ONS member Suzanne Carroll, MSN, RN, AOCN®, clinical nurse manager at Roswell Park Comprehensive Cancer Center in Buffalo, NY, and member of the Western New York ONS Chapter, joins Chris Pirschel, ONS staff writer/producer, to discuss ethical distress, how it impacts patient care, and ways nurses can navigate distress in their practice. Music Credit: "Fireflies and Stardust" Kevin MacLeod (incompetech.com) Licensed under Creative Commons: By Attribution 3.0 Episode Notes Check out these resources from today’s episode:  The NCPD activity for this episode has expired, but you can still earn NCPD through many other Oncology Nursing Podcast episodes. Find a full list of opportunities.   Ethical Dilemmas at the End of Life  Have the Moral Courage to Do the Right Thing  How to Have Ethical Discussions in Your Practice  Navigating Moral Distress in the Face of Ethical Dilemmas Ethics in Oncology Nursing  The Code of Ethics for Nurses 

Episode 78: Ethical Distress Impacts Nursing Practice

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“One of the things that I know Dr. [Tom] Connor worked on very heavily in his career is the long-term impact on the health of nurses and other exposed healthcare workers. We definitely need more longitudinal studies, which are difficult to do. And it’s not something that you see every day where I talk to chemo nurses and said, ‘Hey, I’ve been in this 20 years. It hasn't bothered me at all.’ Well, until it does. Therefore, it’s so important when we’re training incoming nurses—how very important it is to start with these practices early in the career and throughout the career,” Charlotte A. Smith, RPh, MS, senior regulatory advisor at Waste Management PharmEcology Services in Milwaukee, WI, told Lenise Taylor, MN, RN, AOCNS®, BMTCN®, oncology clinical specialist at ONS, during a conversation about hazardous drug and waste disposal.  Music Credit: “Fireflies and Stardust” by Kevin MacLeod  Licensed under Creative Commons by Attribution 3.0   Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at myoutcomes.ons.org by April 19, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center’s Commission on Accreditation.  Learning outcome:  Learners will report an increase in knowledge related to hazardous drugs and hazardous waste.  Episode Notes    Complete this evaluation for free NCPD.  Oncology Nursing Podcast episodes:   Episode 209: Updates in Chemo PPE and Safe Handling Episode 142: The How-To of Home Infusions   ONS Voice articles:   Two Oncology Nurses Implement Process to Allow Patients to Disconnect Pumps From the Comfort of Their Own Homes  The Oncology Nurse’s Role in Oral Anticancer Therapies  Strategies to Promote Safe Medication Administration Practices    ONS Safe Handling of Hazardous Drugs Learning Library ONS position statement:  Infusion of Antineoplastic Therapies in the Home ONS book:  Safe Handling of Hazardous Drugs (fourth edition) ONS course: Safe Handling Basics Clinical Journal of Oncology Nursing articles:  Environmental Risk Factors: The Role of Oncology Nurses in Assessing and Reducing the Risk for Exposure Oral Chemotherapy: A Home Safety Educational Framework for Healthcare Providers, Patients, and Caregivers Oral Chemotherapy: An Evidence-Based Practice Change for Safe Handling of Patient Waste Reconciliation and Disposal of Oral Medication: Creating a Safe Process for Clinical Research Personnel   Pharmacy Practice News article:  Applying NIOSH Hazardous Drug Assessment of Risk Principles To Home Healthcare (by Charlotte Smith and Tom Connor) Books mentioned in this episode:  Silent Spring by Rachel Carson  Our Stolen Future by Theo Colborn, Diane Dumanoski, and John Peterson Myers Generations at Risk by Ted Schettler, Gina Solomon, Maria Valenti, and Annette Huddle   Drug Enforcement Agency: National Prescription Drug Takeback Day Environmental Protection Agency:  Final Rule: Management Standards for Hazardous Waste Pharmaceuticals and Amendment to the P075 Listing for Nicotine MD Anderson Cancer Center:  Chemotherapy at Home: 9 Things to Know (patient resource) Memorial Sloan Kettering Cancer Center:  Safe Handling of Chemotherapy and Biotherapy at Home (patient resource) National Institute for Occupational Safety and Health:  Hazardous Drugs in Healthcare Settings Managing Hazardous Drug Exposures: Information for Healthcare Settings NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings, 2016     To discuss the information in this episode with other oncology nurses, visit the ONS Communities.  To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email  pubONSVoice@ons.org.  Highlights From This Episode  “A hazardous waste is a chemical, some of which are drugs, that EPA has determined is hazardous to the environment. Hazardous waste may be listed waste, which are given actual numbers, or they may be characteristic waste, which meets certain levels of concern, such as ignitability or toxicity. Only a small percentage of drug waste meets the EPA’s definition of hazardous waste, including a number of chemotherapy drugs.” TS 2:09  “The poster child for hazardous waste is warfarin, which, as you may be aware, is not only appropriate for managing clotting time but is also available commercially as rat poison. This is an example of how chemicals can serve more than one purpose and why dosage and regulation are so important.” TS 4:04  “Some of your listeners may have been around long enough to remember the book Silent Spring, by Rachel Carson, in which she eloquently exposed the risks to many species by the widespread use of DDT, an insecticide, at that time. More recently, the book Our Stolen Future by Theo Colborn, a pharmacist, Diane Dumanoski, and John Peterson Myers, raised the specter of the effects of endocrine disruption on wildlife and humans. The effects of drugs like diethylstilbestrol, or DES, once given during pregnancy, on the fetus, impacted the risk of cancer and other untoward effects in the offspring. The book remains a dramatic reminder of the risk of exposure to hazardous chemicals, including drugs.” TS 9:37  “Providing a homecare checklist for both the nurse and the patient and family is a simple way to keep track of all areas that need to be covered. For example, who in the household may be at most risk from exposure? This list includes infants, elderly family members, caregivers, pregnant family members, even pets. Is there a secure area to store the drug that cannot be reached by children?” TS 14:21  “I think what happens—we become so into our routine that what we do on a daily basis, we just kind of go through and do it without always thinking about it. And we can forget that not everyone has the same context of understanding these risks that the medications have to both the environment and the individual exposed to them. And I know it’s challenging to put on all the gowns and the gloves and whatnot. And, you know, it gets in the way of doing their job. It's important to educate each individual potentially exposed to these drugs, as if they do not have the understanding that we do. So embedding those consistent safety practices into daily routine is so imperative to ensure safe handling of hazardous drugs and then the proper disposal of hazardous waste pharmaceuticals.” TS 18:55

