Abstract
Background:
Exposure to chemotherapy is an occupational hazard predisposing nurses to severe health effects. The purpose of this integrative review was to identify the recent literature describing the risk factors for occupational exposure to chemotherapy among nurses.
Methods:
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology was employed to conduct the review. The databases searched were Scopus, PubMed, and CINAHL using the search terms “chemotherapy,” “drugs,” “exposure,” and “nurses.” Included articles were published between January 2010 and February 2022, published in peer-reviewed journals for research conducted in the United States, and written in English language. Excluded articles were studies that did not involve nurses in their samples. Review articles, books, theses, and dissertations were excluded as well. The Johns Hopkins Nursing Evidence-Based Practice Model was used to assess the level of evidence from the reviewed studies.
Findings:
Fourteen studies were included in this review. Ten studies were rated on Evidence Level III, two on Evidence Level II, one on Evidence Level I, and one on Evidence Level V. The main risk factors for occupational exposure were nurses’ knowledge of chemotherapy handling guidelines, nurses’ adherence to using the personal protective equipment, nurses’ health beliefs regarding chemotherapy exposure, and workplace-related factors such as workload and managerial support.
Conclusion:
Addressing the identified risk factors would protect nurses from chemotherapy exposure. More research on nurses’ health beliefs regarding chemotherapy exposure and the cues to adhere to chemotherapy handling guidelines in the work environment is needed.
Background
Chemotherapeutic drugs have been increasingly prescribed to treat patients with cancerous and noncancerous conditions (Centers for Disease Control and Prevention [CDC], 2018). The serious side effects of chemotherapy on patients are well documented (American Cancer Society, 2020) and nurses and other healthcare workers who handle chemotherapy are at risk for severe health effects due to exposure to these drugs (Polovich, 2016). Exposure to chemotherapy occurs through skin or mucus membrane contamination, hand to mouth ingestion, sharp object injection, or through inhalation. Exposure to chemotherapeutic drugs usually occurs during the drug handling procedures including preparation, administration to patients, disposing, or managing spills (United States Pharmacopeial Convention [USP], 2020).
According to the National Institute for Occupational Safety and Health (NIOSH, 2009), the approximate number of healthcare workers who were exposed to hazardous agents including chemotherapy in the United States was 8 million. These estimates have not been updated in the recent literature. However, there are research studies to assess the rate of chemotherapy exposure among oncology nurses. For example, in 2011, the study by Friese and colleagues shows that 16.9% of the nurse participants reported that they had been exposed to chemotherapy at least one time in the previous year. The findings of a survey of chemotherapy exposure among nurses who administer chemotherapy show that 14% of 1,814 nurse participants reported being exposed to chemotherapy or experiencing spills in a period of 7 days (DeJoy et al., 2017). In addition, a more recent study indicates that across 12 oncology settings, 61 chemotherapy spill incidents and 11 chemotherapy exposure incidents while cleaning the spills were reported by 51 nurse participants over a period of 2 years (Friese et al., 2020).
Since chemotherapy is among the treatments of choice for cancer disease (CDC, 2018), it is rationally expected that the rate of chemotherapy exposure among nurses increases, as the number of cancer cases is rising. According to Weir et al. (2021), the estimated number of cancer cases will increase by 49% in 2050 relative to that number in 2015. The serious health effects of exposure to chemotherapy on nurses and other healthcare professionals are well documented and include genotoxicity (Bouraoui et al., 2011), frequent miscarriages, infertility, congenital abnormalities (Connor et al., 2014), and the increased the risk to develop cancer (NIOSH, 2016).
The first safe chemotherapy handling guidelines were published by Occupational Safety and Health Administration in 1986. Over the years, these guidelines have been updated and additional guidelines for hazardous drugs handling were published by other organizations such as the Centers for Disease Control and Prevention (CDC, 2018), the National Institute of Health, Oncology Nursing Society, and the United States Pharmacopeial Convention (USPC, 2020) (NIOSH, 2004, 2009, 2016). Generally, chemotherapy handling guidelines include strategies from the hierarchy of control to prevent chemotherapy exposure among oncology healthcare workers such as hazard identification, practices for hazardous drug storage, preparation, administration, and disposal, correct procedures for managing spills, and using personal protective equipment (PPE) (USP, 2020). Despite the presence of chemotherapy handling guidelines, nurses report incidents of chemotherapy exposure (DeJoy et al., 2017; Friese et al., 2015; Friese et al., 2019). The purpose of this integrative review was to identify the recent literature describing the risk factors for occupational exposure to chemotherapeutic agents among nurses.
