Nurses' Health and Workplace Exposures to Hazardous Substances
Caring for patients during a typical workday, nurses handle dozens of chemicals, drugs, and other agents that are designed to prevent, diagnose, control, or cure diseases and other health conditions. These therapeutic agents can heal, but have side effects as well. For most patients, the benefits of tightly controlled doses usually outweigh the risks. But the same may not be true for nurses.
Nurses absorb a small fraction of the substances they use to care for patients, day after day. They incur risks from these exposures in the absence of benefits. But the magnitude of health problems nurses may face from their diverse, chronic, workplace exposures to hazardous cleaning, disinfecting, and sterilizing agents, radiation, mercury, potent medications, and other chemicals has never been studied.
A new online survey of workplace exposures and disease conditions among 1,500 nurses was conducted by the Environmental Working Group (EWG) and Health Care Without Harm (HCWH), in collaboration with the American Nurses Association and the Environmental Health Education Center of the University of Maryland's School of Nursing, and supported by numerous state and specialty nursing organizations. Nurses were asked to provide information about their health, the health of their children, and about their exposures to 11 different common health care hazards.
This comprehensive survey shows that participating nurses who were exposed frequently to sterilizing chemicals, housekeeping cleaners, residues from drug preparation, radiation, and other hazardous substances report increased rates of asthma, miscarriage, and certain cancers, as well as increases in cancers and birth defects, in particular musculoskeletal defects, in their children. There are workplace safety standards for only six of the hundreds of hazardous substances to which nurses are exposed on the job.
Survey findings: Nurses' children, cancer, and birth defects
The many substances that nurses inhale, ingest, and absorb during a typical workday include some that are known or suspected to harm the development of a child in utero. In this survey, nurses report health problems in their children that are associated with exposures to an array of hospital hazards:
- Analysis of survey data shows that nurses' reported exposures during pregnancy to hazardous drugs, housekeeping chemicals, anesthetic gases, and disinfecting and sterilizing agents are associated with increased incidence of birth defects among their children (Figure 1).
- Children born to nurses reporting high exposures to these chemicals (at least once a week for nine months) were up to two times more likely to be born with a congenital defect than children born to nurses with low or no exposures to these agents, and up to nine times more likely to suffer from musculoskeletal defects at birth. Of the hundreds of compounds in these exposure categories, for only one has the government set standards specifically to restrict nurses' exposures (the sterilizing agent ethylene oxide).
- Nurses reporting high exposures to radiation during pregnancy (at least once a week for nine months) disclosed a 36 percent higher cancer incidence among their children than nurses exposed less often or not at all. The government does restrict allowable radiation doses for pregnant nurses. However, monitoring is infrequent, equipment can be faulty, and only the state of California mandates that the lowest possible effective doses be used for patients' X-rays and CT scans.
- These findings are consistent with other studies showing that children face risks from their mother's exposures to hazardous substances. Although the doses that cause harm are often not well-defined, a child in utero faces higher risks than the mother from hazardous exposures. EPA studies show that children are far more sensitive to carcinogens than adults (EPA 2005), and biomonitoring research demonstrates that chemicals linked to cancer and birth defects cross the placenta as readily as alcohol or cigarette residues (EWG 2005).
Figure 1. Nurses in the category of high exposure to hazardous hospital chemicals during pregnancy report elevated rates of birth defects among their children.
Comparative rates of birth defects in nurses' children, scaled to reflect the number of birth defects expected in a population of 1,000 nurses based on the findings of this study. Increased incidence of birth defects in children of nurses with high exposure, relative to those with low exposure, is listed above the bars representing high exposure.
Notes: "High exposure" refers to reported exposure frequency of at least once weekly during pregnancy. "Low or no exposure" refers to all other, lower reported exposure frequencies. Birth defect rates reflect all congenital defects reported by surveyed nurses, with the exception of data shown for high level disinfecting and sterilizing agents (ethylene oxide and glutaraldehyde) and anesthetic gases, which apply to musculoskeletal defects only. See Table 1 for further details of survey findings, including sample sizes.
