Knowledge and safe handling practices affecting the occupational exposure of nurses and midwives to hazardous drugs: A mixed methods systematic review

Background: Hazardous drugs are inherently toxic and present a potential occupational exposure risk to nurses and midwives. Hazardous drugs require special handling to minimise the risk of exposure and adverse health effects. Although the use of hazardous drugs in oncology services is well recognised, they are also used in other healthcare areas where nurses and midwives may be unaware there is a risk. Objective: To investigate what nurses and midwives know and do about their occupational exposure to hazardous drugs, and what factors affect their knowledge and practice. Design: Mixed methods systematic review. Methods: A systematic review was conducted, and studies were included if the authors described what nurses or midwives knew about hazardous drugs, or what they did in their clinical practice to reduce their risk of occupational exposure (PROSPERO registration CRD42024437493). The databases were searched for any year until the 26th of January 2024.Two independent reviewers extracted data using Covidence and assessed the risk of bias. The data were extracted into the categories of knowledge of risk and safe handling practices, attitude and factors affecting these, and activities that posed the greatest risk of exposure (preparation, administration, and disposal of hazardous drugs, cleaning hazardous drug spills, and handling excreta from patients who had recently been treated with hazardous drugs). Results: Of the 2702 articles that were identified, 59 quantitative and 3 qualitative studies were included in this review. No studies reported on midwives handling hazardous drugs. Most studies investigated nurses working in oncology services. Nurses reported a lack of education about the risk and safe handling. They were often responsible for preparing hazardous drugs and there was inconsistency in their compliance when using personal protective equipment. Nurses did not always perceive that there was a real risk of exposure, were concerned about the effect of wearing personal protective equipment on their relationship with patients and perceived they lacked the time to don equipment. Conclusions: The risk of occupational exposure to hazardous drugs outside of oncology services was rarely investigated. There were no studies reporting what midwives knew and did about their risk of occupational exposure to hazardous drugs. When nurses were aware of the risks, this did not necessarily translate into the implementation of safe handling practices or the consistent use of personal protective equipment because of a perceived low risk, lack of personal protective equipment availability, and prioritising personal or patient comfort over safety measures. Tweetable abstract: Nurses and midwives are often unknowingly exposed to the toxic effects of hazardous drugs when they prepare and administer these drugs for patients, although knowledge does not always equal safe handling practices.