Method
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Page et al., 2021) was used to review the literature on the factors that affect nurses’ exposure to chemotherapy. The databases searched were Scopus, PubMed, and CINAHL using the search terms “chemotherapy,” “drugs,” “exposure” and “nurses.” The search was done in February 2022.
Articles were included in the review if they were published in peer-reviewed journals for research studies conducted in the United States and published between January 2010 and April 2022. Studies published in this range were included to reflect the most recent conditions in the U.S. healthcare system in the light of the current guidelines for chemotherapy handling. The reason to include United States only studies is to study the factors that influence chemotherapy exposure among nurses who follow consistent guidelines to handle chemotherapy drugs. In addition, included articles were published in the English language for original research studies. Excluded articles were for studies on chemotherapy exposure that involved samples of healthcare workers without including nurses. Books, review articles, conference abstracts, theses, and dissertations were excluded as well.
Results
The PRISMA chart (Figure 1) illustrates the process of this literature review (Page et al., 2021). The initial search returned 124 articles in PubMed, 90 articles in Scopus, and 67 articles in CINAHL. Excluding duplicates (n = 59) resulted in 222 articles. The titles and the abstracts for the remaining 222 articles were screened. Of them, 86 were studies on topics not related to chemotherapy exposure, 55 were not original research studies, 59 were studies conducted outside the United States, 4 were not published in the English language, and 4 were study articles did not involve nurses in the studies’ samples. Therefore, the articles that were covered in this review were 14 articles that met all the inclusion criteria. Record screening and data synthesis were done by the principal investigator and then reviewed by the other investigators independently. Data extraction was done in the light of the focus of this review. Extracted data were presented in Table 1. This table presents information related to the studies’ purposes, samples’ characteristics, the studies’ research designs, the instruments used, the quality of evidence for each study, and the significant findings.
Summary of the Studies
PRISMA flowchart.
Generally, the purposes of the studies were to describe chemotherapy handling practices among healthcare workers, identify the trends of using PPE when handling chemotherapy among healthcare workers, identify the factors that influence these workers’ adherence to the chemotherapy handling guidelines, test interventions targeted to promote the adherence to chemotherapy handling guidelines among healthcare workers, and examine the extent of chemotherapy contamination in oncology settings. The designs for the reviewed studies are quantitative (n = 11), mixed-methods design (n = 2), and case report analysis (n = 1). The quantitative designs are randomized control trial (n = 1), pretest and posttest quasi-experimental design (n = 2), and descriptive cross-sectional designs (n = 8). The size of samples recruited in the reviewed studies ranged from 34 to 40,420. All the studies’ samples were recruited through convenience sampling.
In the cross-sectional design studies, questionnaires were used to collect data related to the studies’ variables. These studies describe nurses’ practices during chemotherapy handling and the factors influencing them. The studies by Boiano et al. (2014, 2015), and Polovich and Martin (2011) identified the pattern of work practices and using the PPE while handling chemotherapy among nurses as well as the factors that affect these practices and result in chemotherapy exposure. These studies show that nurses’ adherence to the guidelines while handling chemotherapy is lower than the recommended level. The factors influencing the exposure identified are insufficient knowledge on chemotherapy exposure, and nonadherence to applying PPE according to the guidelines (Boiano et al., 2014, 2015; Polovich & Martin, 2011).