Survey findings — Do nurses' exposures affect their asthma, cancer, and miscarriage rates?
The 1,552 nurses who completed the survey reported a total of 730 different health conditions ranging from contact dermatitis to migraines, diabetes, and brain cancer. Analysis of the data revealed associations between a diverse range of reported exposures and health problems (Figure 2):
- Nurses reporting high exposures (at least once a week for at least 10 years) to medications of any type reported a 14 percent increase in cancer incidence relative to nurses with low or no exposure. For the nurses reporting high exposure to antineoplastic drugs, this jumped to an over 40 percent increase in cancer incidence relative to nurses with low or no exposure. In addition, nurses with high exposures to radiation disclosed a 20 percent higher incidence of breast cancer.
- Asthma rates increased by up to 50 percent for nurses reporting high exposures to disinfecting and sterilizing agents (glutaraldehyde and ethylene oxide), housekeeping chemicals, and latex, relative to nurses with lower exposures to these hazards.
- Nurses reporting high exposures to ethylene oxide and antineoplastic drugs also reported up to 20 percent higher incidence in miscarriage, on average, than nurses with lower or no exposure.
- Of the literally hundreds of compounds and agents in these exposure categories that are associated with health problems among nurses, for only six has the government set standards that could be used to limit nurses' exposures — radiation, mercury, isopropyl alcohol, the sterilizing agent ethylene oxide, and platinum- and arsenic-based drugs. For all remaining exposures, each health care facility decides what, if any, protective measures to require or recommend to control nurses' exposures to hazardous agents in the workplace.
Figure 2. Nurses report elevated rates of cancer, asthma, and miscarriage linked to their exposures to hazardous hospital chemicals and agents.
Comparative rates of cancer, asthma, and miscarriage in nurses, scaled to reflect the number of health conditions expected in a population of 1,000 nurses based on the findings of this study. Increased incidence of disease in nurses with high exposure, relative to those with low exposure, is listed above the bars representing high exposure.
Notes: "High exposure" refers to reported exposure frequency of at least once a week for at least 10 years. "Low or no exposure" refers to all other, lower reported exposure frequencies. See Table 2 for further details of survey findings, including sample sizes.
Although these results are striking, this study has limitations. The group of participants that responded to the survey was not "controlled," or selected to meet any particular criteria — all nurses who learned of the survey through the publicity efforts of Health Care Without Harm, the American Nurses Association, the Environmental Health Education Center of the University of Maryland's School of Nursing, and other nursing organizations, were free to complete the online questionnaire. Though surveys are common means to collect information on health (e.g. Hemminki et al. 1982, Valanis et al. 1999, Mohan et al. 2003, Dimich-Ward et al. 2004, Yoshinaga et al. 2005, Delclos et al. 2006), research shows that self-selecting respondent pools would be expected to have higher than typical rates of health impacts, and to report higher exposures in cases where the respondent suspects an association with a health problem.
Another common issue when collecting health data via survey is the accuracy with which respondents report their medical conditions. Nurses are typically better educated about disease and health than the general population, and therefore may provide more accurate information via survey, but such "reporting bias" must be considered when reviewing this data. Analytical decisions regarding classification of the nurses into high and low exposure categories may also affect survey interpretation.
Survey analysis did not control for possible confounding factors like a nurses' exposure to multiple chemicals linked to common health effects, or for factors that often influence health, such as age, smoking and drinking habits, and day or night shift work. In particular, this study did not take into consideration the impact of mixed or combined chemical exposures, a serious issue because most nurses are exposed to multiple chemicals in the workplace at the same time. There is a critical need for research on the effects of multiple chemicals and hazardous agents interacting within the human body, similar to studies typically performed to investigate the potential impacts of combinations of medications on human health.
