where the bulk of these drugs are administered see an average of 10–12 patients per day, many of whom are on multiple medications, Friese says.

"It's the long-term, small amounts that we worry about the most, and that's where there's the greatest risk to nurses," he says. "It's a lot of cumulative, low-dose exposure, potentially."

Friese is at the helm of a new study that will examine oncology nurses' use of personal protective equipment (PPE) and biological exposure to hazardous drugs at 11 of the nation's top cancer centers. The four-year DEFENS: Drug Exposure Feedback and Education for Nurses' Safety study has funding from the National Institute for Occupational Safety and Health (NIOSH) and will involve about 380 nurses.

In a preliminary study, Friese found that among 242 surveyed oncology nurses, 16.9% reported skin or eye exposure to hazardous drugs in the past year, and that organizational factors, such as nursing workloads, practice environments, and performance of safety behavior are associated with an increased risk of spills.

The DEFENS study will take that research further. In its first component, nurses will provide information about chemotherapy spills in the clinic and provide blood samples to determine whether the agents are detectable.

The second part of the study will involve nurses receiving an educational module on safe drug handling, with and without specific feedback about how to improve their practice. Friese says some of the nurses will also have access to data about how whether the agents were detected in the participants' blood.

Personal Protection
The study's goal is to increase the number of nurses who use PPE such as gowns and gloves on a consistent basis.

"We hope that we can learn as a community, together, about what practices and procedures clinics across the country can use," Friese says. "We hope that this will allow us to recognize the cause of and the reasons for the spills and the exposures."

In addition, assessing nurse workloads, environments, and performance of safety behaviors "will provide managers with the data that they need… so they can improve the safety within their units," Friese says.

But nurse leaders don't need to wait for the results of the DEFENS study to start improving nurses' handling of these potentially hazardous drugs, he says.

For one thing, Friese says that not every clinic that handles these drugs actually provides PPE to nurses, so nurse leaders need to ensure that such equipment is readily available to all nurses.

A Culture of Safety
When PPE is available, leaders need to create a culture of safety by encouraging nurses to wear it, praising them when they do, and questioning them when they don't. Despite other messages about saving money, nurses need to know that this one-time-use equipment is there for them, to keep them safe.

"Management needs to set the tone," Friese says.

Also, "there's a lot of blame and shame that happens when drugs spill," Friese says. "Nurses really want to do everything perfectly and if there's a drug spill there's often a lot of paperwork and hassle to get it cleaned up. And potentially a lot of expense."

Because of these factors, spills are likely underreported. Instead of using the "blame and shame" tactic, managers should encourage nurses to report and talk about spills with their supervisors. Training activities, such as "spill drills" can help instill proper clean-up and reporting procedures, Friese says.

"It's really up to the leaders and the front line staff to make the environment as safe as possible," he says. "There are certain steps that managers can take today."