Nurses' Health

A Survey on Health and Chemical Exposures

December 11, 2007

Nurses' Health: Nurses' Exposure

Nurses' Workplace Exposures

Environmental Working Group, Health Care Without Harm, the American Nurses Association, and the Environmental Health and Education Center of the University of Maryland's School of Nursing conducted a survey on hazardous exposures and the health of nurses nationwide. 1,552 nurses responding to the survey reported exposures to numerous chemicals and other hazards found in hospitals. Exposures to hazards were widespread, and typically occurred in combination over many years:

(*Exposure was considered frequent if it occurred at least 2-3 times per week, and regular if it occurred at least once per week. In this study, "high" exposure is classified as exposure at least once per week for at least ten years.)

  • 32 percent of nurses reported frequent* exposure to combinations of at least five chemicals and other hazardous agents for ten years or more.

  • Half of nurses reported regular* exposure to combinations of at least six chemicals and other hazardous agents for five years or more.

The cumulative health risks to nurses from their long-term exposures to complex mixtures of chemicals and other hazardous agents have never been studied. Many investigations, however, show that chemicals in combination can be more toxic than would be predicted based on studies of the chemicals singly. For example, a government study of the HIV drug AZT, in combination with another medication commonly prescribed to patients with AIDS, found a far greater than expected level of blood damage when the two were given to mice simultaneously (NIEHS 1998).

The unexpected and unexplained synergistic effect produced by this combination of drug therapies suggests that nurses too may experience health effects difficult to predict based on studies of each chemical exposure individually. This survey 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 evaluating the combined impact of chemicals on the human body, analogous to studies of the potential health impacts of combinations of pharmaceutical agents in patients.

When speaking on indoor air pollutants like those commonly found in hospitals, an EPA official noted that some people are more susceptible than others to what can be very low levels of exposure: "...mainstream medical opinion today would tell you there's no evidence that such low concentrations would cause adverse reactions in people. However, I think a moment's consideration will tell you that people differ in their response to environmental stimuli by many orders of magnitude. And some people are going to react at extremely low concentrations" (Tomlinson and Wallace 1995).

This survey examined 11 specific hazardous exposure categories. These included 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. Exposure frequencies reported by nurses who completed this survey are shown in Table 1.

Nurses' Exposures

Table 1: Nurses are exposed to numerous occupational hazards, often lasting a decade or more, and sometimes while pregnant

Summary of nurses' exposures reported in this survey. All percentages are reported relative to the entire surveyed nurse population.

Hazardous Exposure Any On-the-Job Exposure Regular Exposure for at least Ten Years Any Exposure While Pregnant
Anesthetic gases 36% 11% 12%
Antiretroviral medications 47% 11% 13%
Chemotherapeutic agents 41% 10% 13%
Ethylene oxide 29% 7% 9%
Glutaraldehyde 52% 20% 16%
Hand and skin disinfection 96% 53% 30%
Housekeeping chemicals 92% 40% 29%
Ionizing radiation 53% 17% 19%
Latex 94% 50% 30%
Medications 95% 50% 31%
Mercury-containing devices 77% 36% 27%

It is not surprising that over 90 percent of nurses report workplace exposure to the four most commonplace health care hazards: hand and skin disinfection products, medications, housekeeping chemicals, and latex.

Perhaps more surprisingly, one in five nurses responding to this survey reported regular exposure to glutaraldehyde for at least ten years. Glutaraldehyde is an allergen (Takigawa and Endo 2006), an irritant (Takigawa and Endo 2006), and a suspected asthmagen (Delclos et al. 2006, HCWH 2006), a chemical that can cause those exposed to develop asthma. Animal studies link glutaraldehyde exposure to a number of other health effects, ranging from anemia (Bandman et al. 1994) to leukemia (Van Miller et al. 2002).

One in five nurses reported exposure to ionizing radiation while pregnant. Studies of childhood cancer indicate increases in cancer development in children exposed to low levels of ionizing radiation in utero (Cox et al. 1995, Doll and Wakeford 1997). The National Academy of Sciences Board on Radiation Effects Research (BRER), an authority on the risks associated with occupational exposures to ionizing radiation, considers no exposure to be too low to produce potential health effects (Prasad et al. 2004, BRER 2006).

Examples like these highlight the high frequency and lengthy duration of exposures of many nurses to numerous hospital hazards. Forty-six percent of nurses responding to the survey felt that the administrations at their health care facilities were not doing enough to protect nurses from hazardous exposures. Only 38 percent of nurses reported that chemical hazards like those mentioned in this survey were part of the occupational health programs offered at their workplaces. Armed with the information provided on this site, nurses can advocate for change to reduce their exposure to toxins in their places of work, improving their health and the health of their patients. Of the 11 exposure categories included in this survey, three are highlighted below.