The studies by Callahan et al. (2016), He et al. (2017), Polovich and Clark (2012), and Reeves et al. (2013) addressed the factors that influence nurses’ exposure to chemotherapy. According to these studies, some of the factors influencing the exposure are managerial support, interpersonal influences, nurses’ health beliefs, workload, knowledge on chemotherapy exposure, nurses’ self-efficacy to adhere to the guidelines, and the presence of institutional policies that reflect the current guidelines (Callahan et al. 2016; He et al., 2017; Polovich & Clark, 2012; Reeves et al., 2013). The study by Lawson et al. (2019) identified the practices of pregnant and nonpregnant nurses during chemotherapy handling that could lead to exposure; this study found that not all pregnant and nonpregnant nurses adhere to the guidelines when handling chemotherapy. In addition, the study by Menonna-Quinn et al. (2019) identified the pattern of using the PPE during chemotherapy handling on a sample of inpatient and outpatient oncology nurses. They found that the usage of PPE among inpatient and outpatient nurses is lower than the recommended level with more adherence to the recommendations was noted in the inpatient oncology nurse group. In addition, they found that the most frequently used PPE in both groups was the disposable gloves and the lowest frequently used PPE among them is the eye protection equipment.
Crickman and Finnell (2017) conducted a quasi-experimental study that tested an evidence-based program which included an educational component on chemotherapy exposure to promote nurses’ safe handling of chemotherapy. The program also included placing standardized signs to identify chemotherapy drugs as well as showing messages to nurses within the electronic health record system providing information on the correct PPE to use when handling specific chemotherapy drugs. The intervention program improved nurses’ knowledge on chemotherapy exposure and their adherence to the correct sequence when removing PPE as compared with before the intervention.
The mixed-methods study by Colvin et al. (2016) aimed to assess nurses’ awareness on the degree they adhere to safe chemotherapy handling guidelines. In this study, the authors compared observation findings regarding nurses’ practices when handling chemotherapy with nurses’ self-report findings. The nurse participants in this study perceived the frequency of themselves performing chemotherapy handling practices different from the observed frequencies.
In the randomized controlled trial by Friese et al. (2019), an online educational intervention was tested on a sample of oncology nurses who handle chemotherapy. The results of the study show that there was no significant difference between the intervention and control groups in the scores for PPE usage, chemotherapy exposure knowledge, or the perceived barriers to adhere to using the PPE.
In the case report study, Friese et al. (2020) conducted analysis of unpublished data from a previous study (Friese et al., 2019) to characterize the incidents of chemotherapy spillage and to assess the usage of PPE among oncology nurses when managing these spills. The result of this study indicates that oncology nurses experience frequent chemotherapy spills. However, the level of adherence to using the PPE is less than the optimal level. Moreover, the availability and the functionality status of the chemotherapy-specific transfer devise is a factor influencing nurses’ exposure to chemotherapy.
Graeve et al. (2017) tested a quality improvement intervention that involved making modifications in the work environment to protect healthcare professionals against chemotherapy exposure. For example, they moved the location of chemotherapy gowns from a single locked room to several more accessible locations in the unit. Also, they posted alert signs to remind the staff on safe practices when handling chemotherapy. The intervention resulted in improving staff’s self-efficacy to use PPE, their perceived risks of chemotherapy exposure, and their knowledge on safe chemotherapy handling guidelines.
Data Evaluation
The quality of the studies was evaluated using Johns Hopkins Nursing Evidence-Based Practice Model. In this system, the level of evidence for studies’ designs ranges from Level I to Level V; where Level I refers to the highest level of evidence, and Level V refers to the lowest level of evidence among study designs. According to this system, the quality of the studies in each level is either high, good, or low quality (Dang et al., 2022). The quality of the studies is evaluated based on a set of criteria such as, identifying the gap in the literature, presenting the purpose of the study, sample size, describing the data collection instruments, the reliability and validity of the instruments used, and others. In this review, 10 studies were rated on Evidence Level III, 2 on Evidence Level II, 1 on Evidence Level I, and 1 on Evidence Level V, and they were all of good quality. None of the studies was of high quality due to insufficient reported details related to the reliability and validity of the studies’ instruments. In addition, the majority of the articles do not list detailed criteria for including and excluding participants. Moreover, the mixed-methods studies do not contain enough descriptions on the exploratory component.
Discussion
The purpose of this integrative review was to describe the state of science on the factors that influence the exposure to chemotherapeutic drugs among nurses who handle them. By analyzing the current literature on the factors that influence nurses’ exposure to chemotherapy, this integrative review would help to provide an explanation of the high rate of exposure despite the presence of the guidelines. The reviewed studies discussed the factors that influence nurses’ exposure to chemotherapy. Most of the studies had consistent findings on the topic. The two most frequently reported factors that influence nurses’ exposure to chemotherapy are nurses’ knowledge on the precautionary guidelines and nurses’ adherence to use the PPE when handling chemotherapy (Boiano et al., 2014, 2015; Callahan et al., 2016; Crickman & Finnell, 2017; Friese et al., 2019; 2020; He et al., 2017; Polovich & Clark, 2012; Polovich & Martin, 2011; Reeves et al., 2013).
