Empathy in Action: Enhancing Cancer Care Through the Expertise of Oncology Nurses 

Oncology nurses are at the heart of cancer care. They provide more than just medical expertise—they offer empathy, compassion, and support during some of the most challenging moments in a patient’s life. But what does empathy look like in action, and how can oncology nurses channel it for better patient care while protecting their own well-being?  

This post explores the role of empathy in cancer care, its impact on nurses and patients, and actionable strategies to transform empathy into meaningful, measurable improvements in care environments. 

What Is Empathy in Cancer Care?

Empathy in cancer care goes beyond understanding a patient’s condition. It involves recognizing their emotional, physical, and psychological struggles while providing care that addresses those needs holistically.  

For oncology nurses, this means listening attentively to patients, validating their fears and hopes, and translating those insights into compassionate, personalized treatment. Empathy bridges the emotional gap in patient care, transforming clinical relationships into human experiences. 

Oncology Nurse and little girl undergoing course of chemotherapy

 

The Dual Impact of Empathy in Oncology Nursing

While empathy is essential, oncology nurses often walk a fine line between caring for others and safeguarding their own well-being. Positive nurse and patient experiences are crucial as they are linked to a range of beneficial outcomes. 

The Benefits of Empathy 

 

/ Better Patient Outcomes: Cancer patients often face fear and uncertainty. An empathetic approach helps establish trust and reduces emotional barriers between patients, their families, and caregivers. This trust leads to open communication, creating a collaborative care environment. 1 Empathic care leads to higher patient satisfaction scores, reduced stress levels, and improved adherence to treatment plans. Research shows that empathy in healthcare leads to better treatment adherence and improved patient satisfaction. When patients feel understood, they are more likely to follow care plans and share vital health concerns, leading to better outcomes. 2 

/ Positive Feedback Loops: For many cancer patients, the relationship with their oncology nurse becomes a source of comfort and stability. Empathy fosters a deeper connection, turning routine care into a reassuring and supportive experience. Patients who feel valued often express gratitude, boosting job satisfaction and reinforcing the importance of empathic care.  

/ Enhanced Team Morale: When nursing teams adopt empathy as a shared value, it fosters a collaborative atmosphere, reducing burnout and improving team dynamics.  

/ Stronger financial performance: Workplaces that prioritize empathy foster more positive environments, resulting in higher employee retention, reduced burnout, and fewer cases of illness. 

The Challenges of Empathy 

 

/ Nursing Burnout: Constant emotional engagement with patients can lead to caregiver fatigue and burnout. Many patients endure severe pain or recieve palliative care, and over time, the emotional burden on nurses takes a significant toll. 

/ Pressure to Balance: Nurses must juggle technical responsibilities with compassionate care, which can feel overwhelming. 

A New Perspective on Empathy in Action

Empathy often requires time and focus, both of which are precious commodities in an oncology nurse’s day. Empathy isn’t a one-way street. To provide exceptional care to their patients, oncology staff need the support they rightfully deserve. One innovative way to ensure this is by incorporating CSTDs into their workflow. 

What Are CSTDs?

 

According to NIOSH, a Closed System Drug-Transfer Device (CSTD) is a device designed to mechanically prevent environmental contaminants from entering the system while also ensuring that hazardous drugs or vapors cannot escape. CSTDs allow safe preparation and administration of hazardous drugs, reducing the risk of exposure for oncology nurses. EQUASHIELD® offers CSTDs that are easy to use, efficient, and proven to minimize contamination risks.  

/ Prioritize Personal Safety First:  Driven by their innate empathy, nurses consistently prioritize the safety and comfort of their patients, often at their own expense. By using CSTDs like EQUASHIELD®, nurses are protected from exposure to hazardous drugs. This enables nurses to focus on caregiving without constant concern for personal safety. 

/ Secure Connections:  Experience peace of mind with secure connections, guided by intuitive red-to-red markings and clicking mechanism. Designed with simplicity in mind, it reduces the stress of managing technical administrative tasks, allowing nurses to focus more on building meaningful connections with patients. 

/ Streamline Workflow to Focus on Patient Connection:  By spending less time on technical tasks, you can dedicate more time to building meaningful connections with your patients. Devices like EQUASHIELD®’s CSTD reduce time spent on manual tasks, freeing nurses to concentrate on providing attentive, compassionate care. EQUASHIELD streamlines the compounding process with fewer steps than any competitor and achieves the fastest average administration time in the industry.4,5 

/ Ergonomic Design Means Fewer Repetitive Strain Injuries: Repetitive movements can heighten the risk of joint pain and carpal tunnel syndrome, leading to fatigue, absenteeism, and even long-term disability. These issues often contributes to job burnout, diminishing both motivation and the ability to empathize with others. EQUASHIELD CSTDs are ergonomically designed, ensuring easy handling with minimal force to handle. 

