Safe Handling of Antineoplastic Drug

Evidence for continued risk of occupational exposure to antineoplastic drugs (ADs) is abundant. Therefore, it is recommended for nurses to wear full personal protective equipment (PPE) when handling ADs to decrease the risk of harming their health. It is recommended for nurses to wear PPE while handling ADs. However, nurses’ are not often compliant. This is related to a lack of information or to a lack of serious concern for the potential hazards. Consequently, it is recommended to implement the mandatory training programs regarding the safe handling of ADs. The PPE implementation plan, PPE project, embraces these two evidence-based recommendations. This plan outlines the process of using these two recommendations to develop an implementation plan for the transfer and maintenance of new knowledge into practice. This implementation plan includes the aim, budget, timeline, justification, and ethical implications of the PPE plan. In addition, with the appendix, it also includes the steps to the implementation, maintenance and evaluation of the plan, identified barriers and solutions for actual implementation, and evaluation of outcomes. 

Background and Literature Review

The current problem of the organization is the in compliance of the PPE practice as per policy by the employees, nursing staffs, whilst handling ADs, increasing the risk of putting their health in danger. Studies have associated workplace exposures to ADs with acute health effects, primarily in nurses. These included hair loss, headaches, acute irritation, and/or hypersensitivity (Valanis, Vollmer, Labuhn, & Glass, 1993a; Valanis et al. 1993b). The major reproductive effects found in these studies were increased fetal loss (Selevan, Lindbohm, Hornung, & Hemminki, 1985; Stücker et al. 1990), congenital malformations depending on the length of exposure (Hemminki, Kyyrönen, & Lindbohm, 1985), low birth weight and congenital abnormalities (McAbee, Gallucci, Checkoway, 1993), and infertility (Valanis et al. 1999; Lawson et al., 2011). In addition, several reports have addressed the relationship of cancer occurrence to nurses’ exposures to ADs (Machado-Santelli, Cerqueira, Oliveira & de Braganca Pereira, 1994; Ündeğer, Başaran, Kars & Güç, 1999; Grummt, Grummt, & Schott, 1993). The studies have found that the use of

PPE reduced the risk of developing such adverse health effects. Therefore, nurses are recommended to wear full PPE while handling ADs. Hence, despite of the recommendation, nurses are not compliant with the use of the recommended precautions, and this is the recognized problem at the present. The studies have identified the barriers that are dedicated in preventing the problem, and suggested solutions to overcome these barriers. They are as below:

Barrier_1: Inconsistent use of PPE by nurses while handling antineoplastic drugs (ADs): preparing, administering and disposing cytotoxic drugs, due to practical barriers. Practical barriers will be discussed further in the “Identification of barriers” part.

Suggestion: Start a medical surveillance program for employees, provide annual training, and require the use of PPE while handling ADs. The authors suggest adopting the PARiHS framework, which highlights the evidence, the context and facilitataion, in order to successfully implement evidence into practice (Polovich and Clark, 2012; Fransman et al., 2007).

Barrier_2. Nurses’s adherence to precautions is below recommendations, due to their lack of perceived benefits of PPE and accessibility of PPE, knowledge deficit and various personal beliefs.

Suggestion: Provide education sessions that promote use of PPE, and determine nurse managers’ perspectives on use of safe handling precautions. Ask ward person to efficiently display them for nurses’ easy access. The studies suggest the use of a conceptual model, such as the CURN model, reflecting the five steps of implementing and maintaining new knowledge in practice (Rioufol et al., 2014; Connor et al., 2010).

It is recommended for nurses to wear full PPE when handling antineoplastic drugs to decrease the risk of developing cancer, reproductive, and genetic effects. Nurses’ performance of PPE will be improved once education regarding safe handling of ADs is delivered by organization. Therefore, it is recommended for the organization to implement the training program for nurses, as the evidence showed that 93% of nurses who were educated performed PPE while handling ADs, whereas only 58% of performance noted by uneducated nurses (Fransman et al., 2007; Connor et al., 2010). These two recommendations and above barriers have lead to develop the PPE plan/project to be implemented.

Aim of Implementation

The aims of the PPE plan implementation are to improve nurses’ adherence to proper PPE practices with increased risk awareness and perceived benefits of PPE, and decrease the chance that employees, nurses, will experience adverse effects from chemotherapy drugs, for its outcomes. These outcomes will be evaluated by auditing the PPE program. The review of the program will be performed at six month, and then annually. In addition, the comparison of the use of PPE performance to those before the program began will be conducted, to determine the success or failure of a program.

