https://doi.org/10.33698/NRF0243-Renuka Kadian, Sukhwinder Kaur, Anita Trehan, Sandhya Ghai
ABSTRACT:
Introduction- Across the globe, cancer is leading cause of death among adults as well as children. Cancer in children is rare but heavy burden in the category of dangerous diseases. Emergence of chemotherapeutic drugs has immensely benetted to the current prognosis of childhood cancers but unintentional exposure to these harmful agents may endanger the life of health care workers who repeatedly gets exposed to these cytotoxic drugs. Nurses need to think, act and approach with more specicity and should comply on set standards while handling these cytotoxic agents. Objectives- 1) To identify barriers and facilitators for preparation and administration of chemotherapeutic drugs by nursing staff 2) To seek the suggestions of nursing staff to improve current practices. Methodology- Focus Group Discussions were conducted with nurses handling chemotherapeutic drugs. Total 8 FGDs were conducted with the nurses and each group comprised of 3-4 nurses. Results- It was found that there were various barriers and facilitators related to preparation and administration of chemotherapeutic drugs by the nurses. There was lack of uniformity among the nurses while practicing the procedures, non-existence of standard operational protocols and non-availability of supplies. Various themes and sub themes were generated after the group discussions and some of the suggested facilitators include: availability of written standard protocols and educating the nurses regarding the standard procedures with the help of posters, lectures and demonstrations. Conclusion- This study concluded that all the nurse managers and supervisors need to increase efforts to promote more standardized practices of chemotherapeutic drug preparation and administration so that unnecessary exposure to hazardous drugs can be minimized.
KEYWORDS: SOP-Standard Operational Protocol, Hazardous drugs, Focus Group Discussions, Barriers, Suggested Facilitators
Address for correspondence
Dr. Sukhwinder Kaur Lecturer,
National Institute of Nursing Education PGIMER, Chandigarh
INTRODUCTION: Cancer is 9th leading cause of death among children in India and it is growing rapidly at alarming rates. It is a big relief that most pediatric cancers are c o n t r o l l a b l e i f e a r l y d i a g n o s e d . Chemotherapy is one of the most effective and widely used treatment modality1. Emergence of chemotherapeutic drugs has immensely benetted to the current prognosis of childhood cancers but unintentional exposure to these harmful agents may endanger the life of health care workers who repeatedly gets exposed to these cytotoxic drugs. Nurses are the primary health care professionals dealing with preparation and administration of chemotherapeutic drugs. Dealing with these hazardous drugs demand special equipment, infrastructure and expertise. Poor and non-standardized practices by nurses lead to various complications among patients and nurses who get exposed accidentally to hazardous drugs which may have harmful effects on their health2. Descriptive study design was used to assess the quality of life of oncology nurses from 12 different cities in Turkey. Total 89 oncology nurses participated in the study. This study concluded that the nurses engaged in handling chemotherapy drugs had poor quality of life. Nurses were found to be poor at physical health, psychological h e a l t h a n d i n d o m a i n s o f s o c i a l both are denitely challenging.” It was observed in routine clinical practice o f r e s e a r c h e r t h a t c h e m o t h e r a p y preparation and administration by the nurses lacked uniformity while performing the procedures leading to unintentional exposure of hazardous chemotherapeutic drugs. Therefore, need was felt to assess the barriers and facilitators for preparing and administering chemotherapeutic drugs.
Objectives:
1) To identify barriers and f a c i l i t a t o r s f o r p r e p a r a t i o n a n d administration of chemotherapeutic drugs by nursing staff
2) To seek the suggestions of nursing staff to improve current practices.
Material and methods: Setting of the study was pediatric hematology and oncology units of a tertiary care institute in North India. Study setting consists of 2 pediatric wards and a pediatric Day Care Centre. Sample population was nurses who were preparing and administering the relationships.3 Nurses’ safety is the key chemotherapeutic drugs to children with c o m p o n e n t i n h u m a n r e s o u r c e strengthening and stabilization. It can be ensured with evidence based standard protocols related to chemotherapeutic drug preparation and administration, use of personal protective equipment, handling hazardous waste, spill management etc. Dr. oncological disorders through Oral, IV, IM and SC routes. Technique of sampling was purposive sampling. All FGDs were conducted after the permission of concerned authority and written informed consent was taken from the nurses who were participating. Tool for the FGDs was a Christopher Friese2 (RN, PhD.) suggests FDG guide with unstructured open ended that, “The issues of needle safety, safe handling of hazardous drugs, consistent use of personal protective equipment, safe disposal of cytotoxic waste needs more attention. Key solutions to deal with the issues are training and behavior change, and questions and discussion was guided by the investigator. FGDs were conducted to get the maximum response till the data or information gets saturated. The focus was to explore the major problems, constraints or issues faced by the nurses while handling hazardous chemotherapeutic drugs and suggested facilitators to these problems in accordance with. Total 8 FGDs were conducted with nurses in group of 4-5 as per their availability and sessions were audio recorded. Duration for each FGD was approximately 30-40 minutes. After completing the FGDs, verbatim were written down, themes and subthemes were generated to draw meaningful inferences. Inferences were interpreted based on experience of the investigator and with the help of experts from the same eld. Changes were done according to the suggestions from the experts.
