Mortality and cancer incidence in a cohort of registered nurses from British Columbia, Canada

Epidemiology of Suicide Mortality Among Nurses Internationally

AIM

To examine the epidemiology of suicide mortality among nurses internationally.

METHODS

The literature was searched to identify studies that analyzed suicide mortality among nurses internationally. Cumulatively, n = 61 studies were included (i.e. n = 40 epidemiological and n = 21 cohort).

RESULTS

Epidemiological and cohort evidence on nurse suicide mortality were available for the European Region, Region of the Americas, and Western Pacific Region. Male nurse suicide rates in the European Region were both below and above male age-standardized suicide rates in this region, while female nurse suicide rates in the European Region were above female age-standardized suicide rates in this region. Male nurse suicide rates in the Region of the Americas were above male age-standardized suicide rates in this region, and female nurse suicide rates in the Region of the Americas were both below and above female age-standardized suicide rates in this region. Male nurse suicide rates in the Western Pacific Region were above male age-standardized suicide rates in this region, and female nurse suicide rates in the Western Pacific Region were both slightly below and above female age-standardized suicide rates in this region.

CONCLUSION

There were no epidemiological or cohort studies on nurse suicide mortality within three global regions (i.e. African, Eastern Mediterranean, and South-East Asia), and research in these regions is important in building the evidence base. Cumulatively, it remains difficult ascertaining cross-regional nurse suicide risk, in part, due to the limited availability of global data on occupation-specific suicide mortality.

Suicide, self-harm, and suicide ideation in nurses and midwives: A systematic review of prevalence, contributory factors, and interventions

BACKGROUND

Nurses have been identified as an occupational group at increased risk of suicide. This systematic review examines the prevalence of, and factors influencing, suicide and related behaviours among nurses and midwives (PROSPERO pre-registration CRD42021270297).

METHODS

MEDLINE, PsycINFO, and CINAHL were searched. Articles published from 1996 onwards exploring suicidal thoughts and behaviours among nurses and midwives were included. Quality of included studies was assessed. Articles were subjected to narrative synthesis informed by suicide data examined, study design, and quality. PRISMA guidelines were followed.

RESULTS

A total of 100 studies were eligible for inclusion in the review. Articles examining suicide exclusively among midwives were absent from the literature. Several studies confirmed that nursing professionals, especially female, are at increased risk of suicide, particularly by self-poisoning. Factors contributing to risk include psychiatric disorders, alcohol and substance misuse, physical health problems, and occupational and interpersonal difficulties. In studies of non-fatal suicidal behaviours, including during the COVID-19 pandemic, psychiatric, psychological, physical and occupational factors were contributory. There has been little investigation of interventions for prevention of suicide in nurses.

LIMITATIONS

Only articles published in English language were reviewed.

CONCLUSIONS

The findings highlight the risk of suicide in nurses. They also show a combination of factors contribute to suicide and non-fatal suicidal behaviour in nurses, with psychiatric, psychological, physical health, occupational and substance misuse (especially alcohol) problems being particularly important. The limited evidence regarding prevention measures indicates a major need to develop primary and secondary interventions for this at-risk occupational group, for example, education regarding enhancing wellbeing and safe alcohol use, alongside accessible psychological support.

Suicidal Behaviors Among Nurses in Canada

BACKGROUND

Nurses are regularly exposed to potentially psychologically traumatic events, experience high rates of burnout, and may be at an elevated risk of death by suicide. Few studies have assessed for suicidal behaviors among Canadian nurses, and factors that may increase risk for suicidal behaviors are unknown.

PURPOSE

The current study was designed to assess past-year and lifetime suicidal behavior (i.e., ideation, plans, and attempts) using a large sample of Canadian nurses.

METHOD

Participants (n = 3969; 94.3% women) completed an online survey including measures of suicidal behavior and symptoms of mental disorders.

RESULTS

Considerable proportions of participants reported past-year and/or lifetime suicidal ideation (10.5%, 33.0%), plans (4.6%, 17.0%), and attempts (0.7%, 8.0%), considerably higher than general population estimates. Significant differences were identified across age groups, years of service, marital status, regional location, and nursing type (e.g., registered psychiatric nurses, licensed practical nurses, registered nurses). Participants who screened positive for almost all measured mental disorders had significantly higher rates of suicidal behavior.

CONCLUSIONS

The results necessitate further research to evaluate risk factors contributing to suicidal behavior in Canadian nurses and methods to decrease the risk (e.g., developing effective monitoring and prevention measures).