Caring for Nurses to Care for Patients

For empathy to thrive in cancer care, it must be viewed as a standard—not an optional—practice. Here’s how healthcare institutions and nurses can make that shift permanent: 

/ Leading By Example: Empathy must start at the top. When leadership prioritizes the health and wellbeing of the oncology staff, it sets the tone for the entire team.  

/ Ongoing Guidance and Training: Implementing structured guidance and training in areas like patient communication and stress management helps nurses feel supported in their roles.  

/ Building a Supportive Culture: Healthcare organizations must proactively address compassion fatigue by fostering environments where nurses can debrief, seek mental health support, and recharge.  

/ Patient-Centered Policies: Advocate for systems that prioritize time for patient interactions.  

/ Technology Integration: Use tools like EQUASHIELD CSTDs to streamline repetitive processes, freeing up nurses to focus on the patients. 

When oncology nurses are empowered to protect their well-being, they’re better equipped to care for their patients and continue making a profound difference. 

Empathy as a Transformational Tool

Empathy can transform cancer care. For oncology nurses, it drives patient-centered actions and boosts morale.  

By strategically channeling empathy, oncology nurses can enhance care environments while protecting their own emotional and physical health. EQUASHIELD® recognizes the vital role nurses and pharmacists play in cancer care and is committed to developing solutions that support oncology healthcare workers.  

Curious to learn how EQUASHIELD®’s Closed System Transfer Devices can elevate your practice and keep you safe? Contact us to explore your options. Let’s work together to create safer environments—for your patients and for you. 

USP 800 Questions & Answers

Q: How does USP <800> refer to closed system transfer devices (CSTDs)?

A: CSTDs are referred to as a containment supplemental engineering control that provide adjunct controls to offer an additional level of protection during compounding or administration. Supplemental engineering controls may also facilitate enhanced occupational protection, especially when handling HDs outside of primary and secondary engineering controls.

Q: Does USP <800> acknowledge that all CSTDs will perform adequately?

A: No, USP <800> reveals that there is no certainty that all CSTDs will perform adequately. Therefore, users should carefully evaluate the performance claims associated with available CSTDs based on independent, peer-reviewed studies and demonstrated contamination reduction.

Q: Can hazardous drugs (HDs) vaporize at room temperature increasing risk of occupational exposure?

A: Yes, the Oncology Nursing Society (ONS) Toolkit for Safe Handling of Hazardous Drugs for Nurses in Oncology identifies 8 HDs with the potential to vaporize at room temperature including Carmustine, Cisplatin, Cyclophosphamide, Etoposide, 5-Florouracil, Ifosfamide, Nitrogen mustard and Thiptepa.

Q: Why does USP <800> indicate that it is important to contain HDs vapors?

A: USP <800> states that a potential opportunity of exposure during administration includes generating aerosols of HDs by various routes (Ex. Injection, irrigation, oral, inhalation or topical administration).

Q: Does USP <800> indicate that a CSTD can help contain HDs vapors when utilized?

A: Yes, USP <800> states that some CSTDs have been shown to limit the potential of generating aerosols during compounding.

Q: Does USP <800> still allow for the use of two tiers of containment (Ex. CSTD within a BSC) that is in a non-negative pressure room for facilities that prepare a low volume of HDs?

A: No, USP <800> states that a CSTD must not be used as a substitute for a containment primary engineering control (C-PEC) which must be in a room with negative pressure between 0.01 and 0.03 inches of water column relative to all adjacent areas.

Q: When does USP <800> indicate that a CSTD should be utilized?

A: USP <800> states that a CSTD should be used when compounding HDS when the dosage form allows. Furthermore, USP <800> states that a CSTD must be used when administering antineoplastic HDs when the dosage form allows.

Q: Do USP standards indicate how affixing a CSTD to a vial impact beyond use dating (BUD)?

A: No, USP <797> revisions and USP <800> do not state that attachment of a CSTD to a medication vial either reduces or prolongs the beyond use date (BUD) of a medication vial (single or multiple dose). Therefore, for medication vials with an attached CSTD, BUD remains unchanged from USP standards. USP, Joint Commission and other regulatory bodies also do not currently endorse the utilization of a CSTD for prolonging the BUD of single dose vials, which is also known as dose vial optimization (DVO) due to patient safety concerns.