• Identification of stakeholders, champions and targets

The implementation of the PPE project will involve facilitators of practice change such as project manager, project treasurer, stakeholders, opinion leaders, and champions. Stakeholders are individuals or groups who are interested in or who may be affected by an issue. They will be involved in each of the steps in the implementation process, and provide important and useful insights about the best methods or strategies. They will begin working early in the project, as this will increase their involvement and support of implementation. Opinion leaders will be the clinical nurse educators (CNE), clinical nurse specialists (CNS), and nurse-unit-managers (NUM), as they are people from the local peer group viewed by their associates as respected sources of influence and technically competent (Titler & Everett, 2001). They will be actively engaged with the change process and provides guidance as needed (Rogers, 2003). They will be involved on August 2014. Champions will be clinical nurses, ward clerks, and wardsmen, as they are the ones who are passionate about practice change and provide essential energy to the process of implementing EBP. Clinical nurses will be trained to change their current PPE practice. Ward person will be asked to place the PPE where easily accessible to the nursing staffs, and stock them when its empty, making it available at any time to nursing staffs. Ward clerks will be asked to help opinion leaders with putting up the signs and maintaining them for nurses to remind them of wearing PPE. They will involved on November 2014. The identification, responsibility of each member of the PPE plan team and when they will be involved can be seen in Appendix 1, further in detail.

• Identification of barriers

Barriers that can hinder the implementation plan are miscommunication with stakeholders, organizational and staff level support for practice change, flexibility and adaptability in the change process, staff openness to change, and sustainability of the plan. These barriers are stated as below:

Barrier_1. Organizational level support for practice change, flexibility and adaptability in the change process

Organizational support, ongoing funding, will vastly affect the plan. Organizational support requires the commitment of support both in the beginning and over time. While a few highly motivated individuals may be able to start an EBP system, it will falter over time without organizational recognition of the time, effort, and resources that are needed for sustainability (Leasures, Stirlen, & Thompson, 2008; Newhouse, 2007). For the PPE plan to be successfully implemented and maintained, ongoing funding is necessary as the plan requires a variety of resources such as educational outreach visits and journal clubs, and financial support for every interventions such as developing online training modules for the maintenance.

Barrier_2. Miscommunication with team members.

Miscommunication is a real risk to the success of the plan (Spenceley, S., O’Leary, Chizawsky, Ross, & Estabrooks, 2008). Miscommunication will result the inefficiency in implementing the PPE plan, due to decreased interaction among stakeholders and team members. The most useful communication strategies to meet the communication needs of various stakeholders should be considered.

Barrier_3. Practical barriers

Practical barriers are barriers that make nurses difficult in carrying out the implementation plan. These barriers include inaccessibility to PPE especially, gowns and gloves, nurses’ ignorance to wear PPE due to work overload, and insufficient time to attend educational meetings. 

Barrier_4. Nurses attitude to change

Nurses should have openness to accept and adopt the change of the practice to successfully implement the plan (Eccles, Grimshaw, Walker, Johnston, & Pitts, 2005). However, there are barriers for nurses to have openness and they are further discussed as below.

• Awareness and knowledge

Lack of nurses’ awareness and knowledge of the importance of PPE and the outcome of not performing PPE that will reflect their health will disable the change to occur. Some nurses may feel that PPE plan undermines their autonomy or is not applicable to their ward, and so don’t consistently perform PPE.

• Motivation

Lack of motivation to perform PPE may interfere with their ability to change, resulting in noncompliance with the PPE plan, as motivation is fundamental part in driving and desiring to improve (Woodward, 2007).

• Acceptance and beliefs

Nurses’ personal beliefs and attitudes may impact significantly on their behavior of PPE performance. Some nurses may not believe that recommendations for safe handling of ADs reflect the evidence. This will hinder the implementation of the PPE plan.

Barrier_5. Sustainability of the plan

The health care environment is always changing, nurses move on, and organizational priorities may shift. Therefore, whether the PPE plan can be sustained in the long term or cannot, will effect the implementation of the PPE plan.

SIGNIFICANCE OF THE PROJECT

The change of nurses’ practice, not performing PPE while handling ADs, is necessary. The change will improve the safety of nurses by minimizing exposure and decreasing the potential for adverse health effects. Therefore, the PPE plan/project is significant to be implemented.