Yet despite these potential biases and limitations, these survey findings are remarkably consistent with laboratory and occupational studies of the hazardous agents investigated. While this survey does not provide definitive answers on health risks faced by nurses and their children, it does illustrate the critical need for standards that limit nurses' exposures to hazardous substances. It also demonstrates the necessity of a comprehensive, national study of nurses' health and exposures to chemicals and other hazardous materials.
In collaboration with Health Care Without Harm, the American Nurses Association, and the Environmental Health Education Center of the University of Maryland's School of Nursing, Environmental Working Group scientists designed an online survey to assess the relationships between nurses' health and their exposures to 11 different common health care hazards. Health Care Without Harm, the American Nurses Association, and other collaborating nursing organizations publicized the survey at a variety of their sponsored events. Survey responses were collected between March 26, 2005 and March 20, 2006. The survey was open to all nurses. EWG scientists compiled all completed responses from 1,552 nurses from 50 states who reported detailed information on their job and exposure history, health history, and the health of their 2,498 children.
The survey examined exposures to 11 chemicals, chemical groups, or hazardous agents: the high level disinfecting and sterilizing chemicals glutaraldehyde and ethylene oxide; medications, including antiretroviral and chemotherapeutic agents; hazards deriving from medical devices, such as mercury and ionizing radiation; anesthetic gases; natural rubber latex; hand and skin disinfection products; and housekeeping chemicals.
EWG scientists conducted standard statistical analyses of the data, assessing the incidence of health effects known or suspected to be associated with each category of exposure by comparing rates of these effects from among nurses reporting high exposures (frequent and of long duration) against nurses with lower reported exposures. Analysis revealed a striking concordance between survey findings and the health risks expected from a review of the open scientific literature with respect to the exposures assessed. Remarkably, for almost none of these hazardous substances are mandatory safety standards in place to protect nurses — any exposure, no matter how high, is legal.
Nurses face daily, chronic exposures to complex mixtures of chemicals and hazardous agents
The exposure assessment reveals that nearly all nurses face long-term exposures to diverse mixtures of chemicals and other hazardous agents, many of which are never tested for safety. Exposures to hazards are widespread, and typically occur in combination over many years:
- 32 percent of nurses report frequent exposure (at least twice weekly) to combinations of at least five chemicals and other hazardous agents for ten years or more.
- 52 percent of nurses report regular (at least once weekly) exposure to combinations of at least six chemicals and other hazardous agents for five years or more.
All but eight of the 1,552 nurses surveyed report exposures during their nursing careers to one or more of 11 hazardous chemicals, agents, or products included in the survey, and 10 nurses were exposed to combinations of at least 15 chemicals or agents at least twice a week for at least 10 years. Many nurses indicate long spans of their careers in which they were exposed to combinations of chemicals and agents that raise concerns, including the one of every 15 nurses surveyed who report exposures to combinations of sterilizing agents, waste anesthetic gases, and radiation at least weekly for at least five years.
These diverse exposures should come as no surprise to anyone in the health care community, or to anyone who has been a patient at a hospital or clinic for any length of time. What is surprising, though, is the lack of mandatory protections in place for nurses. Instead, health care workers must rely on their employers to implement voluntary controls, and to choose safer products, even when more hazardous alternatives may be less expensive or more commonly used.
Untested, low-dose mixtures of chemicals and hazardous agents. In this survey nurses report frequent, long-term exposures to compounds and agents for which exposures are typically legal at any level. Anesthetic gases leak from complex anesthesia machines and from a patient's exhaled breath into operating and recovery rooms where adequate ventilation is not mandatory (NIOSH 1994). Disinfecting and sterilizing agents, linked to allergies and cancer, volatilize and aerosolize into hospital air when equipment is disinfected with these chemicals (EPA 2002 & 2006a, Van Miller et al. 2002, NTP 2004, HCWH 2006). Housekeeping chemicals can build up on surfaces and in the air each time cleaning or disinfecting occurs, and may lead to asthma, allergies, and other, more serious health problems (GS 2004, HCWH 2004 & 2006).
