Because of the risks associated with handling chemotherapy drugs, safety guidelines surrounding their proper use have existed since 1981.

 The Oncology Nursing Society (ONS) and the National Institute for Occupational Safety & Health (NIOSH) have both recommended oncology nurses receive hazardous drug education, including safe storage, preparation, labeling, transportation, administration, and disposal of hazardous drugs and proper use of personal protective equipment (PPE).

In 2016, the United States Pharmacopeial Convention (USP) updated the General Chapter 

<800> to set standards for the safe handling of hazardous drugs, with implementation of the new standards set scheduled for December 2019. Almost 3 years after 

 <800> became the recommended standard, some hospitals have improved their compliance, but Seth Eisenberg, ASN, RN, OCN, BMTCN, a retired oncology nurse now working as a consultant in Saint George, Utah, believes implementing 

 <800> is still a work in progress for many hospitals.

<800> requires pharmacies to store hazardous drugs in an externally ventilated, negative-pressure room with at least 12 air changes per hour,” Eisenberg said in an interview with 

®. “For pharmacies that were housed in the basement of a hospital, this entail[ed] expensive modifications. In some cases, it was more cost-effective to build a new pharmacy rather than retrofit an old one.”

 <800> compliance entails increasing education about proper handling of hazardous drugs, implementing closed system drug-transfer devices (CSTDs), and using requisite PPE, according to Eisenberg. “One of the biggest changes in 

 <800> is the requirement to use CSTDs when administering drugs,” he said. “Although ONS and NIOSH had recommended these devices, they weren’t required.”

CSTDs can prevent or minimize drug leakage, but Eisenberg said the cost can be prohibitive for some hospitals and clinics. “[Because] some components of CSTDs are meant for single use, it increases the overall cost of the medication,” he said. “The average price of a CSTD ranges from $8-$12 a dose.”

 <800> requires nurses to double-glove and wear chemotherapy gowns, when administering chemotherapy drugs, which is consistent with ONS guidelines.

“NIOSH has provided best practice guidance for more than 2 decades. But 

 <800> is an enforceable standard with far-reaching implications for all facilities that handle hazardous drugs,” Eisenberg says.

Although guidelines for safe handling of hazardous oncology drugs aren’t new, 

 <800> introduced safety standards that could be enforceable on a state level.

 <800> gave teeth and enforceability to safety practices that already existed,” AnnMarie Walton, PhD, MPH, RN, OCN, CHES, FAAN, assistant professor in the School of Nursing at Duke University in Durham, North Carolina, explained in an interview with 

 <800> is still a work in progress for many oncology units. Some of the oncology units that weren’t already using CSTDs are adopting them now that suppliers are able to meet the demand. Enforceability of the 

 <800> requirement is being decided and regulated at the state level.”

Walton said oncology nurses are in a good position to advocate for safety changes and encourage adoption of 

 <800> if their unit hasn’t already implemented them. In addition, oncology nurses can educate patients and their caregivers on safety measures that should be followed while chemotherapy is administered in the hospital or at home after the patient is discharged.

MiKaela M. Olsen, DNP, MS, APRN-CNS, AOCNS, FAAN, clinical program director for oncology at The Johns Hopkins Hospital in Baltimore, Maryland, works at a hospital that began offering a curbside injection clinic to oncology patients in 2020, during the height of the pandemic. 

“We had to find a way to ensure our patients could safely continue receiving chemotherapy while also protecting them from the coronavirus,” Olsen told 

Johns Hopkins initially conceived curbside injection clinics as a precaution during the pandemic. But Olsen said Johns Hopkins plans to continue these clinics for patients receiving chemotherapy, and other hospitals have taken notice. “For many oncology patients, the curbside injection clinic offers both increased safety and convenience,” Olsen said. “They still have the option of our indoor injection clinic, but for patients with transportation and mobility issues, the curbside clinic is easier. They can have a family member drive them or take an Uber or Lyft to their appointment.”

Nurses staffing the curbside injection clinic wear full PPE, follow safety protocols, and offer services including symptom assessment, port flushes, dressing changes, and chemotherapy. To date, the curbside injection clinic has seen over 7000 patients. Although large health systems such as Johns Hopkins have embraced 

<800>, Olsen acknowledged that some smaller community hospitals are still working to implement 

 <800> safety requirements. One way for hospitals to do this is to request a Health Hazard Evaluation from NIOSH. This evaluation identifies potential health hazards and recommends ways to reduce exposure. There is no cost for the evaluations, but they pay off by providing peace of mind.  “Compliance challenges vary from one health care setting to the next, but nurses can help identify areas in need of improvement,” Olsen said. 

Bernabeu-Martínez MA, Ramos Merino M, Santos Gago JM, Álvarez Sabucedo LM, Wanden-Berghe C, Sanz-Valero J. Guidelines for safe handling of hazardous drugs: a systematic review. 

. 2018;13(5):e0197172. doi:10.1371/journal.pone.0197172

USP<800> Compliance: A Hazardous Drug Safe-Handling Quality Improvement Project for Ambulatory Care Infusion Nurses

. Doctor of Nursing Practice thesis. University of San Francisco; 2020.https://repository.usfca.edu/dnp/218

Articles

Powerful chemicals used in chemotherapy may pose safety hazards for oncology nurses, pharmacists, and other health care providers if not handled properly.

