Why Aren’t Nurses Adhering to PPE Requirements?

In their article in the June 2019 issue of the Clinical Journal of Oncology Nursing, Menonna-Quinn, Polovich, and Marshall shared the results of their study (https://doi.org/10.1188/19.CJON.260-265) investigating oncology nurses’ self-reported use of PPE and the reasons nurses don’t always adhere to all of the guideline requirements.

Chemotherapy Safety Guidelines

More than half of the drugs on the National Institute for Occupational Safety and Health (NIOSH) hazardous drugs list are used in the treatment of cancer, Menonna-Quinn et al. reported (https://doi.org/10.1188/19.CJON.260-265), and most oncology nurses encounter them every day. To protect healthcare professionals from the side effects of regular exposure, the American Society of Health-System Pharmacists created safe handling practice recommendations in 1985 and the Occupational Safety and Health Administration developed guidelines in 1986.  

Although most practices have adopted these in various forms, neither the recommendations or guidelines are enforceable and therefore institutional practices and adherence have been inconsistent, Menonna-Quinn et al. said (https://doi.org/10.1188/19.CJON.260-265). However, the December 2019 implementation of U.S. Pharmacopeia chapter <800> requires mandated compliance in the states that adopt it, which will “significantly influence chemotherapy safe handling practices for all healthcare providers and organizations.”

Personal Protective Equipment

Because “consistent and proper use of PPE can eliminate short- and long-term side effects (https://doi.org/10.1188/19.CJON.260-265) related to chemotherapy exposure,” ONS and other organizations that serve professions that handle hazardous drugs have issued guidelines, practice recommendations, and position statements with information to protect their members (see sidebar). 

Specifically, ONS stressed the importance of wearing the following PPE (https://doi.org/10.1188/19.CJON.260-265) whenever a nurse is preparing or administering hazardous drugs:

• Chemotherapy-designated gowns
• Double-gloving with chemotherapy-
  designated gloves
• Respiratory mask if inhalation is possible
• Goggles or eye protection if splashing is possible (e.g., operating room, peritoneal chemotherapy administration, cleaning a chemotherapy spill)

How Many Nurses Wear Correct PPE

Menonna-Quinn et al. conducted a study of PPE adherence (https://doi.org/10.1188/19.CJON.260-265) in inpatient (n = 27) and outpatient (n = 67) oncology nursing practices using the Hazardous Drug Handling Questionnaire. All of the nurses had at least one year of oncology experience and held a valid ONS chemotherapy provider card. The questionnaire evaluates behavior during three phases: 

• Administration
• Disposal
• Handling post-administration excreta

Administration: Menonna-Quinn et al. found that most nurses always used closed-system devices (https://doi.org/10.1188/19.CJON.260-265) (69%) during chemotherapy administration, always wore chemotherapy-designated gloves (82%), and never used reusable gowns (78%). Almost half (47%) always used chemotherapy-designated gowns. However, practices were split when it came to double gloving: 31% always double gloved but another 31% never did. Finally, 77% never wore eye protection and 26% never wore respirator masks during administration.

Disposal: Again, nurses were mostly adherent to using chemotherapy-designated gloves (74%), but only 43% double gloved. However, more nurses never wore chemotherapy-designated gowns (22%), eye protection (74%), or respirator masks (49%) for disposal.

Handling excreta: In this behavior, fewer nurses adhered to using chemotherapy-designated PPE: only 17% always used chemotherapy-designated gloves and 25% always used chemotherapy-designated gowns. None of the nurses always wore eye protection (conversely, 62% never wore it) when handling excreta, and 68% never wore respirator masks.

What This Means for Oncology Nurses

Menonna-Quinn et al. said that their study findings highlight that nurses are not consistently meeting the standards (https://doi.org/10.1188/19.CJON.260-265) of best practice guidelines for PPE and that other studies have shown similar results. Across the literature, researchers have found that double gloving is the most difficult practice change for most nurses, yet ONS and NIOSH have recommended it for many years. Additionally, Menonna-Quinn et al.’s research found that nurses wore chemotherapy-designated gowns only 47% of the time (https://doi.org/10.1188/19.CJON.260-265) during administration, 31% during disposal, and 25% while handling excreta.

The authors recommended the need for increased education about PPE and the importance of self-protection during oncology nurses’ early training, continued PPE education during orientation, and PPE requirement reviews during annual competencies. “Ensuring that nurses understand when to use and when to wear PPE during all phases of chemotherapy administration can protect the healthcare providers administering hazardous drugs and the patients receiving the therapy,” they said (p. 265). 

For more information about oncology nurses’ practice behaviors for PPE and the opportunity to earn 0.5 CNE contact hours (free for ONS members), refer to the full article (https://doi.org/10.1188/19.CJON.260-265) by Menonna-Quinn et al.