Hazardous medications. Studies that measure residues of medications in nurses' urine indicate widespread exposures to fugitive particles and vapors, even among nurses who don't prepare and administer drugs (NIOSH 2004). Wipe samples from 14 studies show ubiquitous contamination of work surfaces with drug residues, including floors, counter tops, storage areas, and even tables and chairs in patient waiting areas (NIOSH 2004). Nurses are exposed when they touch these surfaces. In addition, they are exposed directly when they breathe vapors and particles as they prepare drugs, expel air from syringes, sort capsules, handle drug containers, or even when they clean a patient's body fluids.

One nurse in this study, who completed an optional survey section tracking potential exposures over a single shift, reported that among all her other types of exposures she also prepared and delivered 19 separate medications, some for multiple patients, that included capsules, intravenous medications, patch medications, gels, liquids, and aerosols.

Although the National Institute for Occupational Safety and Health (NIOSH) acknowledges that "it is known that exposures to even very small concentrations of certain drugs may be hazardous for workers who handle them or work near them," the government has yet to set enforceable limits for nurses' exposures to drugs for any but a few of the nearly 5,700 drugs approved by the FDA (NIOSH 2004); does not mandate that hazardous drugs be prepared in controlled, carefully ventilated environments; and has issued only a guidance document in lieu of standards that would protect nurses from exposures to the hazardous drugs their jobs routinely require them to handle (NIOSH 2004).

Latex. In the decade following Centers for Disease Control and Prevention's (CDC) 1987 recommendation for universal precautions for health care workers to protect against the spread of AIDS, the use of latex gloves in the U.S. soared from a rate of two billion to nine billion pairs each year (Tillotson 1997). Though still the industry standard for gloves, latex is now known to be a potent allergen. NIOSH estimates that 8 to 12 percent of all health care workers have become allergic to latex (NIOSH 1997), with reactions ranging from skin irritation to asthma and anaphylactic shock. Nurses with an allergy to latex have trouble avoiding exposure: Latex is used not only in gloves, but also in catheters, blood pressure cuffs, anesthesia equipment, and even balloons, pencil erasers, and lingerie elastic.

OSHA now mandates that facilities provide alternatives to latex for workers who develop allergies (29 CFR 1910.1030(d)(3)(iii)), but does not require replacement of latex products to prevent allergies in the first place. OSHA continues to allow the use of powdered latex gloves, even though the latex protein allergens bind to the powder, significantly increasing allergy risks for nurses who inhale powder that becomes airborne when gloves are removed (NIOSH 1997). Work in health care facilities can become impossible for nurses who develop severe allergies from latex.

NIOSH recognizes the potential severity of latex reactions, noting that "in some instances, sensitized employees have experienced reactions so severe that they impeded the worker's ability to continue working in their current job" (NIOSH 1997). A review in the journal Nursing gives a more direct assessment: "More than a minor annoyance, a severe latex allergy could end your career" (Lenehan 2002). Latex allergy is a preventable disease that is completely avoidable, but still prevalent among nurses because of the resistance of the government and health care facilities to require the use of widely-available latex alternatives.

Mercury. Although mercury is a widely-recognized, potent neurotoxin, hospitals and other health care facilities across the country continue to use mercury-containing equipment like thermometers and sphygmomanometers. The government continues to allow these uses even though cost-effective alternatives are widely available. When mercury devices break, the mercury vaporizes. Nurses can inhale these vapors, allowing efficient absorption of mercury through the lungs to the bloodstream and then to the brain. Although this survey did not collect data on nurses' exposures to broken mercury instruments, it did gather information on how often and over how many years of their career they used mercury-containing devices. Analysis revealed that more than one-third of all nurses used mercury devices routinely (at least once weekly) for ten years or more.

A typical large hospital might have over one hundred pounds of mercury on-site, contained within hundreds of devices throughout the facility, unless it has taken specific steps to replace mercury-containing equipment (HERC 2004). A large hospital in Los Angeles documented about 18 mercury spills each year, and estimated cleanup costs as $10,000 per year in labor alone (EPA 2002). The cost of replacing mercury-containing devices is modest in comparison. No federal regulations mandate mercury phase-outs in hospitals. Instead, OSHA has set an enforceable exposure limit for nurses that is five times the level known to lead to neurological symptoms after several years of occupational exposure.