USP <800>: Still a Work in Progress?

Clinical trials have long faced a multitude of challenges, including patient enrollment and retention. Now decentralized clinical trials (DCTs) that allow patients to participate remotely intend to simplify the process.

DCTs are defined as studies “executed through telemedicine and mobile/local health care providers, using processes and technologies differing from the traditional clinical trial model.”

 These trials go beyond traditional brick-and-mortar research facilities to allow many clinical trial activities to be conducted virtually rather than in person.

By utilizing technology, such as telemedicine, to deliver consent and education, remote monitoring, direct-to-patient distribution of investigational medicines, and use of local labs and image centers, DCTs offer a more patient-centric approach to clinical trials.

Although there has long been an interest in decentralizing clinical trials, the COVID-19 pandemic significantly sped up the adoption of DCT methods. Suddenly, patients were unable to physically visit clinical trial sites, and the Lancet reports an estimated 80% of non–COVID-19 trials were either halted or interrupted by the pandemic.

Although DCTs are proving to be promising, Abraham says they present some challenges. “During the pandemic, exceptions were made to allow for virtual assessments in our breast oncology research group, and we have the ability to allow more virtual assessment for patients with all cancer types,” she said. “However, insurance requirements have recently become stricter and don’t always allow coverage for out-of-state virtual assessments. Unfortunately, this may hinder the progress of decentralizing clinical trials in the future.

“We’ve worked to decentralize many of our trials to help fit the needs of our patients during the pandemic,” Elizabeth Abraham, RN, BSN, a senior clinical research nurse in breast oncology at Massachusetts General Hospital in Boston, said in an interview with Oncology Nursing News®. “Our team modified the process to allow for virtual prescreening for trials, virtual consents, telephone adverse event assessments, and virtual visits.”

Another challenge is ensuring study participants receive immediate care in the event they become ill. “If a patient is experiencing any adverse events, they must come into [the] clinic or be seen locally for [an] in-person evaluation,” Abraham said. “If they are seen locally, our clinical research team will obtain records for review to provide recommendations and guidance.”

Although DCTs are proving to be promising, Abraham says they present some challenges. “During the pandemic, exceptions were made to allow for virtual assess- ments in our breast oncology research group, and we have the ability to allow

A Southern California Cancer Center Expands Its Reach 

With over 35 locations in Southern California, City of Hope, a cancer research and treatment organization, employs a hybrid approach to decentralizing its clinical trials. Instead of relying on its main campus in Duarte as the primary clinical trial site, it uses its satellite locations in Lancaster, South Pasadena, Upland, and Corona, to recruit patients and stream data. 

Paul Raborar, RN, a clinical research nurse at City of Hope, oversees clinical trials at these satellite sites and believes offering DCTs in the communities where many of their patients live will enable faster and more diverse enrollment in their clinical trials. 

As an example, Raborar cited a recent clinical trial for prostate cancer (NCT04734730), a type of cancer that disproportionately affects Black men, who are more likely to receive a diagnosis at an advanced stage. “The community sites have provided 31% of the study population to date,” he said. “There has been an uptick in enrollment. Opening up in the community created new patient inflow. Some studies incurred their first patients from the DCT.” 

Through City of Hope’s Division of Health Equities, the staff provides prostate cancer education and free screenings to Black and Latino men in the greater Los Angeles area. In addition to conducting outreach, they also discuss City of Hope’s current clinical trials. “We cast a wide net, and through our community outreach events, we [are able to] build trust with patients,” Raborar said. “We also educate our community practice site doctors on our clinical trials so they can refer a wide range of patients to our trials.” 

Although DCTs are gaining in popularity, Raborar says they are not without their own challenges. “The 3 biggest challenges are securing the right infrastructure and technology, ensuring sufficient study target population and diversity at sites, and coordinating financial and insurance concerns in conjunction with study requirements,” Raborar said. “Managing all 3 challenges is essential for patient safety, the protection of study participants’ rights, proper performance of study requirements, and minimizing its financial burden.” 

For oncology nurses, Raborar noted that DCTs represent an interesting job opportunity for those who want to pursue a career in research. “Depending on each site’s requirements, a clinical research nurse should have good assessment skills, exceptional communication and teaching [abilities], and 2 years’ experience in oncology or research nursing, but they do not need to have a background in both oncology and research,” he said. 

To work in DCTs, Abraham said nurses should also have experience working with diverse patient populations while maintaining cultural competency. 

“This requires nurses to work well with non-English speaking patients by using interpreter services by phone,” she said. 

In return, Abraham believes DCTs present oncology nurses with the opportunity to move beyond the bedside and work on research that has the potential to make a significant impact on patient care. In addition to giving nurses the opportunity to improve the telehealth experience for patients and health care workers alike, it allows the nurses themselves more variety in their work. 

“Decentralizing clinical trials allows nurses to have more diverse opportunities,” she said. 

Supporting decentralized trial approaches. Clinical Trials Transformation Initiative. Accessed March 15, 2022. https://bit.ly/3CN7DBL

van Dorn A. COVID-19 and readjusting clinical trials.

