Celebrating Oncology Nursing Day – A Message from our Executive Director

April 5, 2016 |


Oncology nursing day gives us an opportunity to shine the spotlight on  the remarkable nurses who make the extraordinary seem ordinary, the  impossible seem possible and the unmanageable seem manageable.

Everyday  oncology nurses go home knowing that they made a difference in someone’s  life and today is the day where we honour and recognize their tireless,  genuine and worthy contributions to cancer patients and their families.

Oncology nurses are involved in every step along the cancer care journey including prevention, detection, treatment, survivorship and palliative care. They play a pivotal role in working with patients, families and communities at risk for cancer.

You can count on oncology nurses to be there during and after treatment  and you can count on de Souza Institute to be there for oncology nurses.

Since 2008, we have been a proud resource to over 9,000 healthcare practitioners who wanted to further invest in themselves with specialized education and professional development courses.

We are supporting nurses today and preparing them for tomorrow. This  commitment is echoed in this year’s Oncology Nursing Day theme “Future-ready: Together, Towards Tomorrow”. We are proud of our nurses  each and every day, and thankful that Oncology Nursing Day gives us an  opportunity to join Canadians across the country in acknowledging and  celebrating the outstanding contributions of our oncology nurses.

Mary Jane Esplen, PhD, RN
Executive Director
de Souza Institute

Safe Handling of Cytotoxic Drugs

September 5, 2013 |

The below blog post was created on September 5th 2013, by Komal Patel and is reproduced here due to popularity:

Have you ever heard a nurse colleague say, “I don’t want to wear double gloves and/or gown when I’m administering chemotherapy? I haven’t had to in the past 10 years, so why should I change my practice now?”  Many of you are most likely nodding your head yes.  So, is it okay not to wear the appropriate personal protective equipment(PPE) when administering chemotherapy regardless of the route? Of course not! You want to protect yourself.

Many chemotherapy drugs and some biotherapy drugs are classified as hazardous drugs.  Ifind it mind boggling when healthcare professionals feel that it is not important to wear PPE when working with cytotoxic agents such as chemotherapy. Safe handling is a vital consideration for nurses administering and providing care to individuals receiving these.

Because oncology nurses are exposed to cytotoxic agents many times a day, up to five days a week, for their entire career, PPE’s are a must as they help reduce the risk of exposure. Furthermore, it is important to remember that even though chemotherapy agents used to treat individuals with cancer have side effects, the benefits outweigh the risks; for nurses/healthcare professionals the exposure has no benefit.

Did you know that Occupational exposure to cytotoxic drugs was recognized as a potential hazard for health care workers in the 1970s a group of scientists were studying mutagenicity of urine sample and discovered that there was potential risk for nurses handling these drugs? You are shocked?

There’s a great research article called Safe Handling of Parenteral Cytotoxics: Recommendations for Ontario by Esther Green and Colleagues that explains how the cytotoxic guidelines and standards for Ontario were developed. I would definitely recommend reading it as it will give you a better understanding the importance of wearing PPEs. If you want to read the document with recommendations, click here.

de Souza Institute has standardized the education that registered nurses in Ontario receive about chemotherapy and biotherapy. Want to learn more about chemotherapy, biotherapy, and safe handling, consider enrolling in de Souza’s Provincial Chemotherapy and Biotherapy Course for the latest evidence based information.

I would like to hear what are your thoughts about wearing PPE when administering cytotoxic agents by IV, SC, and by mouth?

Below are the comments we received in 2013:

hazardous medication – Submitted by Dr. Vincent Wong (not verified) on Mon, 2013-11-18 16:22.

In your presentation do you consider hazardous medication that are not cytotoxic agents and do you differentiate between final oral form solids and injectables with regard to exposure risk. As you are probably aware the current listing of hazardous medication from NIOSH is extensive and are not limited to cytotoxic agents. In fact it includes some very commonly used medications like paroxetine, risperidone and clonazepam. What would be the recommendation for appropriate PPE for not only the cytotoxic agents but for other medications considered hazardous by NIOSH?
Thank you for you post Dr. Wong. In my blog, I was only highlighting chemotherapy and biotherapy agents. However, you are absolutely correct that there are medications that are not labeled chemotherapy or biotherapy that are considered as hazardous by NIOSH. NIOSH recommends that employers provide appropriate PPE to protect individuals who handle hazardous drugs in their workplace. So the same PPE guidelines apply. I have attached an article by NIOSH called Personal Protective Equipment for Health Care Workers Who Work with Hazardous Drugs that you might find valuable in reading:

Refreshing – Submitted by Anonymous on Sun, 2013-10-20 23:17.

