Approximately 8 million healthcare workers in the U.S. are working in environments that place them at risk of exposure to hazardous drugs (Centers for Disease Control and Prevention, 2012). The risk to healthcare workers increases yearly as new non-antineoplastic pharmaceuticals are added to the National Institute for Occupational Safety and Health’s alert list of hazardous drugs (Connor, MacKenzie, DeBord, Trout & O’Callaghan, 2014). The addition of new hazardous drugs requires continually updating of procedures to prevent an increasing diverse range of potential exposures (Connor, et al., 2014). The purpose of this paper is to examine the study of Callahan, et al. (2016) on nurse practices regarding the handling of hazardous drugs.
Background of the study
Callahan et al, (2016) introduced the study by defining the term “hazardous drug” and reviewing the history of regulations regarding the handling of hazardous drugs in the U. S. from the first formal recognition of the issue with the publication of the Occupational Safety and Health Administration guidelines in the mid-80s (Yodaiken & Bennett, 1986) up to the American Society of Health System Pharmacists (2006) and International Society of Oncology Pharmacy Practitioners (2007) guidelines. The authors review the nature of the toxic effects caused by hazardous drugs and present the relevant literature regarding the extent of safety practices falling below the published recommendations and the level of knowledge about the safe handling of hazardous drugs. The low uptake of precautions revealed by the literature review justified the study.
Absenteeism resulting from non-compliance with recommendations surrounding the handling of hazardous presents a problem for hospital administration. However, the risk to nurses is considerably higher as the drugs disproportionately impact women’s reproductive health, for example, problems such as infertility, birth defects, miscarriage, spontaneous abortion (Callahan, et al., 2016). As Callahan, et al. (2016) state, 90% of nurses are female and within childbearing age. The purpose of the Callahan, et al. (2016) study was to identify the factors that foster compliance with the guidelines on the correct procedures for handling hazardous drugs. The specific objective was to identify the factors associated with the safe handling of hazardous drugs by nurses in an inpatient clinical research department.
Method of Study
Callahan, et al. (2016) used a quantitative, descriptive, cross-sectional research design to achieve the study objective. One hundred and fifteen RNs were recruited from high volume hazardous drugs administering units at the National Institutes of Health Clinical Center in Bethesda, Maryland. The pool of potential participants was 196 nurses working in oncology units and intensive care. As a pre-requisite to work on the oncology units and intensive care unit, nurses had to complete a safe handling of hazardous drugs review course on an annual basis and to complete the ONS chemotherapy and biotherapy certificate course. Participants were recruited through email invitations. The only eligibility criterion was employment in the oncology and intensive care units. No exclusion criteria were mentioned.
Participants were required to complete an on-line survey on the use of hazardous drugs. The study instrument was the recently-developed survey, Hazardous Drug Handling Questionnaire (Polovich and Clark, 2012). Callahan, et al. (2016) reported on the statistical reliability of the Hazardous Drug Handling Questionnaire (HDHQ) and stated that no other surveys of this nature were available at the time of the study. The HDHQ consisted of 65 questions measuring seven variables: self-efficacy, interpersonal influences, workplace safety climate, exposure knowledge, perceived risk, conflict of interest, and barriers. The questionnaire was completed online using Monkey Survey software.
Results
Hierarchical linear regressions were conducted on the significant variables using SPSS Version 21.0. The response rate for the survey was 59%. With respect to demographics, the majority of the participants were women (90%), white (59%), and between the ages of 30 to 49 (66%). Three-quarters of the participants worked full-time and had at least five years of experience handling chemotherapy. Just over half of the nurses were assigned three patients per day or less on average.
The analysis revealed that the participants had a high degree of knowledge on chemotherapy exposure, high self-efficacy with regard to using personal protective equipment (PPE), and high perceived risk of harm following exposure to hazardous drugs. The perceived barrier to using PPE was that the facemask was uncomfortable. The climate of workplace safety was high except when the workflow was also high. On the whole, the use of precautions was highest for disposing of hazardous drugs and lowest for disposing of excreta 48 hours after the administration of hazardous drugs. Levels of experience, education, and nursing speciality were not related to the use of precautions. After controlling for other factors, multiple regressions showed a statistically significant association between the use of precaution when handling hazardous drugs and the number of patients assigned in a given day.