Episode 308: Hazardous Drugs and Hazardous Waste: Personal, Patient, and Environmental Safety

 “When we’re talking about the role of nurses in addressing these challenges, they play a critical role because of when they actually get to see patients. And so, if we can help with early identification and assessment, really finding out, using financial screening tools to identify any patients that might be at risk, early on, of financial toxicity, that can really allow for timely interventions,” Sarah Paul, LCSW, OSW-C, senior director of social work at CancerCare in New York, NY, told Lenise Taylor, MN, RN, AOCNS®, BMTCN®, oncology clinical specialist at ONS, during a conversation about financial toxicity in adolescent and young adult (AYA) cancer survivors.  Music Credit: “Fireflies and Stardust” by Kevin MacLeod  Licensed under Creative Commons by Attribution 3.0   Earn 0.75 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at myoutcomes.ons.org by April 12, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center’s Commission on Accreditation.  Learning outcome:  Learners will report an increase in knowledge related to financial toxicity in the adolescent and young adult population.  Episode Notes    Complete this evaluation for free NCPD. Oncology Nursing Podcast episodes:   Episode 300: AYAs With Cancer: End-of-Life Care Planning  Episode 294: AYAs With Cancer: Clinical Trial Enrollment Barriers and Facilitators  Episode 287: Tools, Techniques, and Real-World Examples for Difficult Conversations in Cancer Care  Episode 276: Support Young Families During a Parent’s Cancer Journey  Episode 62: Financial Toxicity Legislation   ONS Voice articles:  AYA Cancer Survivorship: Younger Survivors Face Different Challenges and Prefer More Casual Support Programs  Nursing Considerations for Adolescent and Young Adult Cancer Survivorship Care  How to Support Adolescents and Young Adults With Cancer at the End of Life  LGB AYA Patients With Cancer Have High Burden of Chronic Conditions in Survivorship  AYA Champions Clinic Fills Gaps in Care and Addresses Unmet Needs   ONS book:  Oncology Nurse Navigation: Delivering Patient-Centered Care Across the Continuum (second edition) Clinical Journal of Oncology Nursing articles:  Two Case Reports on Financial Toxicity and Healthcare Transitions in Adolescent and Young Adult Cancer Survivors Crucial Conversations: Addressing Informational Needs of Adolescents and Young Adults Diagnosed With Cancer A Nurse-Pharmacist Collaborative Approach to Reducing Financial Toxicity in Cancer Care   Oncology Nursing Forum article: A Brief Screening Tool for Assessment of Financial Toxicity ONS Financial Toxicity Huddle Card ONS Nurse Navigation Learning Library Adolescent and Young Adult Cancer Awareness Week American Society of Clinical Oncology CancerCare Got Transition National Comprehensive Cancer Network Patient Advocate Foundation Triage Cancer  To discuss the information in this episode with other oncology nurses, visit the ONS Communities.  To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email  pubONSVoice@ons.org.  Highlights From This Episode  “For nurses that are caring for AYA patients, it’s really important to not only be aware of financial toxicity but know how to assess for financial toxicity because of the pivotal stage that these patients are at in their life. They often don’t have the financial stability or insurance coverage that adults who are maybe middle age or even in the older adult population might have.” TS 2:11  “The idea of [AYAs] not really understanding insurance coverage—I think it’s really important that as a team, we simplify some of this complex information, breaking it down into more manageable steps and providing that guidance on the documents and all the information that’s needed to apply [for financial assistance].” TS 8:59  “We see significant impacts in the AYA community, especially those that are in school or at the early stages of their career, because putting a job or school on hold to focus on treatment can have long-term effects. So, we see a couple of things. In education, we see academic delays; interrupting education can delay graduation or achievement of certain educational milestones, which would affect their ability to pursue higher education or even specialized training for their career. We also see, which is very difficult, loss of scholarships or financial aid. Some AYAs are starting school. It’s based on a scholarship or a grant or financial aid, and they can’t meet those full-time enrollment requirements or be able to maintain the GPA that they need to stay in the program. We see people losing their scholarships, and this is not their fault.” TS 10:11  “Down the road, you have this stress leading to chronic stress. We know that constant worry about finances can create a chronic stress environment. That is going to impact mental health across the board, which can lead to increased irritability, feelings of sadness, or even conflict among family members. So when we talk about managing these dynamics, we really want to focus on the importance of open communication because a lot of times we see families avoid discussing financial issues to shield each other from that additional stress.” TS 18:06  “One of the challenges that we face with this population is that we might assume that if they’re not talking about it, if an AYA is not bringing up finances, that it’s not an issue. And so sometimes even our own assumptions or assumptions of healthcare professionals that they don’t even need to ask, ‘How are finances going? Are you working currently? Do you feel financially stable? Are you insured?’ Often, maybe there’s not room for those questions. Maybe the appointments are too rushed. … Healthcare professionals could maybe take a pause to evaluate their own hidden or implicit bias, reflecting on their own experience, really trying to become aware of the assumptions they might have about this population.” TS 32:46