Thank you for the refreshing information in regards to the safe handling and administering of cytotoxic agents, especially the parenteral route. I can understand some of my senior nursing colleagues not wanting to adhere to recent changes for appropriate PPE with the administration of cytotoxic agents, but it amazes me to see the younger nurses that are new in the profession not adhering to the PPE protocols. They have gone through the proper training and education for the safe handling and administration of cytotoxic agents. When informing these colleagues of the proper method, they will either ignore the advice or look at you as threat to their daily practice, as if you have wronged them in some way. As a colleague, I practice safe handling of these agents, as they can be harmful to my patients, their families and most importantly, me. Sometimes, what we can not visibly see, we tend to ignore the methods put in place and rush through such delicate situations. Staff nurses becoming busier and overworked with the increasing patient loads, tend to cut corners to get all their patient care done as fast as possible.

Cytotxic Drugs – Submitted by Anonymous on Tue, 2013-10-15 17:26.

Have you (de Souza Institute) thought about developing a course on safe handling of cytotoxic agents for all healthcare professional and caregivers working with individuals receiving such agents? I know that there are nurses and healthcare professionals who work in other health care areas besides oncology who would benefit from learning about how to safely handle and dispose of cytotoxic drugs.
Thank you for an informative blog.
Hello, The team has definitely thought about developing a course on safe handling of cytotoxic agents for healthcare providers. Interestingly enough, we will be meeting in a few weeks to discuss development of the course. You are absolutely right that anyone who works with individuals receiving cytotoxic drugs will benefit from such course since everyone should be aware of how to safe handle cytotoxic agents. I’m not really sure when the course will be available, however, I recommend that you continue to keep referring to our website for new courses. Take care,

Here’s a short article that – Submitted by Komal Patel on Wed, 2013-09-25 11:46.

Here’s a short article that highlights what hazardous drugs, how HCP are exposed, what the health effects are, what the law says, and what we can do everyone can do to minimize/ eliminate exposure. It’s short and can serve as a reminder to why is vital to maintain safety when working with cytotoxic/ hazardous drugs. The article is called Antineoplastic Drugs- Hazardous, Handle with Care:…
Absolutely agree!! Why take the risk………..I even tape all my connections on the IV lines in case of drips, etc…………..and when checking chemo, always glove, but so many don’t anymore and it’s scary, even though most the RN’s at my work have taken the de Souza courses!!!! I guess they figure they’ll beat the odds!!
Thank you for your post. That’s definitely alerting. A few simple safety steps definitely helps to minimize long term effects of everyone. What’s an extra 1 or 2 minutes one needs to take to protect themselves? As I always say, safety first. How can you play a role as a mentor to your colleagues who are not following the safety protocols on your unit and in your organization?

Providing emotional care to our patients: Not enough time? Or, too little skill?

June 19, 2013 |


Nurse comforts woman emotionally
Providing emotional care to our patients: Not enough time? Or, too little skill?

All patients will be affected by their cancer diagnoses and treatment. Psychosocial support has been shown to be beneficial in reducing psychosocial distress as well as physical symptoms, such as pain.

Nurses are in an ideal position to assess and address emotional needs of patients. I often say that, nurses have a unique opportunity to make a profound difference in how a patient and their loved ones manage the cancer journey. Just take, for example, that nurses are within closest proximity to a patient, usually getting to know visitors and family members, and are providing the most intimate level of care. Nurses are there continually during the day time as other professionals are, but also at night- when patients are most often “alone” with their thoughts, concerns and fears-an ideal time to check on how someone is doing and on occasion a useful period when a nurse has a few extra minutes to have some quiet time alone with the patient.

Nurses also place high value on their relationships with their patients and they speak often of treasuring the “caring” nature of their work.  How many times have we heard “Nurses care. Doctors cure”.

So, how are we doing in relation to providing emotional care? Generally, nurses want to provide emotional support and in fact, often believe that they are providing adequate or even a high level of support during their care. However, patient surveys continue to demonstrate less than optimal results in relation to this aspect of cancer care, regardless of where they are in the cancer journey. National agencies and care centers continue to try to address these gaps in care.

As nurses we have barriers still, in providing excellence in psychosocial care. And, I have to say I frequently hear about them when I co-lead our de Souza workshop on psychosocial care. Mostly, I hear about the lack of time; the lack of privacy; and that other needs, for example the  more medically-oriented tasks, take precedence over emotional care, or are even valued more so. Yet, it causes me to wonder…

On the one hand, more than ever before, cancer centres and many community or general care settings have access to evidence-based guidelines and tools to do psychosocial assessments, even assessing for symptoms of depression and anxiety. I see that they are now routinely being used and I understand electronic forms such as the kioks with ESAS are now widely distributed. But, what is troubling to learn is how little we sometimes truly know about a score of 4 versus a 7? Do we ask as we should? How are we doing in our communications with patients and families? How are our assessment skills?

