Factors Influencing Nurses’ Use of Hazardous Drug Safe-Handling Precautions

Hazardous drugs (HDs) are defined by the National Institute for Occupational Safety and Health ([NIOSH], 2004) using one or more of the following criteria: carcinogenicity, teratogenicity, reproductive toxicity, genotoxicity, organ toxicity at low doses, and drugs that mimic existing HDs in structure or toxicity. Most of the drugs that match the HD description are cytotoxic antineoplastic agents; however, other classes of drugs are included in this category, such as antivirals, antibiotics, and hormones (NIOSH, 2004). According to the Centers for Disease Control and Prevention ([CDC], 2012), about 8 million healthcare providers in the United States work in environments that could increase their risk of HD exposure. Exposure occurs via inhalation, dermal absorption, ingestion, or contact with conjunctiva (NIOSH, 2004). HD exposure risk occurs during drug-handling activities, such as administration, preparation, and disposal of the drug and patient excreta (Polovich & Martin, 2011). Nurses working in oncology settings frequently handle chemotherapeutic agents, making the nurses particularly vulnerable to exposure. The Occupational Safety and Health Administration (1999) published guidelines in 1986 for the safe-handling of cytotoxic drugs in the workplace (Yodaiken & Bennett, 1986). This publication was the first to recognize the critical need for workplace HD safe handling practices. Subsequently, standards for the safe handling of antineoplastic drugs also were published by professional associations, including the International Society of Oncology Pharmacy Practitioners (2007) and the American Society of Health- System Pharmacists (2006). All guidelines and standards emphasized the importance of using closed-system transfer devices and personal protective equipment (PPE) to reduce risk. Prior to the development of protective standards, however, healthcare provider HD exposure resulted in toxicities and reproductive effects, such as fetal defects and difficulties with fertility (Connor, Lawson, Polovich, & McDiarmid, 2014; Eisenberg, 2009; Polovich, 2011). Those who had direct contact with patients receiving HDs reported acute symptoms such as nausea, vomiting, headaches, dizziness, rash, shortness of breath, and hair loss—symptoms similar to patients receiving these drugs (Valanis, Vollmer, Labuhn, & Glass, 1993). Genotoxic effects also have been reported (Jakab, Jeno, & Tompa, 2001). Fuchs et al. (1995) demonstrated genotoxicity by collecting blood samples from nurses administering HD and found that DNA single-strand breaks and alkali labile sites in peripheral blood lymphocytes were 50% higher when compared to controls. Despite the establishment of protective standards, growing evidence demonstrates the toxicity and detrimental effects that HD exposure can have on fertility and reproductive health, such as spontaneous abortion, miscarriages, infertility, and birth defects (Fransman et al., 2007; Lawson et al., 2012; Valanis, Vollmer, & Steele, 1999). Given that the majority of the nursing workforce is female (90%) and within childbearing years (median age of 31), the relevance of these effects is notable (Spratley, Johnson, Sochalski, Fritz, & Spencer, 2001; U.S. Department of Health and Human Services, 2010). The risk of exposure persists because of environmental contamination and poor healthcare worker adherence to current HD safe-handling recommendations and guidelines (Nixon & Schulmeister, 2009; Polovich & Martin, 2011; Sessink, Connor, Jorgenson, & Tyler, 2010). Suboptimal recommendation and practice adoption have been illustrated in several studies (Martin & Larson, 2003; Polovich & Clark, 2012; Polovich & Martin, 2011). For example, the results from a study of nurses working in oncology centers in the United States indicated that although exposure knowledge, self-efficacy for using PPE, and perceived risk of harm from HD exposure were high, total precaution use was low (Polovich & Clark, 2012). Within this sample, the majority of nurses practiced in outpatient settings in a physician office or community hospital and reported administering chemotherapy to an average of 6.8 patients per day. HD safe-handling policies were present, but many did not reflect current recommendations. The Factors Predicting Use of Hazardous Drug Safe-Handling Precautions model was used to guide Polovich and Clark’s (2012) study. The model suggests that knowledge of the hazard is related to perceived risk and self-efficacy. Higher self-efficacy for using PPE and positive workplace safety climate are expected to decrease perceived barriers. Perceived risk, exposure knowledge, self-efficacy, barriers, workplace safety climate, interpersonal influences, and conflict of interest serve as the predictor variables (see Figure 1) and are expected to affect use of safe-handling precautions. FIGURE 1 Factors Predicting Use of HD Safe-Handling Precautions The purpose of the current study was to examine the HD safe-handling practices of oncology nurses working on inpatient units at the National Institutes of Health Clinical Center (NIH CC) in Bethesda, Maryland, using the Factors Predicting Use of Hazardous Drug Safe-Handling Precautions model. The NIH CC is solely dedicated to clinical research and has robust HD policies and procedures that encompass the required Oncology Nursing Society (ONS) HD safe-handling training program.