Episode 307: AYAs With Cancer: Financial Toxicity

 “At the beginning, like when you first meet someone before they’ve even started anything, kind of get a baseline of ‘What’s your ability to complete your daily activities? How is your coordination? How’s your speech now? How is your writing ability?’ up front before we start anything that could be toxic. And then prior to every treatment, I tend to look at their gait, watch them walk in or walk out of the office, to see if they’re changing at all,” Colleen Erb, MSN, CRNP, ACNP-BC, AOCNP®, hematology and oncology nurse practitioner at Jefferson Health Asplundh Cancer Pavilion in Willow Grove, PA, told Lenise Taylor, MN, RN, AOCNS®, BMTCN®, oncology clinical specialist at ONS, during a conversation about central nervous system toxicity.  Music Credit: “Fireflies and Stardust” by Kevin MacLeod  Licensed under Creative Commons by Attribution 3.0   Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at myoutcomes.ons.org by April 5, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center’s Commission on Accreditation.  Learning outcome:   Learners will report an increase in knowledge related to CNS toxicities.  Episode Notes    Complete this evaluation for free NCPD.  Oncology Nursing Podcast episodes:  Episode 303: Cancer Symptom Management Basics: Ocular Toxicities Episode 290: Cancer Symptom Management Basics: Peripheral Neuropathy Episode 278: Cancer Symptom Management Basics: Hepatic Complications Episode 269: Cancer Symptom Management Basics: Gastrointestinal Complications Episode 256: Cancer Symptom Management Basics: Hematologic Complications Episode 250: Cancer Symptom Management Basics: Dermatologic Complications Episode 244: Cancer Symptom Management Basics: Cardiovascular Complications   ONS Voice articles:   Cognitive Impairment Is Much More Than “Chemo Brain”  When Delirium Is Recognized and Addressed Early, Patient Outcomes Improve  An Oncology Nurse’s Guide to Bispecific Antibodies  CNS Survivorship Needs More Research, Funding, and Training, Expert Panel Says   ONS courses:   Essentials in Advanced Practice Symptom Management  Treatment and Symptom Management—Oncology RN  Nursing Considerations for CAR T-Cell Therapy for Patients With Hematologic Malignancies: Patient Education and Symptom Management   ONS books:   Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (second edition)  Clinical Manual for the Oncology Advanced Practice Nurse (fourth edition)  Core Curriculum for Oncology Nursing (seventh edition)   Clinical Journal of Oncology Nursing articles:  Associated Toxicities: Assessment and Management Related to CAR T-Cell Therapy Dronabinol Therapy: Central Nervous System Adverse Events in Adults With Primary Brain Tumors Primary Central Nervous System Lymphoma: Treatment and Nursing Management of Immunocompetent Patients   ONS Huddle Card:  Immune Effector Cell–Associated Neurotoxicity Syndrome (ICANS) American Society of Clinical Oncology (ASCO)   Nervous System Side Effects Management of Immune-Related Adverse Events in Patients Treated With Chimeric Antigen Receptor T-Cell Therapy: ASCO Guideline     To discuss the information in this episode with other oncology nurses, visit the ONS Communities.  To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email  pubONSVoice@ons.org.  Highlights From This Episode  “Biotherapy, immunotherapy, and cellular therapy can cause changes in cognitive function and personality, even without other signs of obvious neurotoxicity. Things like cytokines, whether it’s infused or as a result of side effects, can bypass the blood-brain barrier and can also alter that vascular permeability to allow other substances to kind of cross the barrier and can also alter your hypothalamic activity.” TS 2:26  “There’s definitely an effect on patients who are older. You know, there’s less pliability, less ability of their nervous system to sort of rebound from an insult in some cases. And I think there’s more exposure. There’s more risk of coexisting conditions, things like diabetes or thyroid issues. There’s also higher risk of impaired liver and renal function or dehydration or polypharmacy-type things. So I think there’s just a lot of sort of inherent risks as people get older and have more coexisting conditions.” TS 5:33  “[Their caregiver says] they used to read all the time—and if you ask the patients, they’re like, “Oh, well, I can’t focus on the words because they all seem too blurry.” … But when you, if you ask them specifically, “Is your vision blurry?” they’ll say no. Then when you really get down to it, that caregiver piece I think is really crucial in this kind of toxicity, because it’s the little things that if you catch them when they’re little things, then won't lead to big things.” TS 11:00   