Contamination of Syringe Plungers During the Sampling of Cyclophosphamide Solutions​

The presence of cytotoxic agents in the urine of operators and in their environment has been demonstrated. The pharmacokinetics of the urinary elimination of cyclophosphamide suggests that these drugs are absorbed cutaneously during handling. In the framework of a more general study on the contamination of hospital environment, the present study addresses the possible presence of cytotoxic agents on the plungers of syringes. The report is based on results indicating that the bacterial contamination of a plunger may result in the contamination of the solution being sampled. The study was divided into two phases. The first phase consisted in measuring the contamination of the plungers of eight syringes used for handling cyclophosphamide. Cyclophosphamide was analysed by gas chromatography – mass spectrometry with a detection limit of 0.1ng/ ml. The aim of the second phase was to localize the contamination on the plunger and thus determine the amount of drug that comes into contact with the gloves of the operators. The contamination was quantified by measuring the activity of metastable technetium. The results of the first phase showed that all the plungers were contaminated with cyclophosphamide amounts varying from 3.7 to 445.7 ng. The second phase showed that the infiltration of liquid onto the plunger depended on the solution being sampled. Almost no infiltration was seen with labelled water, but contamination appeared after the first sampling of a cyclophosphamide solution, then increased as a function of the number of times the plunger was pushed in and out. These results indicate that cyclophosphamide solutions infiltrate onto the plungers of syringes. They suggest that the general procedure for handling cytotoxic agents should be modified, and a regular replacement of syringes should be enforced. They also partly explain why the gloves of 50%/90% operators are contaminated after a single preparation. The contamination seems to depend on the type of solution sampled and the number of samplings. Initial investigations by the manufacturer of the syringes had shown that the acid pH of cyclophosphamide solutions may affect the lubricant of the joint. Our study demonstrates that the contamination of plungers is one of the sources of environmental contamination for health workers handling antineoplastic agents, even in the absence of manipulation errors. More generally, these results demonstrate that the exposure of operators cannot be clearly described unless all existing sources of contamination in their environment are identified. The implementation of suitable procedures should thus take into account all possible sources of contamination, including technical facilities such as the use of a safety cabinet or an isolator.

J Oncol Pharm
Practice (2005) 11: 1-5.

Key words: contamination; cytotoxic; exposure;
syringe plungers

Introduction

In 1979, Falck et al. suggested the possibility that health workers involved in the preparation and manipulation of anticancer drugs underwent occupational exposure to cytotoxic agents.1 The authors subsequently confirmed and quantified such exposure, mainly by measuring agents such as cyclophosphamide in urine. They obtained positive results, then extended their study to environmental contamination.2-7 They showed that the gloves and the overall working environment of these personnel were frequently contaminated by varying concentrations of cytotoxic agents.5,6 The present study, conducted within the framework of a larger study on hospital contamination, focused on the possible contamination of syringe plungers by the solution being sampled, on the basis that the bacterial contamination of syringe plungers can lead to the contamination of the solution itself.8 The presence of a cytotoxic agent on the plungers is a possible source of environmental contamination for people handling the drug whose gloves are generally contaminated, even when no manipulation error is made

MATERIALS AND METHODS

This study was conducted at the Centre Le´on Be´rard (France) with 50-ml, three-piece Becton Dickinson syringes. These syringes were chosen because of their long plungers that compel operators to touch them with their gloved hands. The study consisted of two phases.

Phase 1
In order to study the actual contamination of syringe plungers employed for the preparation of cyclophosphamide solutions, eight syringes were used for about 8 h (9:00 – 17:00), then samples were taken throughout the day when the syringes were needed to fill prescriptions. The number of times the plunger was pushed in and out was recorded. At the end of the day, a half compress (20*20, Tetra Medical) impregnated with 5 mL of water for injectable preparations was applied onto the polypropylene plunger after it had been pulled out to its fullest extension. The compress was then stored in a glass flask at -20oC until analysis.

Sample treatment. The compress was placed in a silanized glass tube with 0.1 mL of a solution of 250 ng/mL trofosfamide (internal control) and 0.5 mL Tris buffer, pH 8. The cyclophosphamide was extracted with 15 mL of unstabilized diethyl ether. The sample was shaken mechanically for 10 min, then the organic phase was removed, centrifuged at 3000 rpm for 6 min, then placed in a silanized glass tube. The aqueous solution was extracted again as before. The entire organic phase was dried with anhydrous sodium sulfate, then evaporated under a light stream of nitrogen at 35oC until a volume of 2 mL was obtained. The diethyl ether residue was transferred to a 3-mL glass flask, then evaporated to dryness under a light stream of nitrogen at 35oC.