METHOD OF KNOWLEDGE TRANSFER

To address the barriers that are identified as above, the following interventions/ actions will be initiated, including stakeholders’ involvement. The evaluation of the results, and the steps to the implementation/ maintenance /evaluation of PPE plan are described in the Appendix 2, with the inclusion of barriers and solutions identified in each steps. The actions to address the barriers are as below:

Barrier_1. Organizational level support for practice change, flexibility and adaptability in the change process.

Action :  The need of the PPE plan will be addressed to the organization, with the      implementation plan outline. The implementation as per plan will be carried out once the organizational readiness is assessed. The project manager will be involved in this stage.

Barrier_2. Miscommunication with stakeholders.

Action :   All stakeholders will be involved and asked their preferred means of  communication. Through these methods of communication, important updates and information will be provided. It will include regular face-to-face contact as it is the most recommended way that can engage all the team members, build relationships, and make the difference with all of members in implementing the PPE plan.

Barrier_3. Practical barriers.

Action :   Obtain support from all departments in an organization to provide staff

support for practice change, flexibility and adaptability in the change process. For example, inform ward person to display and stock the PPE aptly for nurses’ easy access to PPE, asking help to ward clerks to put up and maintain the PPE signs in the medication room, toilets, locker rooms and on the wall of the patients’ rooms, and inform nurse-in-charge to evenly distribute the workload to nursing staffs. In addition, support from NUMs from every unit will be obtained and educational sessions will be offered many times with “bite-sized” information making learning quick and easy during the allocated/permitted time, so that all the staffs can attend the educational meetings with efficacy. Ways to provide protected time for training will be explored during the stakeholders’ meetings.

Barrier_4. Nurses attitude to change.

Action :   Opinion leaders will be involved in this stage. Staff attitude such as awareness and knowledge, motivation, acceptance and beliefs can occur through the educational meetings. These educational meetings will be organized and run by opinion leaders, oncology CNEs or CNSs. These educational sessions will be both in large-scale and small-scale meetings. These educational meetings will deliver not only the scope of the use of

ADs during their preparation, administration, handling, storage, transportation, disposal and spills management, names of ADs, but also the importance of PPE and adverse health effects found from various studies, as an outcome of not wearing PPE while handling ADs, so that they can believe the recommendations are robust and evidence based. Through attending these educational sessions, nurses will increase their awareness and knowledge, motivation, and acceptance and beliefs, making them more prone in adopting PPE plan.

Barrier_5. Sustainability of the plan

Action :   When considering how to implement the PPE project, it is important to plan how the project will be sustained in the long term. Stakeholders will be engaged in discussing and planning it. Evaluation of the plan will involve the CNEs or senior CNSs from every ward to perform monitoring of their unit. Maintenance strategies will be implemented as stated in Appendix 2.

Two ethical implications are identified in implementing the PPE plan. They are as below:

1. Covert observations and monitoring

Assessing the current practice of PPE and monitoring the practice post the implementation of the PPE plan as a means of auditing the project, are vital as it enables to identify the gap and becomes the baseline assessment to be compared with the later outcome, and evaluates the success or failure of the plan, respectively. Therefore, current practice assessment and monitoring of nurses’ actual practice of PPE whilst handling ADs should be performed with accuracy. In this sense, it seems like covert observations and monitoring is an ideal method, since there is a possibility that nursing staff might change their usual practice with knowing they are being observed and monitored. However, covert observations and monitoring has an ethical issue of nursing staffs’ feeling of deception. To avoid this ethical issue, the nurses will be informed about the observation and monitoring process. While informing them, the aim of these processes will be announced as well, so that they can continue what they have been usually doing, preventing them to change their PPE practice. For example, they will be informed that they are not being observed or monitored to be humiliated or penalized by their practice, but observations and monitoring are performed to assess the necessity of the implementation plan and evaluate the plan, so that they can carry out their usual practice.

2. Risk to nurses’ welfare

While nurses are observed and monitored, some of them might be worried about the risks to them, such as being identified if they do not perform PPE when they should, resulting in stigmatization. Therefore, their identities will not be recorded while being observed and monitored, and this fact will be clearly informed to them so that they can continue their practice as usual, halting them from changing their PPE practices, and without having worries about being stigmatized…….

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