Other discussed factors are nurses’ health beliefs, and workplace-related factors, such as nurses’ high workload, presence of cues to adhere to the recommendations in the work environment, presence of institutional policies on chemotherapy handling precautions, presence of medical monitoring programs for chemotherapy exposure, using closed-system transfer devices when preparing and administering chemotherapy, interpersonal influences, managerial support and participating in decision-making (Boiano et al., 2014, 2015; Callahan et al., 2016; Friese et al., 2019, 2020; He et al., 2017; Polovich & Clark, 2012; Reeves et al., 2013).
Nurses Knowledge on Chemotherapy Handling Guidelines
Nurses’ knowledge on chemotherapy handling precautions is critical to control the rate of exposure to these hazardous drugs. Eight studies discussed the importance of educating nurses on the precautionary guidelines, as this enhances their adherence to these guidelines (Boiano et al., 2014, 2015; Callahan et al., 2016; Crickman & Finnell, 2017; Friese et al., 2019, 2020; Polovich & Clark, 2012; Polovich & Martin, 2011). Crickman and Finnell (2017) provided an example of an educational program that was effective in improving nursing knowledge on chemotherapy exposure; their program included modules related to the ways of identifying hazardous drugs, the routes of exposure to them, side effects of the exposure, and the recommended precautions on handling them. Equally important, this emphasized the importance of combining training and debriefing feedback pertaining to the nurses’ performance. (Crickman & Finnell, 2017)
Education and training should include all safe chemotherapy handling guidelines, such as storing chemotherapy drugs in special cabinets, using closed system transfer devices when preparing and administering chemotherapy, the procedure to manage chemotherapy spills, and other measures (USP, 2020). Central to training nurses on handling chemotherapy is the correct technique of applying and removing PPE. According to NIOSH (2016), using PPE is one of the important measures to protect against chemotherapy exposure. In the study by Crickman and Finnell (2017), all the observed nurses applied the chemotherapy PPE correctly, but only 11% of them removed the PPE using the correct sequence. Interestingly, after the introduction of the educational program intervention, the percent of nurses who showed the correct sequence of PPE removal improved to 80%.
Nurses’ Adherence to Using the PPE
Using PPE is the least effective method to control exposure to hazards in the hierarchy of control as it does not eliminate the risk of exposure, consumes time and resources, requires regular training and fit-testing, affects human sensation and performance, and requires workers’ strict adherence (Morris & Cannady, 2019). However, using PPE is one of the primary preventive strategies currently recommended to protect against the exposure to chemotherapy among nurses (USP, 2020). When handling chemotherapy, essential PPE includes chemotherapy gloves, chemotherapy gowns, face shields, respiratory protection, and eyes and face protection (USP, 2020). In the reviewed studies, several barriers have been found preventing nurses from using PPE when handling chemotherapy. For example, insufficient knowledge on the precautionary guidelines makes some nurses underestimate the importance of wearing PPE (Crickman & Finnell, 2017) underestimate the importance of wearing all of the recommended PPE when handling chemotherapy. In the study by Chaudhary and Karn (2012), 92% of nurse participants reported using chemotherapy gloves when handling chemotherapy, but <5% reported using face shields or respiratory masks. Moreover, the study by Menonna-Quinn et al. (2019) shows that during chemotherapy handling, the disposable gloves are the most frequently used PPE by oncology nurses, while eye protection is the lowest PPE used by them.
Furthermore, the respondents in the study by Boiano et al. (2014) reported that considering the exposure to chemotherapeutic drugs as minimal was the most significant barrier to wearing PPE. However, they would not underestimate using PPE if they knew that there is no safe level of exposure to chemotherapy (Boiano et al., 2014). This points out the importance of educating nurses on chemotherapy hazards and how to protect themselves from the exposure. Another significant barrier to use the PPE is the high workload (He et al., 2017). In cases of high workload, nurses may not be able to apply all the required PPE when handling chemotherapy under the pressure of time. In addition, negative interpersonal influences are considered barriers to using PPE (He et al., 2017). These two factors will be discussed further in later sections.