Derivatization. The dried residue was treated with 100 mL of ethyl acetate and 100 mL of trifluoroacetic anhydride (derivatization agent). The solution was shaken for a few seconds, then heated at 708C for 15 min. After the solution had been returned to room temperature, it was evaporated to dryness under a light stream of nitrogen, then 100 mL of toluene were added. After 5 min mechanical shaking, 1 mL of the solution was injected into the chromatograph.

In these conditions, the mean recovery rate (9/SD) of cyclophosphamide with the sampling method described above was 859/10%.

Analytical conditions. Cyclophosphamide was analysed by gas chromatography-mass spectrometry (GC-MS) with a detection limit of 0.1 ng/mL. We used a Hewlett-Packard 5 MS capillary chromatographic column with an internal diameter of 0.25 mm, a film thickness of 0.25 mm, and a length of 30 m. The carrier gas was helium 5.5, the pressure at the head of the column was 17 kPa, the gas flow was 50 mL/min, and the column flow was about 1 mL/min. The splitless injection mode was used.

Gas chromatographic conditions. The initial oven temperature was 1108C. After 1 min, it was progressively increased by 158C/min to 2808C. After 0.5 min, it was increased by 258C/min to 3108C. After 3.57 min, the oven temperature was decreased to 1108C for 0.2 min before the next injection.

Mass spectrometry. The interface and source temperatures were 2808C and 2008C, respectively. The energy of the ionizing electrons was 70 eV, and the trap current was 150 mA.

Characteristics of selected ion monitoring. Two entry windows were used: the first one from 9.00 to 11.20 min, during which the mass filter was adjusted to ions 307, 309 and 212 of cyclophosphamide, and the second one from 11.20 to 13.00 min, during which the mass filter was adjusted to ions 273, 275 and 182 of the internal standard. Under these conditions, cyclophosphamide trifluoroacetate and trofosfamide were eluted at retention times of 10.308 and 12.080 min, respectively.

Phase 2
The objective of the second phase was to localize the contamination on the plunger with solutions of technetium-99m, in order to determine what quantity of cytotoxic agent could come into contact with the gloves of operators. Two solutions were prepared:

  • 50 mL of a solution of 99mTc, with an activity of 1 GBq;
  • 50 ml of a solution of 20 mg/mL cyclophosphamide in water with 1 GBq of 99mTc.

Both were placed in 50-mL polyvinyl chloride bags. Three tests were performed.

  • In the first and second tests, 1, 3, 5 and 10 samples of the solution of 99mTc and of the solution of cyclophosphamide and 99mTc were drawn up by an operator who avoided touching the plunger with his gloves during sampling. The axis of the plunger was unchanged.
  • In the third test, 1, 3, 5 and 10 samples of the solution of cyclophosphamide and 99mTc were drawn up by an operator who touched the plunger with his gloves during sampling. The axis of the plunger was thus modified, which corresponds to the actual situation in normal use. After each in-and-out movement of the plunger, the gloves were removed and the contaminating activity measured with an external Canberra probe. The data points reported correspond to the mean of activities measured on four different syringes.

Sampling on plungers. Three samples were taken from the plunger of each syringe with swabs impregnated with double-distilled water (Figure 1). Samples corresponded to the surface of the upper half of the plunger (E1), the surface of the plunger adjacent to the joint (E2) and the surface of the joint itself (E3), respectively

Analytical method. Activity was measured using a Packard Cobra counter with five measurement wells. Both the background activity and the rate of decay of 99mTc were taken into account in the measurements.

Contamination-of-syringe-plungers-during-the-sampling-1-jpg

Figure 1. Location of samples from syringe plungers.

RESULTS

Phase 1
The plungers of the eight syringes tested were contaminated with cyclophosphamide (Table 1) (mean value, 71.5 ng; range, 3.7-445.7 ng). Cyclophosphamide concentration in the solution was 20 mg/mL, which corresponds to a mean volume of 3.6 nL (0.2-22.3 nL). 

Contamination reached 50 ng or more in one of three syringes, and about 5 ng in two of three syringes. No relationship was found between the number of in-and-out movements of the plunger and the quantity of cyclophosphamide on the plunger.

