Occupational Risk Factors Among Nursing Professionals​

Background

Health care and social assistance makes up 12.4% of the Ontario workforce [1]. In 2019, there were over 160,000 nurses working in Ontario [2]. Nurses treat people who are sick, injured, or infirm, and support the delivery of around-the-clock care for patients. They also provide health services to the public.

The Occupational Disease Surveillance System (ODSS) follows 36,400 nurses in the health care sector:

• 79% work in Hospitals
• 6% work in Related Health Care Institutions such as nursing and long-term care homes
• 6% work in Welfare Services such as boarding houses for the aged, day nurseries, and shelters
• 5% work in Miscellaneous Health Services such as voluntary health associations primarily engaged in promoting health and health services
• 4% work in Diagnostic and Therapeutic Services such as medical, dental or x-ray laboratories providing analysis, diagnosis or treatment services
• 1% work in Offices of Physicians and Surgeons or Offices of Para-Medical Personnel (Practitioners)

Note: Percentages do not total to 100% as nurses may have worked in more than one sector  

Occupational Exposures

Nurses work in a variety of settings and circumstances that result in different occupational exposures. Potential occupational exposures include night shift work, ionizing radiation, antineoplastic (anti-cancer or chemotherapy) drugs, and wet work. These occupational exposures are highlighted here based on their link to disease outcomes currently monitored in the ODSS. Other occupational exposures in nursing that are not addressed in this alert include infectious diseases and traumatic stress, among others.

Night shift work
Night shift work impacts approximately 18% of workers in health care and social assistance [3]. It is classified as a probable cause of breast cancer by the International Agency for Research on Cancer [4]. Working night or rotating shifts can also lead to poorer quality of sleep, increased stress, lifestyle disturbances, reduced sun exposure and disruptions to the body’s circadian rhythm [5]. Scheduled nursing shifts typically range from about 8-12 hours, and approximately 25% of nurses report working overtime hours [6].

Ionizing radiation
Nurses may be exposed to low-dose ionizing radiation such as x-rays when assisting patients during diagnostic imaging procedures, or caring for patients undergoing treatments involving radioactive substances (i.e. brachytherapy or therapeutic nuclear medicine) [7,8]. Ionizing radiation is a known risk for cancer development [9] and some studies have linked long-term exposure to low doses of ionizing radiation with an increased risk of some cancers, though the evidence is inconsistent [10-13].

Antineoplastic drugs
Preparing and administering antineoplastic drugs can lead to occupational exposure for workers through dermal contact (touching a contaminated surface), ingestion (via hand-to-mouth contact), inhalation (of aerosols from liquid medications or dusts from crushed tablets), and possibly through accidental injection from sharps and needles [14, 15]. Health risks resulting from occupational exposures to antineoplastic drugs include cancer and adverse reproductive outcomes (i.e. stillbirth, low birthweight, congenital anomalies) [16-18].

Wet work
Wet work involves extensive hand washing (more than 20 times per shift), immersing hands in water for more than 2 hours per shift, or wearing gloves for extended periods. Wet work has been identified as a main risk factor for hand dermatitis which can cause hands to be itchy or painful. It may occur for a short period (acute) or be a long-lasting (chronic) condition.

Occupational Disease Risks

Elevated risk of breast cancer, melanoma, thyroid cancer, myeloma, non-Hodgkin lymphoma, asthma, and carpal tunnel syndrome were observed among nurses compared to other occupations in the ODSS. Contact dermatitis is also an occupational disease risk common in nurses although this relationship was not observed in the ODSS.

Breast Cancer
Nursing professionals employed across institution types had consistently increased risks of melanoma. Previous studies have similarly observed higher risk for melanoma among nurses although the relationship is not well understood [19-21].

Sub-sector or occupation	Increased risk
Female nurses, overall	20%*
In hospitals	22%*
In diagnostic and therapeutic services	40%*
In offices of physicians and surgeons	85%
Males working in nursing, therapy and related assisting occupations	351%
*Statistically significant (α=0.05)

Melanoma
Nursing professionals employed across institution types had consistently increased risks of melanoma. Previous studies have similarly observed higher risk for melanoma among nurses although the relationship is not well understood [19-21].