Psychosocial social support is key to me- as it supports all the other cancer care interventions- including medical decision-making, adherence to difficult treatment regimes, and is necessary to facilitate quality of life and decrease the burden of cancer. Psychosocial care involves a complexity of skills. It is so much more than “nurses exhibiting a caring attitude and stance”. Yes, nurses care. When I hear the words “nurses are empathic”, it makes me ask what do folks mean by that statement?  Are they really able to articulate the role of empathy and all that it encompasses as a scientifically- informed, intentional, purposeful set of responses and an approach? Responding to a patient’s expressions of fears or concerns, or to a needs for further information and comprehension or clarification concerning their treatments or diagnosis, involves a sophisticated set of evidence-based skills in assessment and delivery of care. Communication skills and psychosocial care involves culturally- attuned approaches to assess psychological, social and spiritual functioning and needs. Emotional care involves complexity in  active listening, observations of body language, paying attention to the voicing of nuances, and of “silence”, making eye contact, asking a set of carefully crafted questions to assess the specific and concrete issues that are driving the psychosocial need, monitoring the patient, and our own reactions as they are occurring. In other words, this means paying attention to the minute-by-minute reactions, as well as self-monitoring our own reactions, feelings, perspectives etc. This is important as patients and their families are continually scrutinizing nurses’ responses and even our nonverbal behavior, in the looking for clues and the need to manage their sense of uncertainty that comes along with a life-threatening illness, such as cancer.

The “care” part involves carefully timed responses, followed by an assessment of those responses in order to follow up with the appropriate level next nurse response. All this is scientifically based, (although I do recognize the role of natural talent and the “art” of communication); but empathy and psychosocial care are highly informed.

Assessment skills are actually necessary in order for nurses to build relationships- something we value- and also for one to feel a sense of competency, professional confidence and satisfaction in our work.

But are nurses feeling prepared? I frequently see room for growth in this area of skill development. Nurses can benefit from further understanding on how a “4” on an ESAS scale for one patient is different than a “4” reported by another patient. A common criticism on the use of screening instruments- which are an ideal “first step” to providing care, is that the scores are recorded but nurses are not responding or documenting about their specific care.  I think it can be  fairly straight forward to determine the need based on a high score and its “red flag” to refer or find out more about the distress, but there is that large group of patients who have needs who score above a 2 or more , but who continue to have unmet needs. Scoring in and of itself or charting a score, are not enough. A score doesn’t tell us anything about the concern. For example, what is driving the depression or anxiety score up? How is the patient feeling about that level of distress or managing with it? What methods are they using to manage the distress? What works for them? Or has worked in the past?

Mishra et al. (2010) found that beyond the barriers of time and workload, nurses are at times unwilling to delve deeper into concerns when it comes to the psychosocial realm , for example , in relation to a cancer diagnosis or prognosis. Mishra et al. (2010) found that nurses feared they could not appropriately respond or had the capacity to deal with such concerns. Similarly, I have had nurses open up about such difficulties in our workshops, admitting that they have indeed felt badly to purposely not open up subject matters that they feel “are a can of worms” or where they do not feel they can adequately lead the discussion. This is a courageous disclosure and important to recognize in addressing the need for further skill. My experience is that nurses, in fact, wish to delve deeper and can really build on their skills and really have a significant impact on a patient’s experience. The emotional care of our patients is a part of the nurses’ work life that contributes job satisfaction and when not addressed in practice, can be associated with increased compassion fatigue

We can learn, we can do better…and we must do better. Oncology is an existential illness-everything about it, whether viewed as a chronic or terminal illness. It evokes issues around the finiteness of life. Authenticity in our work is important for us; Feeling supported and effective is an important component of being a health professional and it is an integral part of nursing care- Indeed, CANO recognizes it as a standard of care- and emotional care and addressing emotional, spiritual and social needs of our patients is part of overall cancer care excellence.

In our workshops we have a tool that allows nurses to delve deeper.We utilize the BATHE model which helps nurses practice with a set of specific questions which help guide them in learning about a patients specific concern or issue (Lieberman & Stuart, 1999). This helps the nurse to understand much more fully what the “4” means for one person exactly -versus someone else’s “4”. And, so the nurse can more effectively employ a well-tailored intervention to address the patient’s personal need and concern. As a result, patient experience is automatically enhanced: the patient is listened to and understood and has a far better chance of having his/ her need or concern met. But also importantly, the nurses’ work life satisfaction and value in their work increases.

If managing your patients’ emotional wellbeing is a clinical area where you need assistance, please consider attending one of our courses or IPODE series courses. This is definitely an area where we can all keep continuously building on our skills. There are levels of skill in assessment and intervention delivery that we as nurses can make a big difference in our patient’s management of their illness.


Lieberman, J. A., 3rd, & Stuart, M. R. (1999). The BATHE Method: Incorporating Counseling and Psychotherapy Into the Everyday Management of Patients. Prim Care Companion J Clin Psychiatry, 1(2), 35-38.

Mishra, S., Bhatnagar, S., Philip, F. A., Singhal, V., Singh Rana, S. P., Upadhyay, S. P., & Chauhan, G. (2010). Psychosocial concerns in patients with advanced cancer: an observational study at regional cancer centre, India. Am J Hosp Palliat Care, 27(5), 316-319. doi: 10.1177/1049909109358309