Research conducted on nurses who work on oncology units showed that those nurses were found to have acute exposure to chemotherapy. Researcher Baniasadi et al. found that 46% and 16% of nurses studied had cyclophosphamide and ifosfamide in their urine respectively (1).
Cyclophosphamide and ifosfamide are two types of alkylating agents used to treat a variety of malignancies such as Ewing’s Sarcoma and Medulloblastoma. However, these two chemotherapy agents are also known to cause reproductive issues such as infertility.
The oncology nurses studied were found to have these two chemotherapies in their urine, which increases their personal risk of infertility. There are no studies to show any benefit for nurses who have acute exposure to chemotherapy, only health and physical harm.
86% of the those nurses reported symptoms of acute exposure to chemotherapy during their shift which included as headache, fatigue, nausea, and dermatitis (2).
These are 3 barriers that increase your nurses’ risk of acute chemotherapy exposure.
1. Lack of consistent and effective training
OSHA mandates all healthcare organizations that handle hazardous medications to provide training to their staff regarding safe handling (2).
Staff must be trained prior to their initial assignment and have competency checks to evaluate their safe handling practices on a regular basis, usually annually.
Hazard Communication is mandated by OSHA and includes:
List of hazardous drugs administered
Safety Data Sheets for each hazardous drugs
Written communication on training
Written communication of reproductive risks to staff
Most units train nurses prior to their initial patient assignment; however, units do not evaluate competency on a regular annual basis.
2. Nurses' low risk perception influences PPE usage
Nurses who handle hazardous drugs like chemotherapy perceive their risks to acute as relatively low (3). Researcher, Sharour, found that nurses' who had more years of experience had lower usage of PPE (3). Less than 50% of the nurses who give chemotherapy knew their exposure risk. Only 1/3 of those nurses used a chemotherapy gown (3).
When nurses inaccurately perceive their acute exposure risk to be low, they are less likely to follow safe handling guidelines and PPE strictly.
Despite nurses’ low perception of risk, several research studies have shown nurses to have acute chemo exposure such as headaches, nose-burning, and fatigue (4).
Common PPE and safe handling mistakes nurses make are:
Nurses using a single chemo glove.
Nurses using 1 standard glove and 1 chemo glove.
Nurses hanging up and reusing single use chemo gowns.
Nurses not using chemo gowns when hanging IV medications.
Nurses not checking chemotherapy in designated areas.
Putting chemotherapy directly on surfaces without using a chemo mat or plastic-backed mat barrier.
Nurses not using PPE when handling
Nurses do not consistently use PPE when handling bodily fluids like emesis and urine.
3. No clear and consistent communication on how to handle patient’s bodily fluids such as urine.
Certain chemotherapies can be very nephrotoxic meaning it can cause kidney damage and dysfunction to the patient. Nurses who administer these nephrotoxic chemotherapy drugs are constantly performing urine dipsticks on their patient’s urine.
The constant checking and handling of a patient’s urine is a hazardous nursing procedure because chemotherapy can be found in their patient’s urine not only during chemotherapy, but for 2-7 days afterwards depending on medication half life (5).
Even though these patient’s urine is hazardous for several days, USP <800> has no clear communication on how to safely handle the patient's urine which can be found in urinals, hats, and diapers.
Certified Nursing Assistants (CNA’s), who often handle patient’s urine are often overlooked when it comes to safe handling training. CNAs who worked on oncology departments who handle patient's urine while on chemotherapy reported having little to no knowledge (Foot 6):
What to do if they come into contact with potentially hazardous urine
How long chemotherapy can stay in the body
Proper PPE usage when handling hazardous urine
Of those CNAs, 44% did not receive orientation for safe handling of chemotherapy (Foot 6).
63% report not having an annual safe handling refresher of chemotherapy or do not remember (6)
This lack of communication, training, and policies regarding handling of hazardous waste can also be dangerous to untrained nurses and nursing assistants who float from other departments (like Medical-Surgical, CV Acute, Rehab) to oncology departments because they have no knowledge handling hazardous drugs and bodily waste.
Nurses who administer chemotherapy on a regular basis often view their risk to its hazardous effects as low. You can change this misconception by making safe handling a priority in your organization.
Not having annual safe handling competency evaluations is a missed opportunity to identify incorrect practices and create tailored in-service training to address your unit’s safe handling issues.
Questions to consider for your organization?
Do you provide your staff with safe handling training prior to hire? How is training records documented and maintained?
How often are safe handling refreshers happening?
Are Certified Nursing Assistants included in training of safe handling of chemotherapy?
How do float personnel get trained on the hazards handled on your unit?
Footnotes
Baniasadi S, Alehashem M, Yunesian M, Rastkari N. Biological Monitoring of Healthcare Workers Exposed to Antineoplastic Drugs: Urinary Assessment of Cyclophosphamide and Ifosfamide. Iran J Pharm Res. 2018 Fall;17(4):1458-1464. PMID: 30568703; PMCID: PMC6269561.
Hospitals eTool OSHA. https://www.osha.gov/etools/hospitals/hospital-wide-hazards/hazardous-chemicals
Abu Sharour L, Subih M, Bani Salameh A, Malak M. Predictors of Chemotherapy Safe-Handling Precautions and Knowledge Among a Sample of Jordanian Oncology Nurses: A Model-Building Approach. Workplace Health Saf. 2021 Mar;69(3):115-123. doi: 10.1177/2165079920959991. Epub 2021 Jan 14. PMID: 33446086.
He B, Mendelsohn-Victor K, McCullagh MC, Friese CR. Personal Protective Equipment Use and Hazardous Drug Spills Among Ambulatory Oncology Nurses. Oncol Nurs Forum. 2017 Jan 6;44(1):60-65. doi: 10.1188/17.ONF.60-65. PMID: 28067030; PMCID: PMC5225785.
Safe Handling of Chemotherapy Waste Material. https://hillman.upmc.com/patients/community-support/education/miscellaneous/chemotherapy-waste
Walton AL, Kneipp S, Linnan L, Asafu-Adjei J, Douglas C, Leff M, Rogers B. Nursing Assistants' Use of Personal Protective Equipment Regarding Contact With Excreta Contaminated With Antineoplastic Drugs. Oncol Nurs Forum. 2019 Nov 1;46(6):689-700. doi: 10.1188/19.ONF.689-700. PMID: 31626622; PMCID: PMC7886377.
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