Estimating National-Level Exposure to Antineoplastic Agents in the Workplace: CAREX Canada Findings and Future Research Needs

OBJECTIVES

Occupational exposure to antineoplastic agents occurs in various environments and is associated with increased cancer risk and adverse reproductive outcomes. National-level information describing the location and extent of occupational exposure to antineoplastic agents is unavailable in Canada and most other countries. CAREX Canada aimed to estimate the prevalence and relative levels of occupational exposures to antineoplastic agents across work setting, occupation, and sex.

METHODS

'Exposure' was defined as any potential for worker contact with antineoplastic agents. Baseline numbers of licensed workers were obtained from their respective professional bodies. For unlicensed workers, Census data or data extrapolated from human resources reports (e.g., staffing ratios) were used. Prevalence was estimated by combining population estimates with exposure proportions from peer-reviewed and grey literature. Exposure levels (classified as low, moderate, and high) by occupation and work setting were estimated qualitatively by combining estimates of contact frequency and exposure control practices.

RESULTS

Approximately 75000 Canadians (0.42% of the total workforce) are estimated as occupationally exposed to antineoplastic agents; over 75% are female. The largest occupational group exposed to antineoplastic agents is community pharmacy workers, with 30200 exposed. By work setting, 39000 workers (52% of all exposed) are located in non-hospital settings; the remaining 48% are exposed in hospitals. The majority (75%) of workers are in the moderate exposure category.

CONCLUSIONS

These estimates of the prevalence and location of occupational exposures to antineoplastic agents could be used to identify high-risk groups, estimate disease burden, and target new research and prevention activities. The limited secondary data available for developing these estimates highlights the need for increased quantitative measurement and documentation of antineoplastic agent contamination and exposure, particularly in work environments where use is emerging.

Occupational exposure and risk of breast cancer

Breast cancer is a multifactorial disease and the most commonly diagnosed cancer in women. Traditional risk factors for breast cancer include reproductive status, genetic mutations, family history and lifestyle. However, increasing evidence has identified an association between breast cancer and occupational factors, including environmental stimuli. Epidemiological and experimental studies demonstrated that ionizing and non-ionizing radiation exposure, night-shift work, pesticides, polycyclic aromatic hydrocarbons and metals are defined environmental factors for breast cancer, particularly at young ages. However, the mechanisms by which occupational factors can promote breast cancer initiation and progression remains to be elucidated. Furthermore, the evaluation of occupational factors for breast cancer, particularly in the workplace, also remains to be explained. The present review summarizes the occupational risk factors and the associated mechanisms involved in breast cancer development, in order to highlight new environmental exposures that could be correlated to breast cancer and to provide new insights for breast cancer prevention in the occupational settings. Furthermore, this review suggests that there is a requirement to include, through multidisciplinary approaches, different occupational exposure risks among those associated with breast cancer development. Finally, the design of new epigenetic biomarkers may be useful to identify the workers that are more susceptible to develop breast cancer.

Comparative analysis of hospital energy use: pacific northwest and scandinavia

OBJECTIVE

This study aimed to establish the potential for significant energy reduction in hospitals in the United States by providing evidence of Scandinavian operational precedents with high Interior Environmental Quality (IEQ) and substantially lower energy profiles than comparable U.S. facilities. These facilities set important precedents for design teams seeking operational examples for achieving aggressive energy and interior environmental quality goals. This examination of operational hospitals is intended to offer hospital owners, designers, and building managers a strong case and concrete framework for strategies to achieve exceptionally high performing buildings.

BACKGROUND

Energy efficient hospitals have the potential to significantly impact the U.S.'s overall energy profile, and key stakeholders in the hospital industry need specific, operationally grounded precedents in order to successfully implement informed energy reduction strategies. This study is an outgrowth of previous research evaluating high quality, low energy hospitals that serve as examples for new high performance hospital design, construction, and operation. Through extensive interviews, numerous site visits, the development of case studies, and data collection, this team has established thorough qualitative and quantitative analyses of several contemporary hospitals in Scandinavia and the Pacific Northwest. Many Scandinavian hospitals demonstrate a low energy profile, and when analyzed in comparison with U.S. hospitals, such Scandinavian precedents help define the framework required to make significant changes in the U.S. hospital building industry.

METHODS

Eight hospitals, four Scandinavian and four Pacific Northwest, were quantitatively compared using the Environmental Protection Agency's Portfolio Manager, allowing researchers to answer specific questions about the impact of energy source and architectural and mechanical strategies on energy efficiency in operational hospitals.

RESULTS

Specific architectural, mechanical, and plant systems make these Scandinavian hospitals more energy efficient than their Pacific Northwest counterparts. More importantly, synergistic systems integration allows for their significant reductions in energy consumption.