Nurses’ Health Beliefs
Three of the reviewed studies investigated the relationship between nurses’ health beliefs with regard to adherence to the guidelines as preventive health behaviors and their adherence to these guidelines when handling chemotherapy. According to the Health Belief Model, nurses’ health beliefs regarding chemotherapy exposure influence their adherence to these guidelines when handling chemotherapy. These beliefs include the perceived seriousness of chemotherapy exposure, the perceived susceptibility to experience the side effects of the exposure, the perceived benefits of adhering to the safe chemotherapy handling guidelines, the perceived barriers to adhere to these handling guidelines, as well as the perceived self-efficacy to follow to these guidelines (Becker & Maiman, 1975; Champion & Skinner, 2008; Rosenstock, 1974). Moreover, according to the model, the modifying factors such as knowledge, gender, age, and level of education influence an individual’s health beliefs (Becker & Maiman, 1975; Champion & Skinner, 2008; Rosenstock, 1974).
The results of Polovich and Clark (2012) study show that there are relationships between nurses’ adherence to the guidelines when handling chemotherapy and each of the nurses’ health beliefs; the perceived risks of chemotherapy exposure, the perceived self-efficacy to use the PPE, and the perceived barriers to use the PPE. Interestingly, the study found that the level of nurses’ knowledge on chemotherapy exposure is high, but it is not associated with the adherence to the guidelines when handling chemotherapy. According to their study, nurses’ health beliefs are what influence the adherence to the guidelines not the exposure knowledge itself. This could be interpreted in the light of the Health Belief Model. According to the model, knowledge is a modifying factor that influences the health beliefs, not the health behaviors. The health beliefs, in turn, influence the health behaviors.
Similarly, the study by Callahan et al. (2016) indicates that nurses who have high perceived self-efficacy to use the PPE and those who have high perceived risks to chemotherapy exposure effects are more likely to adhere to the guidelines when handling chemotherapy. Thus, the interventions that positively influence these health beliefs would help in decreasing the rates of chemotherapy exposure among nurses. An example of these interventions is the quality improvement program that was implemented in the study by Graeve et al. (2017) and resulted in increasing nursing self-efficacy to use the PPE and the perceived risks of exposure.
Two of the reviewed studies addressed the relationship between nurses’ demographic characteristics and the adherence to chemotherapy handling guidelines, both studies found no relationship between nurses’ demographic characteristics and nurses’ adherence to chemotherapy handling guidelines (Polovich & Clark, 2012; Polovich & Martin, 2011). In the light of the Health Belief Model, these demographics are modifying factors that influence nurses’ health beliefs. However, no studies have been found focusing on the relationships between nurses’ demographics and nurses’ health beliefs. Also, no study has been identified investigating the effects of other health beliefs in the Health Belief Model such as the perceived benefits of adhering to the guidelines, and the perceived susceptibility to acquire the negative health effects of chemotherapy exposure.
Workplace-Related Factors
Workplace-related factors have been mentioned in several of the reviewed studies. These factors include:
Nurses’ high workload
This factor has been identified in three of the reviewed studies (Callahan et al., 2016; He et al., 2017; Polovich & Clark, 2012). High workload resulting from nursing shortage is associated with an increased risk for chemotherapy exposure (Friese et al., 2011); nurses with a high workload would have less time to adhere to all the recommendations when handling chemotherapy.
Presence of cues to adhere to the recommendations in the work environment
As stated in the Health Belief Model, these cues are important and can influence nurses to adhere to the recommendation when handling chemotherapy (Becker & Maiman, 1975; Champion & Skinner, 2008; Rosenstock, 1974). Examples of these cues are many, but few have been identified in the reviewed studies. In the study by Crickman and Finnell (2017), the authors implemented an intervention program and used signs to help nurses in identifying chemotherapy drugs as well as using e-reminders for nurses on the correct PPE to apply when handling chemotherapy. The program improved nurses’ knowledge on chemotherapy exposure and their adherence to using the correct technique when removing the PPE. Similar strategy was implemented in the quality improvement program in the study by Graeve et al. (2017), where alerts were posted in the oncology department to remind nurses to use the disposable chemotherapy gowns only one time. The program was effective in improving nurse self-efficacy to use PPE, perceived risks, and the knowledge on chemotherapy precautions.
