Inquiries received in the ONS clinical inbox (clinical@ons.org) often ask about various responsibilities of nurses who hold an ONS chemotherapy provider card and have been deemed competent to administer cancer treatments within their practice setting.

One issue periodically mentioned is an institutional policy or procedure that requires specially trained oncology nurses to start treatment infusions on units that may not have nurses with adequate training to do so, such as an intensive care or telemetry unit. In some instances, chemotherapy-competent nurses are asked to leave their patient assignment to perform a treatment order verification, start or discontinue an infusion on another unit, and return to their own unit and patient workload while the treatment is infused. In these situations, the question to ask is, does the person monitoring the patient receiving treatment have the education and training to be able to recognize an infusion reaction or other toxicity and to properly intervene?

Organizational Procedures and Training

The training of nurses who administer and monitor chemotherapy and care for clients receiving chemotherapy needs to be established by each institution. Safety of the patient and nursing staff are of utmost importance, and organizational policy and procedure development should be guided by practice recommendations and standards, such as the ONS position statement on the Education of the Nurse Who Administers and Cares for the Individual Receiving Chemotherapy and Biotherapy, the American Society of Clinical Oncology/ONS Chemotherapy Administration Safety Standards, and the ONS Standard for Educating Nurses Who Administer Chemotherapy and Biotherapy.

Regardless of the care setting type, treatment indication, route of administration, or patient population, any healthcare professional who handles hazardous drugs should be specially educated regarding their use, side effects, administration practices, safe handling, potential spill issues, patient complications, and potential for emergency procedures.

Timeframe for Monitoring

A key point that both the ONS Access Device Standards and the Intravenous Nurses Society’s Infusion Therapy Standards of Practice support is that the clinical evaluation of treatment administration includes the entire time an agent or regimen is infusing, from the start to the end of the infusion. This includes monitoring the administration site while protecting the patient from adverse events throughout the infusion.

Therefore, a chemotherapy-competent nurse who initiates the infusion holds responsibility for assessment of infusion site complications and immediate or acute symptoms until patient care transitions to another chemotherapy-competent nurse. Although evidence is lacking regarding a recommended time frame in which a patient needs to be monitored for symptoms following treatment, drug-specific and patient-related factors that can affect treatment response must be considered. As a result, the staff monitoring patients receiving chemotherapy and caring for those who have received chemotherapy must have the knowledge, skills, and ability to identify and safely address issues that may arise during and following treatment.

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Posted by Sheryl Stewart… (not verified) 3 weeks 5 days ago

I agree with this 100%. However after 30 years as a oncology nurse working in patient, out patient from bedside, chairside, staffing, research, education management, to CNS and now back to direct patient care as A staff RN I have yet to see such a standard supported by hospital administration. I have witnessed this at 5 different hospitals. I have served in advanced roles and sat on many committees involved with making practice change based on EBP. Bottom line, the support is not there. If anyone has been successful in making this happen, I would be very interested in your pathway to success. Thanks!

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Posted by Lorie Shepard, RN (not verified) 3 weeks 5 days ago

It is a great liability for the Oncology nurse, when asked to start an infusion for another unit, then go back and care for her own patients on her floor. The question lingers, is the nurse who started the infusion responsible for the outcome? We cannot give a crash course on the monitoring procedure of a chemo agent in a few minutes and hope it all turns out all right. In the past I have worked at hospitals that would have an off duty onc nurse come in just to administer the chemo on the other floor and stay with the patient until it finishes. But this is not always possible. It is a great liability to the Oncology nurse, who has her own patients to care for on her floor. She/he is putting their license on the line, in the event of any untoward reaction or event happening with that patient on the other unit. Very good article.

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Posted by Robin Atkins (not verified) 3 weeks 5 days ago

Oh my, I also totally agree with ONS on this subject. I too have been in outpatient oncology for nearly 30 years, 100% of the time at the chairside, +/- managerial roles, served on conference committees, facilitated the live, 2-day Chemo Bio course when it was in vogue, and continue to volunteer for ONS as a reviewer. But for the last 6 years I've worked in an outpatient setting that is also now a department of the greater medical center we were affiliated with. Our center is a first for this health system and unfortunately, the health system routinely fails to heed the advice and guidance of the oncology leadership in place at the time of the transition. You are right, Sheryl, the support is not there. Our health system is enjoying being associated with the legacy of our founding physicians, who are no longer with us, yet are not investing in the ongoing development of the speciality service line. I am so frustrated with this. Sheryl, were any of the institutions you worked in specialty hospitals or health systems dedicated to cancer care only? I'm wondering if this is the problem...that oncology care should stand alone as an institution rather than be a part of a hospital system...thoughts?

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Posted by Jo Herrick (not verified) 3 weeks 4 days ago

I appreciate the information in this article.

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Posted by Stephanie youn… (not verified) 3 weeks 4 days ago

In our hospital the patient needing chemotherapy is always transferred to the oncology unit. We never send nurses to other floors to administer chemotherapy for the very reasons cited above. While this may not be feasible in every institution, I do not see how this is safe practice allowing a non-oncology-experienced staff monitor a patient receiving chemotherapy. Even if the oncology RN begins and makes periodic "checks;" this is not up to standards of ONS!

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Posted by ONC RN (not verified) 3 weeks ago

I have worked as a bedside nurse for 8 years. This has recently been a hot item for our organization. We travel all over the hospital and administer chemo. ICU/PCU/ MS/IR for Intrathecal. It is not safe, for the patient or any staff involved. Especially when you consider the RN: patient ratio with which it is being administered in. It would be wonderful is someone started caring for the safety of the patient vs. the money.

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