Results: FGD is basically a cooperative, problem solving activity which seeks a consensus regarding the solution to a problem. These tables are depicting the themes and subthemes generated from various FGDs with nurses related to barriers and suggested facilitators for preparation and administration of chemotherapeutic drugs. Common barriers expressed by the nurses in pediatric hematology and oncology wards and Day Care Centre were: lack of knowledge and motivation among nurses regarding the necessity of standard procedures of c h e m o t h e r a p y p r e p a r a t i o n a n d administration, shortage of staff and supplies, Lack of separate designated area for the preparation of chemotherapeutic drugs, non-availability of necessary equipment including personal protective equipment, plastic backed sheets, medication trays, additional pads, spill kit, washed bedsheets/linens for patients, Biosafety Cabinets and Laminar Flow Devices. Lack of regular teachings regarding chemotherapy preparation and administration, lack of time and poor methods of waste disposal in the setting.
Common suggested facilitators by the nurses were: Regular classes for nurses should be arranged so that new changes can be introduced and existing information can be updated and revised. Orientation and induction program for newly posted Nurses, increase manpower, use of diversional therapies and facilitating therapeutic play, improvement in management issues by providing necessary equipment and supplies. Availability of comprehensive and standard protocol for nurses which can be used as a guide and r e f e r e n c e t o o l b y n u r s e s w h i l e administering chemotherapy drugs.
RCA (Root Cause Analysis) is a method of seeking a solution for the problem by identifying the root causes or faults. It is a collective term that describes a vivid approaches, tools and techniques used to identify the causes of problems. This analysis helped the researcher to look deeper into the problems and nd out why they are occurring and how they can be tackled in most effective manner. The four major domains of analysis were equipment and supplies, issues related to people and staff, environment and the workplace and the issues related to management including policies, procedures and rules.
Discussion: Across the globe, cancer is leading cause of death among adults as well as children. Cancer in children is rare but a heavyweight in the category of dangerous diseases. Despite of fast growing, most pediatric cancers are potentially either controllable or palliable if early diagnosed and appropriately treated.2
When chemotherapy is used as treatment modality, its safe administration is highly signicant issue due to high potential for harm from these chemotherapeutic agents. Nurses are the primary health care professionals handling chemotherapeutic drugs. As chemotherapies can be hazardous for patients and staff, it is therefore essential that they are prepared and administered in possible safest way. In 1992, a systematic review was done to know the hazards of chemotherapy and implementing safe h a n d l i n g p r a c t i c e s . T h i s s t u d y r ecommended t hat a l l t he health professionals involved in preparation and administration of chemotherapeutic agents should have specialized training. The used equipment, human waste and unused drugs should be treated as cytotoxic and chemically hazardous waste and should be disposed according to institute’s policy4. There should be proper guidelines for administration of chemotherapeutic agents.
Common themes generated as barriers from the FGDs were: lack of updated knowledge among nurses practicing and handling hazardous chemotherapeutic drugs. FGDs with nurses highlighted various other issues also like lack of time, appropriate spacing, storage and supplies. There was non- availability of standard protocols for nurses t o p r e p a r e a n d a d m i n i s t e r chemotherapeutic drugs in uniform and specic ways.
Regarding facilitators, most of the nurses stressed the importance of SOPs in the wards which can be used as ready references. Bhawna Sirohi conducted a systemic review in India in 2014 which highlighted the means to deliver high quality and cost effective cancer care services by trained CNS (Clinical Nurse Specialist) as concept of Nurse Consultants in UK. Their roles need to be strengthened by training and educating oncology nurses who are involved in delivering care to cancer patients. She also mentioned, “We as oncologists need to be more accountable and take greater responsibility for the entire cancer journey of each patient. It is the delivery of quality evidence-based care to each cancer patient, with unified protocols across the country, within l imited resources, that is the key.”5
The FGDs helped the investigator in identication of root causes and most c o m m o n b a r r i e r s w h i c h l e a d t o inappropriate methods of chemotherapy preparation and administration. This practice by nurses poses higher risk of occupational health hazards and avoidable complications to children with oncological disorders. The nurse managers and supervisors need to make efforts to promote m o r e s t a n d a r d i z e d p r a c t i c e s o f chemotherapeutic drug through SOPs for preparation and administration of c h e m o t h e r a p e u t i c a g e n t s s o t h a t unnecessary exposure to hazardous drugs can be minimized.
