Analysis

Protecting cancer nurses' health from work hazards and pressures

Cancer nurses handling chemotherapy drugs have called for urgent research regarding health and safety risks they face when administrating medicines

A growing number of cancer nurses are raising concerns about the health and safety risks of handling chemotherapy drugs as part of their roles, highlighting the urgent need for more research in this area


Picture: Alamy

Nurse academics from Birmingham City University (BCU) are calling for the mandatory use of closed system drug transfer devices (CSTDs).

The CSTDs prohibit the transfer of environmental contaminants into the therapy system and prevent hazardous drugs or vapour concentrations escaping.

46%

of 200 nurses surveyed reported adverse health effects related to handling chemotherapy drugs

This is designed to minimise the risk of nurses being exposed to potentially dangerous cytotoxic medicines during the chemotherapy treatment process.

'Plenty of evidence'

BCU senior lecturer in cancer care and chemotherapy Alison Simons says: ‘There is now plenty of published evidence showing the dangers nurses face when administering chemotherapy and we’ve heard a lot more anecdotal evidence that has convinced us CSTDs should be mandatory.’

Of the 200 nurses surveyed by Ms Simons and her colleague, BCU senior lecturer in haematology and chemotherapy Samantha Toland, almost half responded saying they had experienced health issues such as headache, dizziness or nausea, or a combination of two or more symptoms.

One in every ten respondents said they had experienced miscarriage or fertility problems, which they attributed to the drugs they had worked with, and a further 9% said they had experienced hair loss. A total of 23 research studies on the use of CSTDs reviewed by researchers offered no evidence for or against their use.

Top tips for safety when handling systemic anti-cancer therapies 

  1. Be aware of the health risks associated with handling.
  2. Use closed system devices wherever possible
  3. Use appropriate personal protective equipment
  4. Do not eat and drink in systemic anti-cancer therapies (SACT) administration areas
  5. Ensure appropriate glove use, remove gloves and wash hands immediately after handling
  6. Minimise risk of exposure to SACT contaminated waste by using closed system devices or specialist hazardous drugs waste disposal systems
  7. Adhere to policies and protocols in relation to spillage and contamination management
  8. Discuss concerns about exposure in your working environment with your manager
  9. Report any accidental exposure to SACT agents appropriately and inform your occupational health adviser
  10. Be compliant, protect each other and stay safe

Ms Simons says she and Ms Toland experienced miscarriages while delivering chemotherapy.

‘But it is hard to prove the link,’ says Ms Simons.

Lack of UK-based studies

Ms Toland says much of the research is from the United States and countries such as Spain, Holland and Sweden.

‘There is a serious lack of UK studies in this area and we need to fill this gap.’

She adds that many nurses they have spoken to are ‘shocked and surprised’ by the potential risks.

‘We felt there was quite a big lack of awareness out there.’

To counter this, Ms Toland and Ms Simons have launched a website, SACT safety, to highlight the risks that healthcare professionals may face when providing chemotherapy to patients.

‘Changing clinical practices and introducing new equipment can be time-consuming and add to costs, but the benefits outweigh the challenges,’ says Ms Simons.

However, due to the lack of good-quality UK evidence, other nurses in the profession are reluctant to support the need for CSTDs.

The UK Oncology Nursing Society (UKONS) is set to publish a position statement, following its recently published Cochrane review of 23 studies on closed systems.

‘Based on very low-quality evidence’, the authors write in a review summary, ‘there is currently no evidence for or against adding CSTD to safe handling of hazardous medicines. Further well-designed studies are necessary.’

The research also found variation in whether CSTDs delivered cost savings, with some studies reporting increased costs and some decreased costs after implementation.

Beyond chemotherapy, cancer nurses have to navigate other health risks that come with the territory.

‘Radiotherapy is a risk,’ points out Ms Toland. ‘But everyone wears a badge to know how much radiation they are being exposed to.

‘With chemotherapy we have no way of monitoring how safe the drugs are.’

Other treatments such as monoclonal antibodies immunotherapy may carry potential risks, adds Ms Toland.

‘We don’t know the long-term risks of these drugs because they are new.’

The emotional toll of cancer nursing

1 in 10

nurses reported suffering miscarriage or fertility problems in the same survey

In addition to the potential risks associated with providing chemotherapy, nurses' health can take a knock through having to grapple with poor staffing, working long hours and the challenge of managing the different emotions they experience when caring for people with cancer.

Christie NHS Foundation Trust research fellow Carole Farrell says the rising prevalence of cancer and a lack of time and resources have escalated to ‘peak’ unsustainabilty for the profession.

Dr Farrell says: ‘Nurses' workloads are increasing, but there are insufficient numbers of staff to meet clinical demands.

‘This results in daily challenges and can have a negative impact on “caring nurses” who are struggling to contact all patients in a timely manner and maintain the quality of their service.

‘The risk for nurses is emotional burnout, increased anxiety and potential depression unless there is good managerial support and clinical supervision.

‘There are also increased risks for nurses' physical well-being, with potential chronic fatigue and insomnia.’


Carole Farrell. Picture: Neil O'Connor

Dr Farrell adds there is an emotional burden for nurses caring for people with metastatic disease, including those at end of life, which takes its toll over time.

University of Glasgow undergraduate nursing programme director Doreen Molloy agrees.

Dr Molloy says: ‘When I started a family in my early thirties and was seeing dying patients at the same age with children of the same age, that was difficult for me.

‘I took time out from clinical work because I was getting upset in consultations.’

With the number of risks and challenges to cancer nurses’ health, experts agree it is crucial that more research and funding is directed towards ensuring their safety.

Closed system drug transfer devices trial

Despite the evidence gap, a number of organisations are implementing closed system drug transfer devices (CSTDs) to deliver chemotherapy, although it is not known how many in the UK have done so.

The Dudley Group Foundation NHS Foundation Trust is one.

Lead chemotherapy nurse Allison Field says the potential of risk to the trust’s staff was enough for the board to approve implementation.

‘We have a duty of care to our nursing staff, if there is a potential risk and if there is something we could be doing differently or better to protect our nurses, then we have a duty of care to do that.’

Ms Field says there is a need for more concise national guidance on the subject.

The Health and Safety Executive (HSE) has recommendations on use of personal protective equipment, safe handling and hygiene practice and staff training, but there are no national regulations or mandatory guidelines in the UK on the implementation of CSDTs.

‘Legislation as it stands at the moment is not definitive,' says Ms Field.

'It's just “mitigate the risks as best you can, use totallly enclosed systems where reasonably practicable, issue personal protective equipment where adequate control cannot be achieved by other measures alone, and risk assess”.

'So there is potential for improvement – and this is what our trust has done.'

 

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