CONCLUSIONS

This quantitative comparison of operational Scandinavian and Pacific Northwest hospitals resulted in compelling evidence of the potential for deep energy savings in the U.S., and allowed researchers to outline specific strategies for achieving such reductions.

the risk of cancer among Taiwanese female registered nurses: a nationwide retrospective study

Background

To evaluate the risk of cancer among Taiwanese female registered nurses (RNs) using a nationwide population-based dataset.

Methods

We recruited female RNs without antecedent cancer from the Taiwan National Health Insurance Research database during 2000–2010. Standardized incidence ratios (SIRs) of cancer were calculated. We also compared rates of Papanicolaou (Pap) smear use between the RNs and the general population matched by age and sex.

Results

A total of 2,077 cancers developed among 184,809 female RNs, with a follow-up of 1,371,910 person-years (median follow-up of 7.86 years), leading to an increased SIR of 1.10 [95% confidence interval (CI) 1.05–1.15]. RNs aged between 40–59 years also had a significantly increased SIR (1.14, 95% CI 1.08–1.21). For specific cancer types, RNs had an increased SIR for breast (1.28, 95% CI 1.19–1.37), thyroid (1.26, 95% CI 1.10–1.43), lung and mediastinum (1.36, 95% CI 1.13–1.62), and uterine cancers (1.23, 95% CI 1.01–1.49). A decreased SIR was found for cervix (0.48, 95% CI 0.37–0.61) and liver and biliary tract cancers (0.68, 95% CI 0.50–0.90). Pap smear use averaged 5.80 times per person among female RNs aged 35 years or older and 5.50 times per person in the age-matched control group (p = 0.009).

Conclusion

This study found that overall cancer risk was higher among female RNs than general population. For individual cancers, the risks of breast, lung, thyroid and uterine cancer were higher and the risks of cervix and liver cancer were lower than general population. The lower risk of cervical cancer might be partially explained by the increased use of Pap smears in the RNs group. Further large, unbiased population-based prospective studies are needed to investigate the association between nurses and cancer risk and identify the risk factors of cancer in nurses.

Work-related leukemia: a systematic review

Leukemia is a complex disease, which only became better understood during the last decades following the development of new laboratory techniques and diagnostic methods. Despite our improved understanding of the physiology of the disease, little is yet known about the causes of leukemia. A variety of potential risk factors have been suggested so far, including personal habits and lifestyle, and a wide range of occupational or environmental exposures. A causal association with leukemia has only been documented to date for ionizing radiation, benzene and treatment with cytostatic drugs, but there is an ongoing scientific debate on the possible association of leukemia with a number of other work-related hazards. In this article, we have reviewed scientific studies, published over the past 5 years, which investigated potential associations between leukemia and exposure to occupational risk factors. The systematic literature review took place via electronic databases, using specific search criteria, and independent reviewers have further filtered the search results to identify the number of articles, presented in our paper. A large number of studies included in the review referred to the effects of ionizing radiation, where new data suggest that the effects of exposure to small doses of ionizing radiation should probably be reevaluated. Some other works appear to substantiate a potential association of the disease with certain pesticides. Further research is also suggested regarding the role of infectious agents or exposure to certain chemicals like formaldehyde or butadiene in the pathogenesis of leukemia.

Update of the NIOSH life table analysis system: a person-years analysis program for the windows computing environment

BACKGROUND

Person-years analysis is a fundamental tool of occupational epidemiology. A life table analysis system (LTAS), previously developed by the National Institute for Occupational Safety and Health, was limited by its platform and analysis and reporting capabilities. We describe the updating of LTAS for the Windows operating system (LTAS.NET) with improved properties.

SOFTWARE DEVELOPMENT PROCESS

A group of epidemiologists, programmers, and statisticians developed software, platform, and computing requirements. Statistical methods include the use of (indirectly) standardized mortality ratios, (directly) standardized rate ratios, confidence intervals, and P values based on the normal approximation and exact Poisson methods, and a trend estimator for linear exposure-response associations.

SOFTWARE FEATURES

We show examples using LTAS.NET to stratify and analyze multiple fixed and time-dependent variables. Data import, stratification, and reporting options are highly flexible. Users may export stratified data for Poisson regression modeling.

CONCLUSIONS

LTAS.NET incorporates improvements that will facilitate more complex person-years analysis of occupational cohort data.

Exposure to anesthetic gases and congenital anomalies in offspring of female registered nurses

BACKGROUND

Studies of offspring of mothers exposed to anesthetic gases have shown associations with congenital anomalies reported by the mothers, but rarely in studies with objectively ascertained outcomes. We conducted a retrospective cohort study to examine associations between registry-ascertained congenital anomalies in offspring and anesthetic gas exposure of mothers employed as nurses.

METHODS

A cohort of registered nurses in British Columbia, Canada, was linked to records of births and congenital anomalies from 1990 to 2000. Exposures were assessed via a survey of anesthetic gas use in all hospitals in the province and records of nurses' jobs, departments, and hospitals.