Table 1: Problems faced by nursing staff and suggested facilitators while preparing and administering chemotherapeutic drugs
| S.No. | Themes | Verbatims | Suggested Facilitator |
| 1. | Lack of knowledge and Motivation New cancer treatment protocols for children
Lack of facility for storage of hazardous drugs
Nursing assessment of patients by nurses
Don and Doff PPE
Accurate method of preparation and administration of chemotherapeutic drugs through Oral, IV, SC and IM routes. |
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| “Kuch medicines or treatment nae ate h or nurses ko treatment card se hi nayi medicines ka pata chalta h.”
Nurses don’t know some of the newer medicines and treatment protocols which are newly introduced. |
Regular classes for nurses should be arranged so that newer changes can be introduced, and existing information can be updated and revised. | ||
| “Sabhi patients ki medicines rakhne ke liye fridge me space nayi ha or na hi boxes ha to mix hone k chances rehte ha.”
There is not enough space for the storage of medicines in fridge and boxes and there are chances of mixing of medicines. |
Large size fridge may be purchased with enough space in it. | ||
| “Kisi bhi tarah ka assessment nurses day care centre me nahi krti h. jbi patient ata h to bas fever bhi parents se hi pooch liya jata ha.”
Nurses do not perform any kind of pre-assessment when the child comes for chemotherapy. They record vital signs only that too by asking the parents. |
Orientation and induction program for newly posted Nurses. | ||
| “Chemotherapy preparation ke time par konse PPE pehen na jaroori ha or kaise pehen ne chahiye, ye hum sbhi ko ache se nahi pta ha.”
We are not well worse with the donning and doffing of Personal Protective Eqiupments. |
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| “Koi standard guidelines ya protocol nahi ha jise nurses follow kr sake.”
“Nayi posting ke bad ek dum se chemotherapy me kam karna mushkil hota ha.” There are no standard guidelines and set protocols for the administration of chemotherapeutic drugs. It is difficult to deal with chemotherapeutic drugs in new postings. |
Table 2: Problems faced by nursing staff and seeking their suggestions while preparing and administering chemotherapeutic drugs.
| S.No. | Themes | Verbatims | Suggested
Facilitator |
| 2. | Shortage of Staff | “Nurse patient ratio zyada hone k karan hum sabhi bacho par dhyan nahi de pate h. day care centre me OPD days me to bacho k bhaithne ki space b nahi hoti h.”
There are large number of patients and shortage of staff. In Day Care Centre, there is no space for children to sit due to rush on OPD days. Morning shift me or bhi bhot sare kam dekhne hote h or evening or night shift me ward me 4 staff hi hote h or patient itne zyada assign hote h.” There is more burden in wards in morning shift and there is shortage of staff in evening and night shift and more patients are assigned to individual nurse |
Increase Manpower. |
| 3. | Poor development of IPR | “Patient se baat karne ka bhi time nahi hota. Bas bache apne parents k sath ate h or short chemotherapy lagwakar jaldi se ghar jane ki sochte h.”
There is lack of time due to shortage of nurses and parents are in hurry to go back home after short chemotherapy administration. “Patients bhi nurses ko dekh kar rona start kr dete h”. Patients are afraid of nurses and start crying. |
Increase Manpower |
| 4. | Un cooperative patients and Poor Compliance. | “Kuch baccho ko injection or cannula lagana bohot mushkil ho jata h. wo rote h or haath pair maarte h, apni body ko bhi stiff kr lete h.”
Many times, it is difficult to insert cannulas in children, they start crying, move their limbs and makes their body stiff. “Kaa bar bacche apna cannula nikal lete h.” “Bohot sare bache apni feeding tube nikal dete h.” Children pull out their cannulas and feeding tubes many times. |
Use of Diversional therapies and facilitating therapeutic play. |
| “Bacho ko samjhana mushkil h kyoki unhe apne ache bure ki samajh nahi h.”
“Bachhe bohot bar treatment lene nahi ate.” It is difficult to make the child understand the benefits of medication and harms if not taken. There are children who don’t even come for the treatment. |
Table 3: Problems faced by nursing staff and seeking their suggestions while preparing and administering chemotherapeutic drugs
| S.No. | Themes | Verbatims | Suggested
Facilitator |
| 5. | Non-availability of advanced equipment such as Biosafety Cabinets and
Laminar Flow Devices. |
“Laminar Flow chemotherapy prepare karne ke liye hone chahiye. Nurses ki safety ke liye ye zaroori h. Hospital me kai places par ye available h.”