Episode 306: Cancer Symptom Management Basics: CNS Toxicities

 “A couple of things I think are really important when you look at this class of drug: It developed by a concerted effort in cancer drug development to look at new agents that would be effective based on the mechanism. And then once they found a drug in this class that was beneficial, they further modified it to try to get better efficacy and less toxicity,” Rowena “Moe” Schwartz, PharmD, BCOP, FHOPA, professor of pharmacy practice at James L. Winkle College of Pharmacy at the University of Cincinnati in Ohio, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a conversation about the nitrosoureas drug class.  Music Credit: “Fireflies and Stardust” by Kevin MacLeod  Licensed under Creative Commons by Attribution 3.0   Earn 0.5 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at myoutcomes.ons.org by March 29, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center’s Commission on Accreditation.  Learning outcome: Learners will report an increase in knowledge related to nitrosourea administration.  Episode Notes    Complete this evaluation for free NCPD.  Oncology Nursing Podcast episodes:   Episode 286: Pharmacology 101: Alkylating Agents  Episode 288: Pharmacology 101: Antimetabolites  Episode 296: Pharmacology 101: Anthracyclines and Other Antitumor Antibiotics  Episode 299: Pharmacology 101: Plant Alkaloids   ONS Voice article:  The Oncology Nurse’s Role in Oral Anticancer Therapies ONS courses:   ONS/ONCC Chemotherapy Immunotherapy Administration Certificate™  ONS Fundamentals of Chemotherapy and Immunotherapy Administration™   ONS books:   Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (second edition)  Clinical Guide to Antineoplastic Therapy: A Chemotherapy Handbook (fourth edition)  Safe Handling of Hazardous Drugs (fourth edition)   Clinical Journal of Oncology Nursing article:  Primary Central Nervous System Lymphoma: Treatment and Nursing Management of Immunocompetent Patients Oncology Nursing Forum article:  ONS Guidelines™ to Support Patient Adherence to Oral Anticancer Medications  ONS Oral Anticancer Medication Learning Library  ONS Oral Adherence Video National Institute for Occupational Safety and Health: Hazardous Drugs in Healthcare Settings   To discuss the information in this episode with other oncology nurses, visit the ONS Communities.  To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email  pubONSVoice@ons.org.  Highlights From This Episode  “With the nitrosoureas, there’s something really interesting because there’s another mechanism that has been identified. And that is that when you put these nitrosoureas in the body, they break down into intermediates, and one of them is an isocyanate. … These isocyanates, what they do is they inhibit DNA repair, therefore have an impact on cells that are damaged. You can think of it as the second mechanism, and people that work in the neuro-oncology space think of this when they think of drugs like lomustine in brain cancer, how that drug decreases the DNA repair protein O6-methylguanine-DNA methyltransferase.” TS 4:11  “These drugs are very lipophilic, meaning they cross the blood-brain barrier. That’s why we use them in brain tumors, so that’s one of the key things. That’s also one of the toxicities we see when drugs cross blood-brain barrier; we see neurotoxicity. So that’s one to at least always consider but also the benefit of it crossing over and being able to treat cancers within the CNS.” TS 8:19  “As a group, these drugs are alkylating agents, so definitely the safe handling is essential. And with DNA-damaging agents, that means anybody who is going to come in contact with these drugs. So, carmustine is given intravenously. Lomustine or CCNU, those are capsules. So handling is different depending on the agents.” TS 12:45  “The thing with the lomustine or the CCNU capsules, the thing that’s really important here is that the dosing is really different than how we normally give oral medications. And so, it’s really important that patients are aware of exactly how much they take and not that they don’t repeat the dose every day. So I think just like with other oral regimens that are not daily, we really have to make sure patients are aware of the specifics of how they take the drug.” TS 14:25

