Date of Award


Scholarly Projects

Projects: SPU Access Only

Degree Name

Doctor of Nursing Practice (DNP)



Faculty Chair

Bomin Shim

Faculty Reader

Bomin Shim

Executive Summary

Executive Summary

Title: Improving Hazardous Drug Knowledge and Personal Protective Equipment (PPE) Use in Non-Oncology Nurses in Primary Care Settings

Background and Significance: Eight million healthcare workers in the United States (U.S.) are potentially exposed to hazardous drugs each year (The National Institute for Occupational Safety and Health [NIOSH], 2020). In 2016, NIOSH published safe handling guidelines and an expanded list of hazardous drugs, many of which are administered in non-oncology settings (NIOSH, 2016). Yet most research and educational interventions for preventing hazardous drug exposures only target oncology nurses (Occupational Safety and Health Administration [OSHA], 2016). Occupational exposures to hazardous drugs can cause acute toxicities and long-term health effects, including cancer and reproductive abnormalities (Elshaer, 2017; Nassan et al., 2021; NIOSH, 2019; Roussel et al., 2019).

Problem and Purpose Statement: Only one study has been found to date targeting hazardous drug education for non-oncology nurses (Wang et al., 2022). The implication of this gap in the literature is that a large group of nurses are unknowingly exposed to hazardous drugs in the workplace and likely not educated on the risks of hazardous drugs and how to protect themselves (NIOSH, 2020). This quality improvement (QI) project aimed to increase hazardous drug handling knowledge and PPE usage in non-oncology nurses in primary care clinics.

Methods: This QI project was a pre-/post-intervention study design. The participants were RNs and LPNs working in injection room clinics that administer hazardous drugs. The intervention consisted of a 30-minute multimodal evidence-based educational program on hazardous drug safe handling. A pre- and post-survey instrument measuring hazardous drug exposure knowledge and self-reported PPE use was administered online through Survey Monkey using the Revised Hazardous Drug Handling Questionnaire (Polovich & Clark, 2012). Direct observations of nurses’ PPE use during hazardous drug administration were also conducted pre- and post-intervention. The survey and observations occurred one month before the intervention and again one month after the intervention. The mean knowledge and self-reported PPE usage scores were calculated pre- and post-intervention. To determine the statistical significance of the difference in mean scores, an independent two sample t-test assuming unequal variances was used with alpha selected at 0.05.

Results/Outcomes: The project successfully developed hazardous drug safe handling education that improved hazardous drug exposure knowledge in non-oncology nurses. There was a significant increase in hazardous drug knowledge from pre-intervention (M = 10.53, SD = 1.19) to post-intervention (M = 11.57, SD = 0.53); t (20) = -2.83, p = .01. However, the increase in knowledge did not translate into increased PPE usage. There was not a significant difference in PPE use during hazardous drug administration from pre-intervention (M = 3.11, SD = 1.57) to post-intervention (M = 3.47, SD = 2.13); t(4) = -1.13, p = .32 or during hazardous drug disposal from pre-intervention (M = 3.06, SD = 1.62) to post-intervention (M = 3.40, SD = 2.27); t(4) = -1.01, p = .37.

Sustainability: The educational intervention was recorded using Microsoft PowerPoint with active links included about the facility’s hazardous drug policies, procedures, and hazardous drug list to assist nurses with accessing hazardous drug resources in the future. Additionally, a hazardous drug fact sheet was created to serve as a quick reference guide and a competency form was developed to validate the nurses’ proficiency in hazardous drug administration. All training materials were provided to the facility for future use.

Implications: New knowledge was revealed on the current state of non-oncology nurses hazardous drug exposure knowledge and PPE usage, which is lacking in the literature. This project may prompt further study of the non-oncology nurse population in the future. The project demonstrated that multimodal training on hazardous drug safety was effective in advancing nurses’ hazardous drug exposure knowledge, but this was ineffective in increasing their PPE usage. More research is needed to find successful methods of increasing safe handling behaviors. Clinical Nurse Specialists can build on the lessons learned from this QI project and focus educational efforts on using PPE correctly and consistently for all hazardous drugs.


Elshaer, N. (2017). Adverse health effects among nurses and clinical pharmacists handling antineoplastic drugs: Adherence to exposure control methods. Journal of Egyptian Public Health Association, 92(3), 144-155.

Nassan, F. L., Chavarro, J. E., Johnson, C. Y., Boiano, J. M., Rocheleau, C. M., Rich-Edwards, J. W., & Lawson, C. C. (2021). Prepregnancy handling of antineoplastic drugs and risk of miscarriage in female nurses. Annals of Epidemiology, 53, 95-102.

The National Institute for Occupational Safety and Health [NIOSH]. (2016). NIOSH list of antineoplastic and other hazardous drugs in healthcare settings, 2016.

The National Institute for Occupational Safety and Health [NIOSH]. (2019). Hazardous drug exposures in healthcare: Effects of occupational exposure.

The National Institute for Occupational Safety and Health [NIOSH]. (2020). Hazardous drug exposures in healthcare: Overview.

Occupational Safety and Health Administration [OSHA]. (2016). Controlling occupational exposures to hazardous drugs. United States Department of Labor.

Polovich, M., & Clark, P. C. (2012). Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. Oncology Nursing Forum, 39(3), E299-E309.

Roussel, C., Witt, K. L., Shaw, P. B., & Connor, T. H. (2019). Meta-analysis of chromosomal aberrations as a biomarker of exposure in healthcare workers occupationally exposed to antineoplastic drugs. Mutation Research - Reviews in Mutation Research, 781, 207-217.

Wang, C. Y., Lu, C. Y., Yang, S. Y., Tsai, S. C., & Huang, T. W. (2022). 3D virtual reality smartphone training for chemotherapy drug administration by non-oncology nurses: A randomized controlled trial. Frontiers in Medicine, 9, 1-9.

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