High Skin, Eye Exposure to Chemo in Ambulatory Care Nurses Underscores Need to Shore Up Safety Practices

A statewide survey of oncology nurses administering ambulatory chemotherapy found a high rate of self-reported chemotherapy exposure, with nearly one-fifth of nurses surveyed experiencing skin and eye exposure in the last year. The investigators, from the University of Michigan, Ann Arbor, concluded that the structure and processes of chemotherapy delivery in the ambulatory setting need to be systematically strengthened, to address workload, education, and resource issues, and to promote adherence to practice standards for safe administration of hazardous drugs.

The findings of the “Practice Environments of Oncology Nurses Study” were reported online on August 16 in the British Medical Journal by Christopher R. Friese, RN, PhD, AOCN, and coinvestigators. The authors examined correlations between unintentional exposure of ambulatory care oncology nurses to chemotherapy and the nurses’ perceptions about the quality of their practice environment, as well as their workload and the extent to which they followed seven standards for safe administration of ambulatory chemotherapy. The authors adapted the standards from the voluntary safety standards for chemotherapy administration that were jointly issued by the Oncology Nursing Society (ONS) and the American Society of Clinical Oncology (ASCO) in 2009.

In the United States each year, an estimated 84% of 23 million adult patient visits for chemotherapy occur in ambulatory settings, with the chemotherapy delivered mainly by nurses, the authors emphasized. “The absence of a consistent regulatory framework for chemotherapy delivery in ambulatory oncology settings exacerbates the potential risk to nurses,” wrote lead investigator Dr. Friese, who is Assistant Professor in the Division of Nursing Business and Health Systems at the University of Michigan School of Nursing, Ann Arbor.

The Study

The oncology nurses were studied between April and June 2010, from a sample of 1,339 oncology nurses who resided in one southern state and reported they were employed outside of hospital inpatient units; nearly one-third of the nurses (402) responded to the survey. Of the 242 in the analytic sample, 41 (16.9%) said they had been exposed to a chemotherapeutic agent in their skin or eyes in the past year.

The investigators randomized the nurses to either internet or paper questionnaires (with identical content), which captured sociodemographic variables and included measures of organizational structure, processes of care, and outcomes.

To assess the presence in the nurses’ institutions of organizational features that support professional nursing practice and promote favorable patient outcomes (as an indicator of the level of safe practices), Friese and colleagues had the nurses complete the Practice Environment Scale of the Nursing Work Index (PES-NWI), an instrument with established high reliability and validity in professional assessment of inpatient nurses. Using focus groups, interviews, and clinical expert reviews, the investigators modified the PES-NWI to be appropriate for studying nurses in an ambulatory setting. 

The subscales assessed by the modified PES-NWI were:

? nurse participation in hospital affairs;
? nursing foundations for quality of care;
? nurse manager leadership, ability, and support of nurses;
? staffing and resource adequacy;
? collegial nurse–physician relationships; and
? supportive relations with medical assistants.

A set of 23 items within these 6 subscales was ranked by the nurses on a scale of 1 to 5, with 1 being “strongly disagree” and 5 being “strongly agree” that the characteristic was present at the nurse’s institution.  Nurses were also asked to categorize their current practice environment as “favorable,” “mixed,” or “unfavorable” in terms of their ability as nurses to deliver high-quality care. Workload was measured using nurses’ reports of the number of patients for whom they assumed the primary care on their last shift.

Intriguing Findings

Friese and his coinvestigators found no significant differences in demographics between the sample of nurses in the analytic sample and those who did not respond to the survey or the chemotherapy exposure question. Nor did individual characteristics of nurses who were exposed to chemotherapy (race, oncology certification status, education level, number of years employed as a nurse) differ significantly from characteristics of nurses who were not exposed.

However, nurses who reported exposure to chemotherapy within the last year did have lower (worse) scores on several PES-NWI subscales, reporting less participation in practice affairs and less adequate staffing and resources. The exposed nurses reported a significantly higher average patient assignment per shift (11.1 vs an average of 8.43 patients per shift reported by nurses not exposed to chemotherapy; P = .02), though there was such variation in workload among the respondents (0 to 38 patients) that the investigators said this relationship must be interpreted with caution.

Notably, 96.9% of nurses not exposed to chemotherapy responded that chemotherapy orders were verified by at least two nurses on a “frequent” or “very frequent” basis, compared with 82.9% of nurses exposed to chemotherapy (P < .01). The investigators said this finding is “intriguing” and suggested that “it may serve as a proxy for various processes to protect patients and nurses,” noting that centers adhering to the ASCO/ONS recommended safety practices “likely are predisposed to a positive safety culture.”

Models showed that nurses who reported favorable (rather than mixed or unfavorable) practice environments had a significantly lower likelihood of exposure to chemotherapy (OR = 0.44, 95% CI 0.21–0.92), even after adjusting for individual nurse characteristics, workload, and chemotherapy verification (OR = 0.45, 95% CI 0.21–0.95).

The Bottom Line

Friese et al, noting that their study is one of the few to assess chemotherapy safety of oncology nurses in the ambulatory rather than inpatient setting, and the first to assess the impact of organizational structures and processes on exposure risk, emphasized that, besides strengthening an institution’s safety culture, initiatives by leadership can go far to protect nurses from harm when it comes to accidental exposure to chemotherapy. “Practice managers can distribute nursing workloads more evenly, assure the availability of adequate time, space, and personnel for chemotherapy verification, and assure that requisite resources are available to administer chemotherapy in ways that minimize occupational exposure,” they concluded.

Future studies aimed at reducing ambulatory oncology nurse exposure to chemotherapy, they said, also should assess nurses’ uses of safety devices and protective equipment, and should investigate details regarding types of activities (such as mixing, administering, disconnecting, disposal) performed at the time of exposure.