1. Problem/ Purpose Statement
Increasing Confidence and Competence when a Chemotherapy Spill Occurs: A Quality Improvement Project
Teaching Culturally Competent Care to Healthcare Providers in Practice
Bethany Rolfe Witham, DNP, FNP-BC
Seattle Pacific University, Seattle, WA
Coreen Klein, BSN, RN
Background
Despite HD engineering controls, administrative controls, and personal protective equipment (PPE), chemotherapy spills are an ongoing issue in the oncology setting. 
10 to 25% of nurses reported chemotherapy spills within the year1,2,3. 
When a spill occurs, issues arise regarding adherence to hospital PPE protocol.  Across multiple studies, adherence was low, leading to safety risks 1,3,4,5.
Adherence is low due to multiple barriers, including: Lack of equipment, lack of education, lack of understanding, lack of hospital support , and poor staff-to-patient ratios1,2,3,4,5.
Barriers for chemotherapy safe handling could be partially mitigated through an improved staff training program2,3,5,6.
Results
Implications
Washington state law outlines a necessary eight-hour training in order to respond to a chemotherapy spill— the required training did not correlate to competence or confidence during the simulated spill scenario, which implies that additional training is necessary in order to maintain nurse and patient safety.
Didactic training may have been enough for foundational chemotherapy spill knowledge but hands-on simulation is necessary to ensure competence and safety.
Organizations should not correlate prior spill experience, nurse confidence, or prior work experience to competent performance.
Ongoing educational efforts must be prioritized by hospitals in order to maintain staff and patient safety in the event of a chemotherapy spill.
Sustainability
Run second simulation cycle before increasing nurse participation: include environmental service staff and Code Orange Team.
Measurement tools and simulation outline provided to the hospital for ongoing PDSA cycle completion.
Problem/ Purpose Statement
Problem: While hospital protocols and education exist for the management of chemotherapy spills, evidence shows that nurses inconsistently adhere to hospital spill protocols, and are ill-trained to safely manage HD spills1,2.  Therefore, a current practice gap exists between chemotherapy spill education, and nurse implementation of education into practice.
Purpose: Increase oncology nurse competence and confidence when a chemotherapy spill occurs through didactic and simulation-based education interventions.
Survey:
The mean confidence of all pre-survey questions was “somewhat confident” (M= 3.17).
Three participants showed a decrease in confidence after the simulation (-0.143, , and , respectively).
Participant 4 showed the only statistically significant confidence increase (p= 0.005).
Qualitative data showed 2 themes: safety and ongoing simulation training.
Observation:
Nurses did not keep themselves or the patient safe during simulation.
Touched outside of hazardous drug (HD) bag with dirty gloves.
Exposed patient to chemotherapy an extended time.
Needed prompting during several steps.
References
Boiano, J. M., Steege, A. L., & Sweeney, M. H. (2014). Adherence to safe handling guidelines by health care workers who administer antineoplastic drugs. Journal of Occupational and Environmental Hygiene, 11(11),
Friese, C. R., Himes-Ferris, L., Frasier, M. N., McCullagh, M. C., & Griggs, J. J. (2012). Structures and processes of care in ambulatory oncology settings and nurse-reported exposure to chemotherapy. BMJ Quality and Safety, 21, doi: /bmjqs
He, B. Y., Mendelsohn-Victor, K., McCullagh, M. C., & Friese, C. R. (2017, January). Personal protective equipment use and hazardous drug spills among ambulatory oncology nurses: Results from a mailed survey. Oncology nursing forum,44(1), doi: /17.ONF.60-65
Polovich, M., & Clark, P. C. (2012, May). Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. Oncology Nursing Forum, 39(3),
Friese, C. R., McArdle, C., Zhau, T., Sun, D., Spasojevic, I., Polovich, M., & McCullagh, M. C. (2015). Antineoplastic drug exposure in an ambulatory setting: a pilot study. Cancer nursing, 38(2), 111.
DeMacedo, S. (2016) Educating oncology nurses with simulation: A chemotherapy spill, improving oncology nurses knowledge, competence, and confidence. LAP LAMBERT Academic Publishing.
Methods
Discussion
The single cycle of the QI initiative failed to increase nurse confidence when a chemotherapy spill occurred.
Participants with the highest levels of pre-survey scores showed an overall decreased confidence level. The less-confident participants improved from pre to post-survey.
The pre-test confidence scores and simulation observations suggest that high levels of confidence may not correlate with safe practice.
While the didactic education and simulation failed to increase confidence, nurses universally reported that simulation was useful, and needed to be repeated for further learning.
Tools:
Nurse confidence: Pre and post mixed-method survey.
Nurse competence: Observation checklist.