Residues of hazardous medications cover chairs, tables, and counter tops throughout the hospital as a result of nurses administering these therapeutic agents in poorly ventilated areas (Minoia et al. 1998, Connor et al. 1999, Pethran et al. 2003). Latex gloves spur severe, debilitating allergies including anaphylaxis in some nurses (NIOSH 1997). Mercury-containing equipment breaks, spreading mercury vapors through the air of a room where a nurse works and breathes (OSHA 2006). When a nurse cleans or moisturizes a patient's skin or hair with personal care products, the products used contain ingredients that may be hazardous and that are never required to be tested for safety (EWG 2005), and when a nurse disinfects skin and hands to protect against the spread of infectious disease, she or he is exposed to additional chemicals that are also largely without safety limits (EWG 2005).
It is not surprising to find that most nurses feel unprotected at their workplace. In this survey, 46 percent of nurses report feeling that the administrations at their health care facilities are not doing enough to protect them from hazardous exposures, and 37 percent do not think that occupational health is taken seriously at their place of employment. Without safety standards, hospitals should at a minimum educate nurses to protect themselves, but only 38 percent of nurses report that chemical hazards like those mentioned in this survey were part of the occupational health education programs offered at their workplaces.
Nearly one in 10 nursing jobs in the U.S. currently stands open (AACN 2007). Projections show that this gap is expected to grow, as the 40 percent of nurses currently over age 50 begin to retire (ANA 2006); enrollment at nursing schools has not kept pace with this increased retirement rate (AACN 2007). As this country struggles to fill job vacancies and to plan for worse nursing shortages to come, government officials and health care administrators also expect nurses to work increasing numbers of hours, to care for more patients, and to do this in an environment that can be polluted with chemicals and other hazardous agents that have no safety standards and that pose long-term health risks.
To sustain the quality of health care in the U.S., and to encourage new, talented people to enter the nursing field, nurses need mandatory protections that provide them with a healthy and safe environment where they can focus on caring for others, knowing that their own health, and that of their children, will not be at risk in the process.
The government, individual health care facilities, nurses, and patients alike must take action to protect nurses from excess exposures to hazardous substances:
- The government should conduct a long-term, national survey of nurses' health and exposures to chemicals and other hazards, and use this data to regularly assess health risks nurses face from occupational exposures, and to inform efforts to improve safety standards. Those responsible for existing, broad studies of nurses' health should begin to collect data on occupational exposures to chemicals and other hazards. In 2001, the Centers for Disease Control and Prevention announced plans to implement a National Exposures at Work Survey within the health care industry. This survey, which would be repeated every ten years, would provide much needed data on nurses' exposures to hospital hazards, a first step towards identifying those hazards most in need of new or updated safety standards. After extensive preparation, including two pilot studies, funding for the survey has finally been secured. To protect nurses everywhere, we ask that further governmental approval of the study be expedited, so that it can be conducted as soon as possible.
- The government should establish mandatory limits for nurses' exposures to hazardous drugs, chemicals, and agents in the workplace, and should mandate that hospitals phase out the use of hazardous materials, like mercury and latex gloves, that new technologies can render obsolete.
- Health care facilities should act now to replace hazardous materials and to provide engineering controls nurses need to reduce exposures. Hospitals should phase out mercury-containing equipment, replace or control hazardous sterilizing agents, construct ventilation systems to clear waste gases from the air, and phase out latex gloves. They should monitor the air, surfaces, and even nurses' bodies for chemicals. They should educate nurses on the hazards and safe use of chemicals and other hazardous agents. And they should not wait for these actions to be mandatory.
- Nurses should work within their own facilities to catalyze these changes and reduce their own exposures.