.2020;396(10250):523-524. doi:10.1016/S0140-6736(20)31787-6

Evolving technology and adaptability allow for a more patient-centric approach to clinical trials; however, there are some limitations.

Decentralized Clinical Trials: Bringing Care Directly to Patients

When the COVID-19 pandemic began, oncology units faced a daunting challenge. They had to adapt to providing cancer treatments without sacrificing the health and safety of immunocompromised patients, their families, and oncology staff. Today, as COVID-19 persists and new variants emerge, oncology units have implemented a variety of safety measures that allow them to coexist with the coronavirus, while ensuring the continuum of cancer care.

“Post pandemic, medical care will never be the same,” said Anna L. Rodriguez, MSN, MHA, RN, OCN, NEA-BC, chief nursing officer and vice president of nursing and patient care services at Fox Chase Cancer Center in Philadelphia, Pennsylvania. "The coronavirus pandemic has highlighted the ability of hospitals to quickly adapt their care models in response to external factors, to ensure a safe environment for staff and patients,” she said.

Rodriguez expects many of the rigorous safeguards implemented to protect patients and staff to remain in place long after the pandemic ends. As one example, she points to the use of technology platforms for virtual staff meetings and patient visits. “Having this flexibility has allowed health care organizations to maintain business operations while allowing for required social distancing as the current conditions dictate, to protect our patients and workforce,” she said. “I believe the efficiencies, work-life balance, and accessibility offered by these platforms will ensure their continued use.”

At City of Hope, a leading cancer research and treatment hospital near Los Angeles, California, use of the hospital’s telehealth platform skyrocketed during the pandemic. The Hope Virtual platform offered a way for doctors and nurses to safely communicate with patients.

Susan J. Brown, PhD, RN, senior vice president of patient care services and chief nursing officer at City of Hope, believes that telehealth has replaced many routine oncology appointments by allowing oncology team members to communicate with patients over a secure video platform via smartphone, tablet, or computer.

“Telehealth is used when patients, or someone they are in close contact with, are symptomatic with COVID-19 or the flu, when they have transportation issues, or when they would like a family member to join the appointment from another location,” Brown said. “Prior to the pandemic, we conducted approximately 10% of visits using telehealth. Today, approximately 35% to 40% of patient visits are conducted using telehealth.”

Brown said nurses can safely evaluate patients with cancer using telehealth; they can also manage the adverse effects of treatment, review laboratory and scan results, answer questions, and include family members in the patient’s care. City of Hope plans to expand their telehealth program to include remote chemotherapy support, telegenetics, and much more.

In February 2020, UC Davis Medical Center in Sacramento, California, reported the first case of community transmission of COVID-19 in the United States. This led to important changes in the Centers for Disease Control and Prevention (CDC) guidelines for novel coronavirus testing.

Devon Trower, BSN, RN, OCN, a nurse manager in adult infusion at UC Davis Comprehensive Cancer Center, said the entire medical center quickly implemented safety procedures. These included limiting the number of visitors, screening patients and employees for infection daily, maintaining social distancing, mandating masks, and providing ample sanitizer and handwashing facilities.

If an oncology patient tests positive for COVID-19 but is asymptomatic, their doctor will balance the risk of postponing their treatment with their diagnosis. If the patient is exhibiting symptoms, the doctor will determine whether they have recovered enough to undergo treatment.

“We now have several isolation rooms that use negative air pressure where we can administer medications intravenously to oncology patients who have tested positive for COVID-19,” Trower said.

Since the beginning of the pandemic, the oncology unit has been working closely with the hospital’s infection control staff to safeguard the health of patients and oncology team members. “The pandemic has given us all a heightened awareness of infection prevention,” Trower noted. “While we always wore PPE [personal protective equipment] when administering chemo[therapy], our staff now wears N95 or surgical masks all the time.”

Findings from a survey released in March 2021 by the American Society for Radiation Oncology showed that enhanced safety protocols remained widespread at radiation therapy clinics. Masking for patients and staff (99%), social distancing in the clinic (100%), and screening patients and staff for COVID-19 exposure (95%) were nearly universal. Increased sterilization (93%), face shields for staff during procedures (80%), and no-visitor policies (73%) were also common.

At the beginning of the pandemic,according to Brown, City of Hope quickly began implementing new screening protocols and safety measures recommended by the CDC, as well as guidelines offered by the Oncology Nursing Society. As PPE was only available in limited quantities, City of Hope changed their policy to preserve supplies.

“Staff used to don a mask when entering a hematology patient’s room and throw it away when exiting; it wasn’t unusual to go through 50 to 60 masks in 1 day,” Brown said. “We changed our policy to 1 mask per employee per day and haven’t experienced any increases in infection.”

In fact, in the midst of the pandemic, City of Hope was awarded the prestigious Magnet recognition from the American Nurses Credentialing Center, a distinction bestowed on only 9% of hospitals in the United States. Brown says the pandemic also underscored the importance of supporting and celebrating nursing staff, while ensuring their safety.

“When we presented our nurses with DAISY awards over the past 2 years, we practiced social distancing by decorating golf carts and parading the award winners around our campus,” she explained. “It’s been so well received that we plan to continue the tradition post COVID-19.”

Brown noted that one safety protocol that will probably be altered is the hospital’s visitor policy.