Sub-sector or occupation	Increased risk
Nurses, overall	53%*
In hospitals	44%*
In related health care institutions	54%
In diagnostic and therapeutic services	92%*
In miscellaneous health services	219%*
In welfare organizations	54%
*Statistically significant (α=0.05)

Thyroid Cancer
The thyroid is one of the body’s most sensitive organs to ionizing radiation and studies have shown that occupational exposures to low doses of ionizing radiation have an effect on thyroid function [22].

Sub-sector or occupation	Increased risk
Nurses, overall	23%*
In hospitals	23%*
In related health care institutions	32%
In diagnostic and therapeutic services	23%
In miscellaneous health services	17%*
*Statistically significant (α=0.05)

Myeloma
Previous research has found increased risks of myeloma among health care workers and suggests that the higher risks may be attributed to exposure to viral and bacterial infections [23,24]. Working in diagnostic and therapeutic services may lead to higher levels of exposures to infectious patients or infectious substances in patient bio-samples.

Sub-sector or occupation	Increased risk
Nurses, overall	26%
In hospitals	29%
In diagnostic and therapeutic services	295%*
*Statistically significant (α=0.05)

Non-Hodgkin lymphoma (NHL)
Occupational risk factors for NHL are not well understood. Some previous studies have found an increased risk of NHL among patients exposed to ionizing radiation from medical imaging, as well as among people infected with certain viral pathogens. While occupational exposure has not been directly linked to increased risk, these may be possible NHL risk factors for nurses [25].

Sub-sector or occupation	Increased risk
Nurses, overall	—
In hospitals	23%
NHL results were not statistically significant.

Asthma
Previous studies have observed increased risk of asthma among health care workers and have attributed this to the use of cleaning products and administration of aerosolized medications [26-28].

Sub-sector or occupation	Increased risk
Nurses, overall	—
In related health care institutions	56%*
In diagnostic and therapeutic services	165%*
*Statistically significant (α=0.05)

Carpal tunnel syndrome
Repetitive or forceful hand and wrist movements may put nurses at risk of developing carpal tunnel syndrome. Pushing down the plunger in syringes, pressing blood pressure bulbs, or manually lifting or moving a patient are some of the repetitive movements that nurses may encounter.

Sub-sector or occupation	Increased risk
Nurses, overall	—
In related health care institutions	17%
In welfare organizations	40%*
*Statistically significant (α=0.05)

Contact dermatitis
Nursing professionals are generally considered high risk for dermatitis due to exposure to wet work through hand hygiene and extensive glove use. Studies have reported that contact dermatitis among health care workers remains high even with the promotion of preventative measures such as developing best practice guidelines for glove use, using hand moisturizing products, and using hand alcohol with emollients (moisturizer) instead of soap and water as a disinfectant when appropriate [29,30].

This association was not observed among nurses in the ODSS. A possible explanation may be that nurses may be more likely than other workers to self-manage their skin condition, so no physician diagnosis is captured in the data sources establishing the ODSS [31].

Resources: Free e-learning module on work-related contact dermatitis offered by Public Services Health & Safety Association.

Occupation and industry descriptions

1. Nurses: occupations concerned with assisting physicians and giving nursing care to the sick or injured. This definition includes Nurse Practitioners, Registered Nurses, Registered Psychiatric Nurses, and Licensed Practical Nurses. This does not include nursing supervisors.
2. Diagnostic and Therapeutic services: Establishments primarily engaged in rendering diagnostic and therapeutic services not elsewhere specified. This includes laboratories (dental, medical, x-ray, etc.), providing professional analysis, diagnosis, or treatment services, or organizations such as the Red Cross Blood Transfusion Service, and St. John Ambulance.
3. Nursing, Therapy, and Related Assisting Occupations: encompasses occupations concerned with giving nursing care to the sick and other related assisting occupations such as nursing supervisors, graduate nurses, registered nursing assistants, physiotherapist, occupational therapists, nursing aides and orderlies, and other related assisting occupations not elsewhere classified.
4. Related Health Care Institutions: Establishments such as nursing homes and infirmaries primarily engaged in providing nursing care and accommodations for inpatients.
5. Miscellaneous Health Services: Establishments commonly referred to as voluntary health associations primarily engaged in promoting health and health services other than diagnostic or therapeutic services. This includes places such as Canadian Hospital Association, Canadian Public Health Association, National Cancer Institute.
6. Welfare Organizations: Establishments primarily engaged in providing basic home care (no treatments or nursing care), such as homes for the aged, blind or senile, boarding houses for the aged, day nurseries, or shelters.