- Patients should begin to ask their health care providers about programs in place designed to reduce a hospital or other health care facility's use of hazardous materials. Any such programs will protect not only nurses, but also patients, who can be exposed to the same chemicals that nurses contact day after day.
Nurses are exposed not only to chemicals used in the workplace, but also to trace contaminants in food, air, water and ingredients in consumer products. Studies of ordinary people indicate that typical Americans are contaminated with low levels of a range of man-made chemicals (e.g. EWG 2003). For almost none of these chemicals is the manufacturer required to conduct even the most basic of safety studies. Nurses' total body burden of chemicals, and ultimately the health risks these exposures impart, stem from these complex mixtures of largely untested, low doses of industrial and occupational chemicals.
Nurses' exposures demonstrate that dramatic improvements will require measures that go beyond those that would protect nurses from hospital exposures. Far-reaching reform is needed to overhaul an outdated system of public health protections, laid out in the 1976 Toxic Substances Control Act, that allows broad exposures to chemical mixtures, beginning even before the moment of birth, with largely unknown consequences to human health. This Act is the only major pubic health and environmental statute that has never been updated (GAO 1994 & 2005). Its reform should be a priority for anyone devoted to protecting public health.
Table 1. Study details - Nurses with high exposures report elevated rates of cancer and birth defects among their children
|Increased incidence in children of nurses with high exposure during pregnancy (versus low or no exposure)||High exposure during pregnancy: Nurses' children with the listed health problem (values in parentheses are scaled to per 1,000 children)||Low exposure during pregnancy: Nurses' children with the listed health problem (values in parentheses are scaled to per 1,000 children)||Selected supporting studies|
|Cancer among nurses' children|
|Radiation||36%||5 of 466 (11 of 1,000)||16 of 2,023 (8 of 1,000)||Studies from several countries indicate that past radiographic examinations of the abdomens of pregnant women produced an increased risk of development of childhood cancer of about 40 percent (Doll and Wakeford, 1997). Nurses' risk of having children stricken with cancer from occupational radiation exposures in utero has never been studied.|
|Birth defects (all types) among nurses' children|
|Medications, all types||74%||63 of 751 (84 of 1,000)||84 of 1,738 (48 of 1,000)||A study of nurses in Finland revealed rates of birth defects 4.7 times higher for those handling chemotherapeutic agents, based on eight cases (Hemminki et al. 1985).|
|Antineoplastic drugs||67%||29 of 319 (91 of 1,000)||118 of 2,170 (54 of 1,000)|
|HIV (antiretroviral) drugs||82%||29 of 296 (98 of 1,000)||118 of 2,193 (54 of 1,000)|
|Housekeeping chemicals||97%||63 of 687 (92 of 1,000)||84 of 1,802 (47 of 1,000)|
|Musculoskeletal defects among nurses' children|
|Glutaraldehyde||639%||6 of 206 (29 of 1,000)||9 of 2,283 (4 of 1,000)||Animal studies indicate glutaraldehyde and ethylene oxide exposures in utero may cause birth defects of the musculoskeletal system (Marks et al. 1980, NTP 1987, Rutledge and Generoso 1989). Studies of this effect among children of nurses exposed to disinfecting and sterilizing agents are needed.|
|Ethylene oxide||639%||6 of 206 (29 of 1,000)||9 of 2,283 (4 of 1,000)|
|Anesthetic gases||824%||8 of 274 (29 of 1,000)||7 of 2,215 (3 of 1,000)||Animal studies indicate exposures to anesthetic gases in utero may cause birth defects of the musculoskeletal system (Fujinaga et al. 1991). More studies of the health of children of nurses and other health workers exposed to anesthetizing agents are needed.|
Notes: "High exposure" refers to reported exposure frequency of at least once weekly during pregnancy. "Low or no exposure" refers to all other, lower reported exposure frequencies.