“Inpatients can only have 1 visitor at a time and each visitor must provide proof of full COVID-19 vaccination or a negative [result from a] COVID-19 test taken within the prior 72 hours of each visit,” she said. “Visitors must also be masked at all times.”

Although the practice safeguards the health of patients and staff, Brown noted
the policy has been hard for both nurses and patients.

“Patients miss having their families present and our nurses have realized how much families not only help with patient morale, but also assisting with simple things such as bringing their loved one a glass of water,” Brown said. “Patients have been largely communicating with their extended family via iPads or smartphones.”

Visitor policies have also changed in the outpatient setting. Brown says trained City of Hope escorts meet patients in the lobby and accompany them to infusion and radiation treatments.

“At our main campus, 1 visitor may accompany adult patients and 2 visitors for those under 18 when they meet a physician for the first time and for presurgery anesthesia testing, before and after surgery, and urgent care visits,” she said.


 To ensure patients test negative for the disease prior to undergoing surgery, City of Hope also implemented drive-through COVID-19 testing to screen patients.

“If they test positive, the surgery might still be conducted if deemed urgent,” Brown says. “If not, the surgery will be postponed.”

Rebecca Farrell, MSN, RN, clinical nurse manager of ambulatory care at Fox Chase Cancer Center, added that interventions to screen and prescreen patients for COVID-19 symptoms prior to their treatments may also become the new normal. These screening tests evaluate for symptoms such as a new or worsening cough within the past 14 days, shortness of breath, fever, and possible COVID-19 exposure.

“Prescreenings and pretesting might become part of our oncology playbook,” she said. “We’ve also seen how team-based nursing care models can be effectively used to care for critical patients during the COVID-19 surge, with nursing staff cross-training in various specialties and departments.”

Some nurses see safety measures such as increased masking and hand-washing stations throughout the hospital remaining.

“While we’ve always been concerned about infection prevention, we’ve seen how these enhanced safety measures taken to prevent the spread of COVID-19 have also squashed the transmission of seasonal influenza and respiratory viruses and maximized safety for our patients,” said Trower.

Results of a national physician survey by the American Society for Radiation Oncology (ASTRO). ASTRO. Accessed January 10, 2022. https://bit.ly/332MTZm

The COVID-19 pandemic has affected oncology practice in many ways. What will safe treating look like moving forward?

Shifts in Oncology: Safely Treating Patients in a Post–COVID-19 World

Although surgery is an option for some patients with lung cancer, unmet needs related to postoperative recovery can negatively affect a patient’s quality of life and increase the family caregiver’s burden, explained Virginia Sun, PhD, MSN, RN, associate professor in the Division of Nursing Research and Education at City of Hope, a cancer research and treatment organization near Los Angeles, California.

To address these needs, Sun and her colleague, Jae Kim, MD, assistant professor and chief of the Division of Thoracic Surgery at City of Hope, launched a 5-year study in 2018 focusing on how to best support family care-givers after a loved one has undergone surgery for lung cancer. Sun and Kim developed the study after working on a previous research project that showed although standard intervention and education methods, such as videos and printed materials, were helpful for patients, they weren’t as helpful for caregivers.

Sun’s study examines the differences between a caregiver control arm that receives traditional education materials and one that receives these materials as well as face-to-face sessions with an oncology nurse to help address specific patient and caregiver needs and problems.

Although some oncology centers have nurse navigators that work with family caregivers, that isn’t the case with all medical centers. Sun said it’s important for all oncology nurses to ensure good outcomes for patients with lung cancer by ensuring their caregivers are well prepared.

With an increase in minimally invasive surgery for lung cancer, the length of hospital stays has decreased, with patients now typically spending 2 to 3 days in the hospital after minimally invasive surgery. Although many patients prefer to recover at home, Sun said when caregivers aren’t adequately prepared, patients with lung cancer can experience complications that result in being readmitted to the hospital.

Caregiver preparation often consists of videos and print materials developed by groups, such as the American Society of Clinical Oncology. Although those resources are informative, caregivers often need more personalized support, Sun said.

“Oncology nurses can help families and family caregivers by simply asking them about their needs and how they are doing,” she said. “Many family caregivers report they’ve never been asked about their needs. A simple question can lead to improved assessment, provision of relevant information, and referrals for support to families.” Sun recommended that oncology nurses determine who will be the primary family caregivers for a patient, and whether there will be more than 1 family member taking on this role, and assess their knowledge needs and caregiving preparedness. “Most family members are interested in how they can better prepare for the day of surgery and the recovery process, and what to expect during these times,” Sun said. “If possible, nurses can think about how we can best use the preoperative period to educate and prepare families for what’s ahead and to also encourage care- givers to think about their own self-care plan, as many family caregivers may be coping with their own illness.”

Shayne Cardozo, RN, nurse coordinator for the thoracic surgery and oncology clinic at the University of California, San Francisco Health, works with many patients with lung cancer and their family caregivers and strives to give them the information and support they need after they’re discharged from the hospital. “The quality of life for these patients with lung cancer should be the same or better after surgery,” Cardozo said. “We stress an active recovery where, after receiving approval from their doctor, they engage in walking and deep breathing exercises. The more they can do, the faster they will recover.”