The study of Polovich and Clark (2012) revealed that there is insufficient formal monitoring from nursing managers for nurses’ adherence to the guidelines; this could be a contributing factor that makes nurses undermine the importance of adherence to the guidelines when handling chemotherapy. Another example of the cues to action in this context has been identified in the study by Reeves et al. (2013); in this example, nurses were required to put contact precaution alerts for patients who received chemotherapy.
Presence of institutional policies on chemotherapy handling guidelines
These policies are considered the guide for nurses during their practice, and upon which their practice will be evaluated. This factor has been identified in two of the reviewed studies (Polovich & Clark, 2012; Reeves et al., 2013). Unfortunately, both studies revealed that some institutional policies were not updated to reflect the current guidelines. Therefore, systematic updating to these guidelines as well as sharing them with nurses is necessary to protect nurses against the risk of chemotherapy exposure.
Presence of medical monitoring programs for chemotherapy exposure
Medical monitoring programs are recommended by USP (2020) as a strategy to protect healthcare workers against chemotherapy exposure. These programs include assessment of physical symptoms and blood and urine tests to assess the extent of chemotherapy exposure among nurses (Boiano et al., 2015). The reasons why some nurses and other healthcare workers do not participate in these programs are the lack of these programs in their work institutions or the decline in participation in these programs by the healthcare workers (Boiano et al., 2015). Declining from participating in these programs could be due to individual factors and health beliefs that make them underestimate the importance of these health preventive behaviors.
Despite the importance of the medical monitoring programs to control occupational exposure to hazardous substances, controversy exists on many aspects of these programs. Certain criteria should be considered to initiate monitoring programs to guarantee the efficacy of these programs such as the sensitivity, specificity, the predictive values of the tests that will be performed, and the prevalence of the health conditions of concern (Gochfeld et al., 2009). Often, the decision to perform medical monitoring programs is based on a risk–benefit analysis. Examples of risks associated with the implementation of these programs are the side effects of the screening tests and unnecessary early treatment on the workers and the time and monetary costs of these programs on the industry (Vearrier & Greenberg, 2017). However, consensus on the benefits of these programs is present as a preventive public health activity (Vearrier & Greenberg, 2017). In the context of oncology nurses who regularly handle several types of hazardous chemotherapy drugs at work, these programs are essential to detect and treat early signs of chemotherapy exposure (USP, 2020).
Using closed-system transfer devices when preparing and administering chemotherapy
Using closed systems to prepare and administer chemotherapy is important to decrease the risk of exposure to chemotherapy (USP, 2020). This factor was mentioned in three of the reviewed studies (Boiano et al., 2015; Friese et al., 2020; Menonna-Quinn et al., 2019). The studies by Boiano et al. (2015) and Menonna-Quinn et al. (2019) reveal that nurses do not use these devices consistently when preparing and administering chemotherapy. Moreover, Friese et al. (2020) study indicates that oncology nurses’ experience technical problems while using these devices which decreases the effectiveness of the devices in protecting against chemotherapy exposure.
Another important issue to be considered when preparing and administering chemotherapy intravenously is priming the intravenous tubes with solutions other than chemotherapy drugs. Unfortunately, in the study of Boiano et al. (2014), 38% of nurses reported that they have primed intravenous tubes with antineoplastic drugs. This would increase the risk of exposure when the drug dips from the end of the tube and contaminates the surroundings.
Interpersonal influences
Interpersonal influences at workplace were reported as a factor influencing nurses’ exposure to chemotherapy in three of the reviewed studies. These studies described different aspects of the interpersonal influences; the study by He et al. (2017) shows that more collegial interpersonal relationships between nurses and physicians are associated with decreased adherence to wearing the PPE when handling chemotherapy. The interpretation of this was made as informal relationships between workers were associated with practices that did not reflect adherence to the guidelines. However, Polovich and Clark (2012) study shows that nurses are more likely to adhere to the recommendations when handling chemotherapy when their coworkers value these recommendations and show adherence. In addition, Callahan et al. (2016) found that stronger interpersonal relationships are related to enhanced adherence to chemotherapy handling guidelines among nurses. Although they did not provide interpretations to such findings, it could be the safe working environment was influenced by positive interpersonal influences. A safe working environment is associated with enhanced nurses’ adherence to chemotherapy handling guidelines (Callahan et al., 2016).