Table 2. Study details - Nurses with high exposures report elevated rates of cancer, asthma, and miscarriage
|Increased incidence in nurses with high exposure (versus low or no exposure)||High exposure: Number of nurses with the listed health problem (values in parentheses are scaled to per 1,000 nurses)||Low exposure: Number of nurses reporting the listed health problem (values in parentheses are scaled to per 1,000 nurses)||Selected supporting studies|
|14%||103 of 777 (133 of 1,000)||90 of 775 (116 of 1,000)||Many pharmaceuticals, notably antineoplastic drugs used to treat cancer, can themselves cause cancer. The International Agency for Research on Cancer has classified 36 antineoplastic drugs as known, probable, or possible human carcinogens (Connor et al. 2006). The few available studies of nurses have found elevated rates of leukemia and chromosome damage associated with exposures to antineoplastic drugs (Martin 2005).|
|Antineoplastic drugs||42%||27 of 159 (170 of 1,000)||166 of 1,393 (119 of 1,000)|
|Radiation||22%||10 of 264 (38 of 1,000)||40 of 1,288 (31 of 1,000)||Three studies of a nationwide cohort of over 140,000 radiological technologists indicate elevated risk of breast cancer in women (Doody et al. 1998, Mohan et al. 2003, Sigurdson et al. 2003). Nurses' risk of breast cancer from radiation exposures has never been studied.|
|Glutaraldehyde||46%||38 of 304 (125 of 1,000)||107 of 1,248 (86 of 1,000)||In a study of health care workers with work-related asthma in four states, nine percent reported that glutaraldehyde triggered asthma symptoms (Pechter et al. 2005). Respiratory therapists using glutaraldehyde were three times more likely to report asthma as those who did not (Dimich-Ward et al. 2004). 3,650 health care workers surveyed in Texas, including 941 nurses, were 2.22 times more likely to develop asthma if they sterilized instruments in the workplace (Delclos et al. 2006).|
|Ethylene oxide||45%||14 of 110 (127 of 1,000)||127 of 1,442 (88 of 1,000)|
|Housekeeping chemicals||47%||70 of 623 (112 of 1,000)||71 of 929 (76 of 1,000)||In a study of health care workers with work-related asthma in four states, 24 percent reported that cleaning products triggered asthma symptoms (Pechter et al. 2005). 3,650 health care workers surveyed in Texas, including 941 nurses, were twice as likely to develop asthma if they performed general cleaning tasks as part of their jobs (Delclos et al. 2006).|
|Latex||39%||85 of 783 (109 of 1,000)||60 of 769 (78 of 1,000)||Natural rubber latex is a widely recognized asthmagen. A survey of 3,650 health care workers in Texas, including 941 nurses, revealed that the likelihood that these workers developed asthma during their careers was 2.17 times greater if they used powdered latex gloves during years 1992 to 2000 (Delclos et al. 2006).|
|Ethylene oxide||24%||33 of 110 (300 of 1,000)||350 of 1,442 (243 of 1,000)||Nurses performing sterilizing procedures during pregnancy were three times more likely to experience miscarriage than other nurses, according to a study of Finnish hospital staff. Increased miscarriage was linked specifically with exposure to ethylene oxide, as opposed to other sterilizing agents (Hemminki et al. 1992).|
|Medications, all types||19%||208 of 777 (268 of 1,000)||175 of 775 (226 of 1,000)||Studies of health care workers from three different countries revealed rates of miscarriage 1.5 to 2.3 times higher for those who handled antineoplastic medications while pregnant, as compared to those who did not (Selevan et al. 1985, Stücker et al. 1990, Valanis et al. 1999).|
|Antineoplastic drugs||14%||44 of 159 (277 of 1,000)||339 of 1,393 (243 of 1,000)|
Notes: "High exposure" refers to reported exposure frequency of at least once a week for at least 10 years. "Low or no exposure" refers to all other, lower reported exposure frequencies.