In addition, Cardozo demonstrates how to properly use devices, such as an incentive spirometer, so patients can expand their lungs to help them breathe more deeply and fully. Doing this, as well as regular breathing and coughing exercises, also helps patients to keep their lungs active during their recovery and prevents complications, such as pneumonia.

Cardozo also works with patients to develop a personal plan to treat postsurgery pain and address common adverse events, such as constipation caused by pain medications. “At-home patients tend to fall behind on their pain medications,” she said. “Many are fearful they will become addicted to pain medications, so it’s important to let them know prescription opioids are generally safe when prescribed by their doctor and taken for a short period of time.”

Cardozo sees the role of a family caregiver as that of a personal trainer who offers encouragement and support to their loved ones by ensuring they follow postoperative instructions, take their medications, and practice breathing exercises. She also advises care- givers to call her in the event they have questions or if their family member experiences a fever, discharge from the incision site, chest pain, or shortness of breath.

Sometimes the most important tool that oncology nurses can provide caregivers is reassurance. “Caregivers need to feel empowered that they are part of the health care team and have the tools and answers in place to care for their loved one,” Cardozo said. 

Prieto R, Ferrell B, Kim JY, Sun V. Self-management coaching: promoting postoperative recovery and caregiving preparedness for patients with lung cancer and their family caregivers. 

. 2021;25(3):290-296. doi:10.1188/21.CJON.290-296

As minimally invasive surgery for lung cancer increases in popularity, more patients are recovering at home, expanding the need for personalized caregiver education.

The Oncology Nurse’s Role in Preparing Patients and Caregivers for Postoperative Recovery

Three years ago, LaToya Lewis, EdD-CI, MSN, RN, and her colleagues embarked on a study to evaluate horizontal violence and bullying among nurses who work in oncology inpatient units and outpatient services at an academic medical center in South Florida.

Although bullying and incivility in nursing are not new issues, they are a pervasive problem. A 2017 survey found that 45% of nurses had been verbally harassed or bullied by other nurses, and 41% had been bullied by managers or administrators. And although previous studies have examined how bullying affects all nurse specialties, Lewis, an assistant professor of clinical at the University of Miami School of Nursing and Health Studies in Florida, and her colleagues specifically looked at how bullying affected oncology nurses.

“Through our survey, we found that bullying was more prevalent in the outpatient oncology clinic, although nurses who worked in both inpatient and outpatient settings experienced conflict,” Lewis said.

Many of the nurses surveyed experienced horizontal or lateral violence, which Lewis described as nonphysical, hostile, aggressive, or harmful behavior toward a coworker.

“Horizontal violence is characterized by emotional, verbal, and defiant behaviors such as snide remarks, public humiliation, talking down to a colleague, mocking, harassment, and intimidation,” Lewis said. “Physical violence can involve pushing, grabbing, or invading a coworker’s physical space.”

All forms of workplace bullying can take their toll on nurses and lead to reduced self-esteem, anxiety, depression, and even physical symptoms such as insomnia and gastrointestinal issues.

“Many nurses reported feeling hesitant to report the bullying because they thought it would only make the situation worse,” Lewis explained. “The effects of horizontal violence and bullying not only negatively impact a nurse’s professional quality of life, they also affect nursing retention and employee and patient satisfaction.”

When the survey was completed, Lewis and her colleagues reported the findings to hospital administrators, who were surprised by the results.

“The administration believed they had a zero tolerance for workplace bullying, and they weren’t aware of some of the incidents,” Lewis said. “Many nurses suffered in silence rather than voice their concerns because they had seen others report horizontal violence, only to have the problems persist.”

As a result, the medical center began incorporating education about appropriate professional behaviors that are consistent with the hospital’s code of conduct into orientations for new hires, Lewis said. Administrators also worked to engage midlevel nurses and other oncology staff to advocate for a culture of kindness and civility.

“In addition to establishing programs that promote awareness and discuss how to address workplace bullying, the medical center also put a renewed emphasis on positive behavior and the contributions of their nursing staff through programs such as the DAISY Foundation awards,” Lewis said. “Nursing leaders can create a positive work environment that serves to thwart workplace bullying.”

Judith Vessey, PhD, MBA, FAAN, the Lelia Holden Carroll Professor in Nursing at Boston College’s Connell School of Nursing in Massachusetts, also has conducted research on horizontal violence and bullying among nurses.

In her study “Bullying of Staff Registered Nurses in the Workplace,”

 which was published in 2009, Vessey and her colleagues found that perpetrators of workplace bullying included senior nurses, charge nurses,
nurse managers, and physicians who publicly humiliated, isolated, excluded, or excessively criticized staff nurses. According to Vessey, stress levels were reported as moderate to severe among nurses. The lack of an
available workplace solution meant that support was found primarily among family, colleagues, and friends.

“It’s important to begin by looking at what’s happening at the unit level, how good is the leadership, and [whether] nurses see themselves as part of a team and have a sense of psychological safety,” Vessey said. “Unfortunately, some nurses work in an unhealthy environment where they don’t feel safe speaking up.”

Vessey explained that psychological safety is when an employee can speak up without risking embarrassment, humiliation, or punishment.

“Psychological safety creates a climate where nurses can do their best work,” Vessey said. “Without psychological safety, a nurse who is being bullied won’t come forward and the bad behavior will continue.”