RESULTS

Departments most frequently reporting anesthetic gas use were operating rooms, post-anesthetic recovery rooms, and maternity units. In the cohort of 15,317 live-borne children of 9,433 mothers, 1,079 had congenital anomalies. Anomalies were associated with ever and probable maternal exposure to halogenated gases (ORs: 1.49, 95% CI: 1.04-2.13; and 2.61, 95% CI: 1.31-5.18, respectively) and to nitrous oxide (ORs: 1.42, 95% CI: 1.05-1.94; and 1.82, 95% CI: 1.11-2.99). Anomalies most frequently associated with exposure were those of the heart (OR, halogenated gases: 2.31, 95% CI: 1.07-4.97) and integument (OR, halogenated gases: 3.56, 95% CI: 1.53-8.32; OR, nitrous oxide: 3.02, 95% CI: 1.37-6.64). Gases most frequently associated with anomalies were halothane (predominantly used early in the study period), isoflurane, and sevoflurane (predominantly used later in the period).

CONCLUSIONS

In this study, where both exposures and outcomes were assessed objectively, certain congenital anomalies were associated with estimated anesthetic gas exposure.

Cancer incidence and adverse pregnancy outcome in registered nurses potentially exposed to antineoplastic drugs

BACKGROUND

To determine the relationships of potential occupational exposure to antineoplastic drugs with cancer incidence and adverse pregnancy outcomes in a historical prospective cohort study of female registered nurses (RNs) from British Columbia, Canada (BC).

METHODS

Female RNs registered with a professional regulatory body for at least one year between 1974 and 2000 formed the cohort (n = 56,213). The identifier file was linked to Canadian cancer registries. An RN offspring cohort from 1986 was created by linkages with the BC Birth and Health Status Registries. Exposure was assessed by work history in oncology or cancer agencies (method 1) and by estimating weighted duration of exposure developed from a survey of pharmacists and nursing unit administrators of all provincial hospitals and treatment centers and the work history of the nurses (method 2). Relative risks (RR) were calculated using Poisson regression for cancer incidence and odds ratios (OR) were calculated for congenital anomaly, stillbirth, low birth weight, and prematurity incidence, with 95% confidence intervals.

RESULTS

In comparison with other female RNs, method 1 revealed that RNs who ever worked in a cancer center or in an oncology nursing unit had an increased risk of breast cancer (RR = 1.83; 95% CI = 1.03 - 3.23, 12 cases) and their offspring were at risk for congenital anomalies of the eye (OR = 3.46, 95% CI = 1.08 - 11.14, 3 cases). Method 2 revealed that RNs classified as having the highest weighted durations of exposure to antineoplastic drugs had an excess risk of cancer of the rectum (RR = 1.87, 95% CI = 1.07 - 3.29, 14 cases). No statistically significant increased risks of leukemia, other cancers, stillbirth, low birth weight, prematurity, or other congenital anomalies in the RNs' offspring were noted.

CONCLUSIONS

Female RNs having had potential exposure to antineoplastic drugs were not found to have an excess risk of leukemia, stillbirth, or congenital anomalies in their offspring, with the exception of congenital anomalies of the eye, based on only three cases; however, elevated risks of breast and rectal cancer were observed.

Estimating nurses' exposures to ionizing radiation: the elusive gold standard

This study assessed ionizing radiation exposure in 58,125 registered nurses in British Columbia, Canada, for a cohort study of cancer morbidity and mortality. Two methods were used: (1) a survey of nurses in more than 100 acute care hospitals and health care centers; (2) and monitoring data reported to the National Dose Registry of Health Canada, considered the gold standard. The mean exposure of cohort nurses monitored during the study period from 1974 to 2000 was 0.27 milliSieverts (7028 person-years of monitoring). Of 609,809 person-years in the cohort, 554,595 (90.9%) were identified as unexposed by both exposure assessment methods. Despite crude agreement of 91% between the methods, weighted kappa for agreement beyond chance was only 0.045, and the sensitivity of the survey method to capture National Dose Registry monitored person-years was only 0.085 (specificity = 0.97). The survey missed exposures outside the acute care setting. The National Dose Registry also missed potential exposures, especially among hospital emergency department and pediatric staff nurses. It was unlikely that either method estimated nurses' true exposures to ionizing radiation with good sensitivity and specificity. The difficulty in exposure assessment likely arises because fewer than 10% of registered nurses are exposed to ionizing radiation, yet the settings in which they are exposed vary tremendously. This means that careful hazard assessment is required to ensure that monitoring is complete where exposures are probable, without incurring the excess costs and lack of specificity of including the unexposed.