Managerial support
Managerial support and participating in decision-making affect nurses’ exposure to chemotherapy. The study by He et al. (2017) shows that encouraging the communication between nurses and their managers, and nurses’ involvement in making decisions regarding work practice issues are associated with increased usage of PPE and decreased reported spills incidents. More specifically, allowing nurses to make decisions regarding the type of PPE offered to them would further help in promoting their adherence use the PPE while handling chemotherapy (He et al., 2017).
Limitations
One of the limitations of this review is that most of the studies reviewed are of similar design, cross-sectional studies, which would affect the diversity of findings from these studies. Another limitation is the quality of the studies reviewed. Although all the studies were classified as good quality, none was rated as high quality; raising some caution regarding the quality of evidence derived from this review. Moreover, including only online published studies in the English language would limit the comprehensiveness of the information resulted from this review.
Implications for Occupational Health Nursing Practice and Research
Education on chemotherapy safe handling should start in the undergraduate education for nurses to prepare them with the knowledge and skills of occupational safety management when handling hazardous substances. In oncology healthcare institutions, providing continuous education and training for nurses on the safe chemotherapy handling guidelines followed by feedback and debriefing are essential. This education is particularly important for newly hired nurses in oncology settings. Equally important, nurses’ health beliefs toward the adherence to the guidelines should be assessed, as knowledge itself would not guarantee the adherence if it does not result in influencing nurses’ health beliefs.
Moreover, oncology healthcare institutions should use standardized signs and alerts for nurses in the work environment and within the electronic system are required to help nurses in identifying chemotherapy drugs as well as the appropriate PPE to apply when handling them. These institutions should offer nurses all the required PPE and chemotherapy closed transfer devices with good functionality and place them in accessible locations. Furthermore, all healthcare institutions that administer chemotherapy should have policies on chemotherapy handling to influence nurses to adhere to the guidelines of safe chemotherapy handling. These policies should be revised regularly to reflect the current standards. Also, institutions should consider formal and systemic monitoring of nurses’ practice when they handle chemotherapy. However, building a supportive work environment and allowing nurses to have input in the decision-making process are essential administrative activities that support nurses who handle hazardous drugs.
These findings have implications for research. It is recommended that future studies focus on the identification of factors that influence nurses’ exposure to chemotherapy to help in developing interventions to address them, thereby, protecting nurses against the exposure to chemotherapy. Research could be directed to study some of the insufficiently addressed factors such as nurses’ health beliefs toward the adherence to the guidelines when handling chemotherapy. Thus, interventions to influence these beliefs could be implemented if needed. Besides that, research on the effects and forms of cues in the work environment that influence nurses’ adherence to the guidelines warrants further attention.
Conclusion
Chemotherapy drugs are sources of occupational hazard to healthcare workers. Greater awareness on the risks of chemotherapy exposure has been achieved since the publication of chemotherapy handling guidelines in 1986. This review reflects the recent factors that influence chemotherapy exposure among nurses in the past decade. Some of the identified factors are nurses’ knowledge on the precautionary guidelines, nurses’ use of PPE when handling chemotherapy, nurses’ health beliefs, and workplace-related factors.
In Summary
Chemotherapy exposure is an occupational risk that affects nurses’ health.
Knowledge on chemotherapy handling guidelines, adherence to using the personal protective equipment, nurses’ health beliefs, and workplace-related aspects are significant factors affecting nurses’ exposure to chemotherapy.
More research on nurses’ health beliefs toward the adherence to the guidelines when handling chemotherapy and methods to assess these beliefs are needed.
The cues to adhere to the recommendations in the work environment to help protect nurses against the exposure should be investigated.
Footnotes
Conflict of Interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research study was supported by the National Institute for Occupational Safety and Health through the Targeted Research Training Program of the University of Cincinnati Education and Research Center (grant no. T42OH008432).