Over time, Vessey says workplace incivility and bullying can lead to low employee morale, increased absenteeism, and high turnover.

“It’s important to create an environment where nurses want to work and incivility and horizontal violence are not tolerated,” Vessey says. “Unit-based leaders may be aware of bullying but unsure how to address it. These leaders can start by creating opportunities for dialogue between staff members and encouraging staff feedback.”

In addition to being patient advocates, nurses also need to master being advocates for their colleagues and for themselves. Conflict resolution training can teach nurses the skills they need to diffuse workplace bullying scenarios, whereas nurse mentorship programs can foster teamwork, combat bullying, and increase retention among nurses who are just beginning their careers in oncology. 

When Patients and Families Become Violent

In addition to cases of horizontal violence among nurses, cases of workplace violence involving patients and family members are also on the rise. In November 2020, National Nurses United surveyed 15,000 registered nurses around the country and found that 20% reported an increase in workplace violence. Among the reasons for the increase, the survey results showed, were decreased staffing levels, visitor restrictions, and mandatory masking.

Typically, nurses are not taught how to handle violence while in nursing school, but, fortunately, there are many free resources available to help nurses learn how to safeguard themselves.

The Crisis Prevention Institute offers programs in nonviolent crisis intervention, verbal intervention, dementia care, conflict prevention techniques, and more. Available online courses teach important deescalation techniques and risk assessment.

The Occupational Safety and Health Administration (OSHA) has published a guidebook for nurses and other health professionals who want to learn strategies for preventing workplace violence.

National Nurses United is offering an online class: “Violence on the Job: Prevention and Advocacy for Nurses.” The hourlong class is free during the pandemic. The 1 continuing-education unit course discusses effective workplace violence prevention measures and how nurses can advocate for violence prevention at their workplace.

The Centers for Disease Control and Prevention offers “Workplace Violence Prevention for Nurses,” a free interactive online course that illustrates how to recognize warning signs of violence in individuals, how to implement a workplace violence prevention program, and more.

The American Nurses Association (ANA) has a free downloadable #EndNurseAbuse resource guide that encourages nurses to send an email to their legislators to end violence against nurses, shows how to report all abuses, and offers strategies nurses can use to protect themselves on the job.

At this time, the ANA notes that OSHA doesn’t require employers to implement workplace violence prevention programs, but it provides voluntary guidelines and may cite employers for failing to provide a workplace free from recognized serious hazards. The ANA notes that many states have laws designating penalties for assaults that include nurses and other health professionals.

In addition, the American Association of Critical Care Nurses has a free downloadable guide, “Standards for Establishing and Sustaining Healthy Work Environments,” which discusses skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

Bassett Healthcare Network in New York has given nurses and other staff a wearable emergency alert system that allows them to discreetly call coworkers or security in the event of an emergency. The Strongline Staff Safety System uses Bluetooth technology and attaches to a nurse’s badge.

All nurses should feel safe in their workplace and have the tools and support needed to combat bullying, violence, incivility, and toxic environments.

Anglade, D., Saber, D., Gattamorta, K., & Piehl, D. (2019). 

Evaluating horizontal violence and bullying in the nursing workforce of an oncology academic medical center,

Portrait of a Modern Nurse Survey Finds Half of Nurses Consider Leaving the Profession,

3. Vessey, J., DeMarco, Rosanna. Gaffney, Donna, Budin, Wendy (2009).

Bullying of staff registered nurses in the workplace: a preliminary study for developing personal and organizational strategies for the transformation of hostile to healthy workplace environment

National Nurse Survey Exposes Hospitals’ Knowing Failure to Prepare for a COVID-19 Surge During Flu Season,

 nationalnursesunited.org (accessed July 2021).

Creating a Safe Space: Preventing Bullying and Violence Among Oncology Nurses

Receiving a diagnosis of either cancer or diabetes can be life changing, but for patients with both diseases, it can prove especially challenging. Research shows that 8% to 18% of individuals living with cancer also have diabetes

 and that treating both simultaneously makes the process more complicated for nurses and their patients. The American Diabetes Association states, “Cancer and diabetes are diagnosed within the same individual more frequently than would be expected by chance.”

“As our population ages and people are living longer, we can expect to see the number of patients receiving diagnoses of both cancer and diabetes increase,” said Jill Olausson, PhD, RN, CDE, an assistant professor and assistant chair, Master’s of Nursing in Healthcare Administration, at Azusa Pacific University in California. Olausson is part of the Glycemic Control for Patients with Cancer Nursing Task Force, a group of nurses committed with improving health-related outcomes and the care of oncology patients with diabetes.


People with diabetes (primarily type 2) are at a higher risk of developing certain cancers than those without diabetes, as the diseases share risk factors such as aging, obesity, poor nutrition, and physical inactivity.

 Olausson notes that predni- sone and other steroids used to treat or prevent nausea, or as a component of cancer treatment, can also cause a spike in blood sugars and compound the management of diabetes. Patients who receive steroids should be closely monitored with premeal glucose testing and additional testing 2 hours after a meal.