Risk Reduction Strategies

It is important to identify and understand workplace hazards to be able to properly control them. The recognizing, assessing, controlling, and evaluating (RACE) process is designed to help identify and address workplace hazards. More information on this process can be found on Ministry of Labour, Training and Skills Development’s Supervisor Health and Safety Awareness in 5 steps document here.

Implementing comprehensive exposure reduction policies and practices at the system and institutional level that include, wherever possible, elimination, substitution, and engineering controls in addition to administrative practices can reduce occupational exposures for workers. Employers should also continue providing workers with education and training in reducing the risk of occupational exposures.

Night shift work
For nurses working in institutions providing around the clock care, night shift work may be unavoidable. However, some of the adverse health effects of shift work may be reduced through modifications to shift scheduling practices [32,33]. Risk reduction strategies presented by the Institute of Work and Health and the Workers Health & Safety Centre include, where possible:

• Avoiding permanent night work
• Using forward-rotating (morning to evening to night) shift schedules
• Limiting the number of consecutive night shifts
• Increasing the speed of shift rotations
• Providing adequate resting time (>11 hours) between shifts
• Limiting weekend work
• Allowing self-scheduling to give individuals some control over their work and rest days

Ionizing radiation
Exposure to ionizing radiation should be kept as low as reasonably achievable. This is accomplished by reducing the time spent in areas with radiation exposure, increasing the distance between the worker and radiation source, and properly using shielding barriers such as a lead apron or concrete walls. Wearing personal dosimeters when at work helps measure radiation exposure and can help prevent overexposure.

There are both federal and provincial regulations governing the use of ionizing radiation in healthcare settings to reduce the risk of ionizing radiation to workers. This includes ensuring adequate shielding is used in the design of workspaces, use of warning indicators, and ensuring regular testing of equipment. More information on government regulations can be found below:

• Radiation-regulation and application in healthcare settings
• Radiation Safety Institute of Canada

Antineoplastic drugs
Ensuring institutions have policies and procedures in place outlining the safe handling of antineoplastic drugs can help reduce the risk of worker exposure. All potentially exposed workers should have access to safety protocols and have routine training on the safety procedures to prevent mishandling. This includes workers at all stages of antineoplastic drug handling, from shipping and storage to disposal.

Implementing engineering controls such as biological safety cabinets, using separate equipment when handling or dispensing antineoplastic drugs, or closed system transfer devices can also minimize occupational exposure.

Resources:
The Public Services Health and Safety Association:

• The Antineoplastic Drug Risk Assessment in Community Settings Manual provides a guide and assessment tool aims to help workplaces identify and reduce their exposure to antineoplastic drugs
• Free e-learning module available on antineoplastic drugs. This module was developed through the Ministry of Labour, Training and Skills Development funding with Dr. Chun- Yin Hop

Occupational Cancer Research Centre:

• Assessment of safe antineoplastic drug handling practices in community pharmacies, veterinary settings and long-term care homes in Ontario report

Screening
Following proper cancer screening guidelines can help identify and treat cancers earlier, and lead to better treatment outcomes.

Breast cancer screening: The Ontario Breast Screening Program encourages most women between the ages of 50-74 to get screened using mammography every 2 years. To learn more about the Ontario Breast Screening Program, visit the Cancer Care Ontario website here.

Skin cancer screening: Ontario does not have a routine skin cancer screening program. Those at higher risk of skin cancer are advised to see their health care provider or dermatologist to discuss their risk and any routine screening recommendations. Examples of factors that may increase the  risk of skin cancer include a family history of melanoma, a personal history of skin cancer (basal or squamous cell carcinoma), or use of medications that weaken the body’s immune response (i.e. immunosuppressive medication after an organ transplant) or make the skin more sensitive to the sun.

The Canadian Dermatology Association has outlined steps for individuals to complete a self-skin examination at home with what to look for during the examination.

The Occupational Disease Surveillance System (ODSS) Surveillance Bulletins provide summaries of occupational exposures and disease risks across different industries and occupational groups detected through occupational disease surveillance. At this time the ODSS includes workers from 1983-2019 and follows their health outcomes until 2020. This bulletin reflects only the diseases currently tracked within the ODSS. The system is updated and expanded on an ongoing basis. 

This bulletin reflects only the diseases currently tracked within the ODSS. The system is updated and expanded on an ongoing basis.

More information about the ODSS including data sources, methods and detailed results can be found at https://www.occupationalcancer.ca/odss/ and OccDiseaseStats.ca.