Implications for Nursing
The applicability and value of the study results is limited by the setting. As a group, the participants were knowledgeable and experienced with hazardous drugs and selected from a single, well-endowed institution. Also, annual review courses on the use of hazardous drugs was mandatory, thus the high scores on knowledge is not surprising. Therefore, the results cannot be generalized to nurses working in smaller hospitals with smaller budgets and providing care to fewer oncology patients. As the only significant factor appeared to be workload, the study results are applicable to the areas of practice and administration. In the area of practice, there is a need to devise ways to safely work around a large patient load. The ability of the administration to assign fewer patients to each nurse may be more efficient scheduling, but probably would come down to budgeting for more nurses. Due to the homogeneity of the participants in terms of education, the results do not address the influence of education on the use of precautions.
Ethical Considerations
The ethical standards integrated into the study were approved by the Human Subjects Research Protection board at the NIH office. Confidentiality of the participants was respected in a number of ways. The website that supported the Survey Monkey software was secure. No logon or password was required so the identity of the participants could not be traced electronically. A unique identity number was assigned to each participant to prevent identification by name. The responses were combined so that the answers of any single participant could not be isolated. Further, the data was only available to the study team. The questionnaire was anonymous and no compensation was offered, thus selection bias on the part of the participants was controlled to the extent possible.
With the exception of the fact that all the participants were employees, there are no vulnerable individuals in the study. Also, the study was unlikely to have an impact on patient care except perhaps to remind the participants of the need for precautions when handling hazardous drugs.
Conclusions
The research design was straight-forward and the research tool was appropriate. Any research that contributes to the literature on workplace safety has value to nurses, the institution, practice, and the ongoing training of nurses. The result that precautions were statistically significantly associated with patient load speaks to hospital administration. That said, the homogeneity of the population was unlikely to reveal any differences in the practice and attitudes of the participants. Also, the study results are only applicable to similar elite institutions. The study would have been more useful if it was truly cross-sectional and included more hospitals, particularly hospitals with different budget restrictions.
References
American Society of Health-System Pharmacists. (2006). ASHP guidelines on handling hazardous drugs. American Journal of Health System Pharmacy, 63, 1172–1193. doi: 10.2146/ajhp050529
Callahan, A., Ames, N. J., Manning, M. L., Touchton-Leonard, K., Yang, L., & Wallen, G. R. (2016). Factors influencing nurses’ use of hazardous drug safe-handling precautions. Oncology Nursing Forum, 43(3), 342–349. doi:10.1188/16.ONF.43-03AP.
Centers for Disease Control and Prevention. (2012). Workplace safety and health topics: Hazardous drug exposures in health care. Retrieved from http://www.cdc.gov/niosh/topics/hazdrug
Connor, T. H., MacKenzie, B. A., DeBord, D. G., Trout, D. B., & O’Callaghan, J. P. (2014). NIOSH list of antineoplastic and other hazardous drugs in healthcare settings 2014. Cincinnati, OH: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2014-138 (Supersedes 2012-150).
International Society of Oncology Pharmacy Practitioners. (2007). ISOPP standards of practice: Safe-handling of cytotoxics. Journal of Oncology Pharmacy Practice, 13, 1–81.
Polovich, M, & Clark, P. C. (2012). Factors influencing oncology nurses’ use of hazardous drug safe-handling precautions [Online exclusive]. Oncology Nursing Forum. 39, E299–E309. doi: 10.1188/12.ONF.E299-E309
Yodaiken, R. E, & Bennett, D. (1986). OSHA work-practice guidelines for personnel dealing with cytotoxic (antineoplastic) drugs. Occupational Safety and Health Administration. American Journal of Health-System Pharmacy, 43, 1193–1204.