Caring for Patients With Diabetes and Cancer


“Cancer patients with diabetes are at an increased risk for developing infections, being hospitalized, and requiring chemotherapy reductions or stoppages,” says Denise Hershey, PhD, RN, FNPBC, an associate professor at Michigan State University’s College of Nursing in East Lansing. Unfortunately, Hershey says there is not sufficient evidence on the best way to manage diabetes in patients with cancer. She believes in looking at each patient’s overall health rather than focusing solely on their cancer.

“It’s important for oncology nurses to work with diabetes educators, nutritionists, and others to form a comprehensive care plan for patients,” Hershey says. “Nurses can assess how well a patient’s diabetes is being controlled by looking at the patient’s A1C [glycated hemoglobin] at the time of their initial cancer diagnosis and seeing if they now appear to [have] hyperglycemia.”

Care plans can help patients balance their glucose levels with their cancer treatment after discharge. “It’s important to look at barriers patients may be facing, such as not being able to afford the high cost of diabetic test strips,” Hershey says. “Rather than just advising them to exercise, letting them know that regular exercise can help stabilize blood sugar levels while also lowering the chances of cancer adverse events [AEs] such as fatigue and neuropathy.”

Recent research shows that blood glucose above 180 increases the risk of complications in hospitalized patients.

 Hershey says oncology patients sometimes make the mistake of prioritizing their cancer diagnosis over their diabetes.

“We know glycemic control plays a role in the overall health quality of life for oncology patients, level of symptom severity, and can also affect overall survival,” Hershey says. “Educating patients about how to self-manage their glycemic control is just as important as treating their cancer, in order to achieve the best outcomes.”

Oncology nurses also need to be aware of changes in a patient’s condition; many
cancer symptoms are also signs of diabetes. Uncontrolled high blood sugar can lead to dehydration, but extreme thirst can also be an AE of chemotherapy. Both diabetes and cancer complications can cause or worsen neuropathy. “We need to look at cancer survivorship and ensure these patients receive optimal diabetes care and achieve their glycemic targets,” Hershey says.

Nurses need to know these key concepts when treating patients who have diagnoses of both cancer and diabetes.

Dual Diagnosis: Nurses Face Challenges in Caring for Patients With Both Cancer and Diabetes

Gretchen McNally, PhD, ANP-BC, AOCNP, microspecializes in immunodeficiency- related cancers. - Photo by Jodi Miller

The current coronavirus disease 2019 (COVID-19) pandemic is not the first instance where nurses have found themselves caring for patients with a mysterious and unpredictable disease. In the early 1980s, hospitals around the world began to see patients, primarily young gay men, presenting with severely compromised immune systems, rare cases of pneumonia, and aggressive cases of Kaposi sarcoma, a cancer that causes lesions in the soft tissues.

At the time, clinicians and investigators had no idea what caused the outbreak, how the virus was transmitted, or how it should be treated. Some referred to the disease as the "gay cancer" or "gay-related immune deficiency." It wasn’t until 1983 that HIV was identified as the cause of AIDS and investigators recognized that HIV could affect anyone.

Today, 40 years after the beginning of the HIV/AIDS outbreak, oncology nurses continue to care for patients with AIDS-related and nondefining AIDS cancers.

Research shows that individuals with HIV/AIDS are at a higher risk of getting certain types of cancer because they have a severely weakened immune system.

Although advancements in antiretroviral medicines now allow those with HIV/AIDS to live longer lives, many of these patients continue to face barriers to cancer care and, in some cases, a stigma that can negatively affect their health outcomes.

Gretchen McNally, PhD, ANP-BC, AOCNP, a nurse practitioner in hematology at The OSUCCC — James in Columbus, Ohio, microspecializes in immunodeficiency-related cancers and says nurses play a critical role in ensuring that patients fighting both HIV/AIDS and cancer receive inclusive services and care.

HOW AIDS-DEFINING AND NON—AIDSDEFINING CANCERS DIFFER

McNally notes that when patients with HIV develop certain types of cancer, their disease has progressed to AIDS.

Gretchen McNally, PhD, ANP-BC, AOCNP, microspecializes in immunodeficiency-related cancers. “These cancers are known as AIDS-defining cancers and include Kaposi sarcoma, aggressive forms of non-Hodgkin lymphoma, and cervical cancer,” she says. “Some patients with HIV are also more likely to develop non—AIDSdefining forms of cancer, but these forms of cancer don’t indicate that their condition has progressed to AIDS.” McNally adds that non–AIDS-defining cancers include head and neck cancer, anal cancer, lung cancer, liver cancer, and Hodgkin lymphoma.

“While AIDS-defining cancers have decreased with effective combination antiretroviral therapy, non—AIDS-defining cancers have increased and account for more than half of all HIV malignancies,” McNally says. “Because people with HIV have a compromised immune system, they’re also more at risk of viruses that can lead to cancer such as the human papillomaviruses [HPV].”

HPV is linked to cancers of the penis, anus, vagina, vulva, mouth, and throat. Although advances in antiretroviral therapy have resulted in HIV being treated as a chronic health condition, McNally says because those with HIV/AIDS are living longer, their increased life span also increases their risk of developing cancer. Approximately 1.2 million individuals in the United States are currently living with HIV.2

Although it’s been more than 40 years since health care professionals first treated cases of HIV and AIDS, stigma and discrimination still persist in health care. In 2018, the Centers for Disease Control and Prevention released a review analyzing HIV-related stigma by health care providers.3 Among their findings, investigators reported that stigma can be manifested through inadvertent behaviors and beliefs, including homophobia, transphobia, racism, and negative views of people who use drugs.