Phase 2
The results of the second phase are shown in Tables 2 and 3. Almost no contamination was found when labelled water was used (A). Contamination remained under 1 nL, even after 10 in-and-out pushes, although a slight increase was noted when the number of plunges increased. The contamination of the plungers was consistently greater with the solution of radiolabelled cyclophosphamide than with the pure radiolabelled solution, regardless of the test or the number of in-and-out pushes. This difference became obvious after the first use of the syringe, whether the operator touched the plunger with gloves or not; however, the total contamination of the plungers was more important after the operator had touched the plunger than otherwise, but this difference disappeared after 10 plunges.

Upper and lower surfaces of the plungers (E1 and E2). The contamination of the upper and lower surfaces of the plungers corresponds to the amount of contaminant that could come into contact with the gloves of operators.

  • Almost none (90 pL, Table 2) was found with radiolabelled water, regardless of the number of inand-out plunges.
  • Contamination increased after only five in-and-out plunges in the test with no contact with the plunger. Little contamination was seen after the first in-and-out plunge, but the amount increased rapidly as a function of the number of plunges; a 50-fold increase was noted between one and 10 plunges (from 0.08 to 3.99 nL).

DISCUSSION

Our results show that cyclophosphamide infiltrates onto the plungers of syringes, suggesting that the general procedure for the manipulation of cytotoxic agents should be modified. Syringes should not be used throughout the day, but should often be replaced with new ones. Systematic replacement after each manipulation is not justified, as we have shown that leakage onto the plunger occurs only after a syringe has been used several times.

These results also call into question the use of twopiece syringes for reconstituting antineoplastic drugs, as these syringes are less watertight than three-part syringes. This study may lead, as was the case for gloves, to establishing recommendations for the use of certain syringes for the manipulation of cytotoxic agents.

The infiltration onto the plunger is higher with the cyclophosphamide solution than with labelled water, and the quantity increases with the number of uses of the syringe. We suppose that the cyclophosphamide solution itself reacts with the joint or the syringe to ease its way onto the plunger. Initial investigations have shown that the acid pH of the cyclophosphamide solution may affect the silicone used to lubricate the syringe.

The finding that cyclophosphamide infiltrates onto the plungers of syringes further accounts for the contamination of gloves, as well as flasks, during drug manipulation,5,6 even when no handling error is made. The different amounts deposited on the upper and lower surfaces of the plunger in the various tests (either when operators touched the plunger on sampling cyclophosphamide or when they did not) indicate that up to 10.2-53.4 ng of the drug may contaminate the gloves of operators after 5-10 in-and-out plunges (Table 3). This contamination, when repeated all day and going unrecognized, or when not efficiently dealt with, might contribute to the occupational exposure of operators.

Table 1. Amounts and volumes of cyclophosphamide on the plungers of the eight syringes

Contamination of syringe plungers during the sampling 2

Table 2. Volumes (nL) of contaminating agents on the plungers of syringes; results of three tests

aE1, upper surface; E2, lower surface; E3, joint.
bA, sampling of 99mTc solution without touching plunger; bB, sampling of a
solution of cyclophosphamide and 99mTc without touching plunger; bC,
sampling of a solution of cyclophosphamide and 99mTc when touching
plunger.

  • No such trend was found in the third test, when the operator touched the plunger (C). The contamination remained relatively stable, with volumes on upper and lower surfaces varying between 0.52 and 1.32 nL (Table 2). However, the contamination after one and three plunges was, respectively, 13.5 and 3.2 times greater in this test than when the operator did not touch the plunger (B). On the opposite, it was, respectively, 2.0 and 3.0 times lower than in B after 5 and 10 plunges.

Surface of the joint (E3). As for upper and lower parts of the plunger, the contamination of the joint was negligible in the test with 99mTc only, although it slightly increased with the number of in-and-out plunges. A linear progression of the joint contamination was seen in the test with cyclophosphamide when the manipulator did not touch the plunger (B). This was not the case when the plunger was touched (C): wide variations were found in the amount of contamination (0.24-6.67 nL), regardless of the number of in-and-out plunges. Changing the axis of the plunger therefore appears to play a critical role in the contamination of the joint.

Table 3. Amounts (ng) of cyclophosphamide present on plungers; results of two tests

Contamination of syringe plungers during the sampling of cyclophosphamide solutions

aE1 upper surface; E2, lower surface; E3, joint. bB, sampling of a solution of cyclophosphamide and 99mTc without touching plunger; bC, sampling of a solution of cyclophosphamide and 99mTc when touching plunger.