There should be availability of Laminar flow for the preparation of chemotherapeutic drugs for the safety of nurses. At few places of hospital it is there. |
Improvement in availability of necessary equipment and supplies. |
| 6. | Lack of space for preparation and
administration of chemotherapeutic drugs. |
“Day Care centre me to kaa bar hum Drugs apne hi table par ya patient ke bed par hi tyar karte h. Bacho ko baithane ki bhi jagah nahi hoti h.”
In day care centre, we prepare drugs on our own tables or on patient’s bedside because there is no space for the patients to sit. |
Improvement in Managerial issues of space and equipment |
| “Fluids Tayar karne ke liye basket use karte h.
Wards me chemotherapty doctors lagate h wo bhi bed par hi tayar karte h.” We use baskets for preparing fluids but in wards doctors prepare chemotherapeutic drugs on patient’s bedside. |
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| 7. | Storage of Drugs Absence of patient’s boxes with labels. | “Patient khud hi apni medicine fridge me rakhte h or waha se nikalte bhi khud hi h.”
Parents or patients keep their medicines in the refrigerator and take out by themselves. “Fridge ki safai karte samay kai bar medicine discard bhi karni padti h. discard tabhi karte h ya to wo kharab hon ya bhot kam bachi ho.” While cleaning the refrigerator, we need to discard the medicines if it is expired or not good to use. “Patients ko apne apne box lane ko bola h, kuch patients laate bhi h. Day Care Centre me ye Zaroori h.” Patients are told to bring their boxes for storing the medicine. It is important in Day Care Centre. |
To improve facilities for drug storage. |
|
Absence of locked cabinets. |
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| 8. | Placement of waste disposal bins. | “Bin ko Day Care Centre me rakhne ki jagah hi nahi h is liye bas black bin ko ander rakha h. Baki waste ko ek badi tray me collect karke bahar rakhe yellow bin me daal kar ate h.” There is no space for the placement of bins in Day Care Centre, that’s why a tray is placed to collect the waste and then it is emptied into yellow bin placed outside the Day Care Centre.
“Attendants khud bhi IV bottles or IV sets yellow bin me dal ke ate h.” Attendants also throw IV bottles and sets in the yellow bin. “Ward me ek yellow bin alag se rakha h.” There is a separate yellow bin in the wards to collect cytotoxic hazardous waste. |
Improvement in Managerial issues of space and equipment. |
Table 4: Problems faced by nursing staff and seeking their suggestions while preparing and administering chemotherapeutic drugs.
| S.No. | Themes | Verbatims | Suggested Facilitator |
| 9. | Limited supply of necessary articles.
PPE- Personal Protective Equipment Plastic backed sheets
Medication trays
Additional packs (Containing 2 small cotton pads and 4×4 gauze pieces) Spill kit
Washed bedsheets/linens for patients. |
“PPE ke nam par bas gloves ate h. Mask bhi ate h par ward me to wo bhi kam pad jate h.”
There is no proper supply of PPE. Gloves and masks are available only in wards, masks are very few.
“Adult chemotherapy Ward me to chemotherapy prepare karne ke liye melena sheet ati h. Yha indent karwane ki koshish kr sakte h, use kam se kam hr shift me to change kar sakte h.” Melena sheet or plastic backed sheets are used in adult chemotherapy ward for managing spills. This can also be used in our setting.
“Teen chaar hi basket h jinme IV medicine prepare karte h, baki to gloves ka paper hi spread kr ke us par hi injection tayar karte h.” 3-4 baskets are available to prepare chemotherapeutic drugs. Rest we use glove packing paper to prepare chemotherapy.
“Additional pack supply me itne nahi ate h ki sabhi procedures k liye ek ek use kar le. Bas kam chalta h.” Lack of supply of additional packs to perform procedure in more sterile way.
“Koi spill kit available nahi h. Bada spill hota h to us par bleach dal k newspaper dal dete h. Hospital Atendant(H/A) apne ap saaf krte h. ha wo gloves pehen lete h.” There is no spill kit available. If there is spill, we pour bleaching powder on the spill and Hospital Attendant wipes it with the newspaper after wearing gloves. “Ward k kam me spill dhayan hi nai rehta h. Koi special management nahi karte.” During the responsibilities and tasks of ward, spill is ignored. There is nothing special done for spill management.
“Har roz wash zyada nahi ati h to patients ki sheet jinki saaf hoti h unki nahi badalte. Day Care Centre me limited hi bedsheets h, hum do se teen din chalate h. kharab hoti h to side change kar dete hai.” Due to shortage of linen, we don’t change bedsheets daily. In Day Care Centre, bedsheets are not changed for 2-3 days. If soiled, we change the sides of bedsheets. |
Need to improve equipments supply. |
Equipment/Supplies People/Staff
Environment/Place
Fig 1. Fish Bone Root Cause Analysis
Management (Rules/policies/Procedure)
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