“The solution to reducing any stigma is education,” says McNally, who has seen the stigma of HIV transcend to both health care providers and patients.

“Some patients suffer from depression because they believe an HIV diagnosis was their fault,” McNally says.

To fully understand the needs of their patients with HIV/AIDS and help reduce the stigma, McNally says, health care providers must expand their knowledge on issues such as sexual orientation, gender identity, and racial disparities. Although the United States has a policy goal of eradicating HIV by 2030, disparities in HIV care continue to exist.

“We’ve been seeing more cancers, including Hodgkin lymphoma and lung cancer, in younger patients,” McNally says. Statistics show that lung cancer is already a leading cause of death in those with HIV, particularly among individuals who smoke, and it is projected to become the most common cause of cancer in individuals with HIV by 2030 if current trends continue.

To combat rising rates and help patients with HIV reduce their cancer risk, McNally says, health care providers should emphasize prevention and address risk factors. Nurses can do the following:

• Recommend smoking cessation programs to those with HIV to possibly reduce their risk of lung cancer and other tobacco-related diseases.

• Educate patients on the importance of regularly taking their HIV medications. Maintaining a higher CD4+ T-cell count can reduce the risk of AIDS-related cancers.

• Encourage patients to get the HPV vaccine. “The vaccine has been shown to prevent anal and cervical cancers,” McNally says.

TREATMENT CONSIDERATIONS FOR PATIENTS WITH HIV/AIDS AND CANCER

In 2018, a team of health care providers gathered to create new National Comprehensive Cancer Network (NCCN) treatment guidelines to ensure individuals with HIV who also have cancer receive safe and necessary treatment.

Piera Wong, MS, RN, AOCNS, an oncology clinical nurse specialist at Zuckerberg San Francisco General Hospital and Trauma Center and an assistant clinical professor at the University of California, San Francisco, says nurses and physicians at her facility continue to follow these guidelines.

“We have a board-certified oncology pharmacist review all proposed cancer therapy and antiretroviral medications to ensure there aren’t any drug[-drug] interactions,” Wong says. “We also follow patients closely from diagnosis to treatment through survivorship.”

Wong stresses that nurses should also address preventive care with patients, encouraging patients to adhere to annual screenings such as colonoscopies, pap smears, and skin cancer checks.

Ensuring that patients with HIV have access to appropriate cancer care is also a priority. One recent study found that individuals living with HIV have lower rates of cancer treatment, which may contribute to worse survival rates in certain cancers. The study also found that barriers to care sometimes include low income, no insurance or underinsurance, employment instability, lack of social support, and HIV-related stigmas.

Yet even with appropriate treatment, Wong says, some patients with both HIV and cancer experience poor outcomes. A study published in 

 found that outcomes for patients over age 65 with HIV and cancer were significantly poorer than patients who were the same age and HIV negative. The study suggested the higher mortality risk was because of immune suppression.

“This is one reason why it’s so important to allow [patients with] HIV to enroll in clinical trials,” McNally says.

Although patients with HIV were excluded from cancer clinical trials in the past, that appears to be changing. Last year, a study conducted at Fred Hutchinson Cancer Center in Seattle, Washington, found that patients with HIV and cancer might be successfully treated with the immunotherapy drug pembrolizumab (Keytruda).

Last year, the National Cancer Institute issued new guidelines for patients with HIV and clinical cancer trials. The guidelines state that individuals who are HIV positive should not be arbitrarily excluded from clinical trials.

The guidelines state that “with effective antiretroviral therapy, individuals with undetectable HIV viral loads by standard clinical assays should generally be considered eligible for a study should they meet all the other eligibility criteria of the trial.”8 “The hope is these new guidelines will ensure all [patients with] cancer who are HIV positive can achieve the same outcomes as those without HIV,” McNally says.

Nurses can take several steps &mdash; from stigma reduction to treatment considerations &mdash; to improve the care of patients with cancer who have HIV or AIDS.

Break Down Barriers to Cancer Care for Patients With HIV/AIDS

Delaware has the highest prevalence of triple-negative breast cancer (TNBC), an aggressive form of the disease that disproportionately affects women in the African American and Hispanic communities. Yet despite its high prevalence, African American and Hispanic women make up a small portion of women seeking genetic testing for the disease.

Nora Katurakes, MSN, RN, OCN, manager of Community Health Outreach and Education at Christiana Care’s Helen F. Graham Cancer Center and Research Institute’s Community Health Outreach and Education Program in Newark, Delaware, hopes to change that through a community outreach program called, “The Story of BRENDA.”

The BRENDA acronym stands for Breastfeed, Reduce consumption of alcoholic and sugary beverages, Exercise 2 ½ hours each week, Nutritious foods, Do not smoke, and Achieve a healthy body weight.

Katurakes is one of many oncology nurses across the country who works as part of a team that goes beyond caring for patients with cancer in a hospital or outpatient setting.

Oncology nurses play a crucial role in educating the public about cancer risk and prevention.

Linda Childers