Episode 305: Pharmacology 101: Nitrosoureas

 “The prescribing information is really a reliable data-driven and comprehensively reviewed tool. That’s not just for healthcare providers when writing a prescription, but also, for example, it is a tool that can be used to generate educational content for healthcare systems as they update formularies and create drug information,” Elizabeth Everhart, MSN, RN, ACNP, associate director for labeling at the U.S. Food and Drug Administration (FDA) in Silver Spring, MD, told Jaime Weimer, MSN, RN, AGCNS-BS, AOCNS®, manager of oncology nursing practice at ONS, during a conversation about drug package inserts and labeling.  Music Credit: “Fireflies and Stardust” by Kevin MacLeod  Licensed under Creative Commons by Attribution 3.0   Earn 0.25 contact hours of nursing continuing professional development (NCPD) by listening to the full recording and completing an evaluation at myoutcomes.ons.org by March 22, 2026. The planners and faculty for this episode have no relevant financial relationships with ineligible companies to disclose. ONS is accredited as a provider of NCPD by the American Nurses Credentialing Center’s Commission on Accreditation.  Learning outcome:  Learners will report an increase in knowledge related to FDA drug labeling.  Episode Notes   Complete this evaluation for free NCPD. Oncology Nursing Podcast episodes:   Episode 126: Oncology Clinical Trials and Drug Development  Episode 242: Oncology Pharmacology 2023: Today’s Treatments and Tomorrow’s Breakthroughs  Episode 273: Updates in Chemotherapy and Immunotherapy   ONS Voice articles:  Oncology Drug Reference Sheets FDA Updates   ONS books:   Chemotherapy and Immunotherapy Guidelines and Recommendations for Practice (second edition)  Clinical Guide to Antineoplastic Therapy: A Chemotherapy Handbook (fourth edition)   ONS Drug Development Learning Library ONS and Hematology/Oncology Pharmacy Association:  Safe Handling Q&A;: How to Determine if a Drug is Hazardous     National Library of Medicine: DailyMed FDA   Prescribing Information Resources Drugs@FDA: FDA-Approved Drugs   National Institute for Occupational Safety and Health: Hazardous Drug Exposures in Health Care   To discuss the information in this episode with other oncology nurses, visit the ONS Communities.  To find resources for creating an ONS Podcast Club in your chapter or nursing community, visit the ONS Podcast Library.  To provide feedback or otherwise reach ONS about the podcast, email  pubONSVoice@ons.org.  Highlights From This Episode  “Nurses can be involved in several ways in creating the labeling. They can be members of the FDA multidisciplinary team that reviews the information submitted by the drug maker. Also in the review and development of the patient package insert or medication guide or the instructions for use that are used to help a healthcare practitioner, patients, or family members use the drug safely and accurately.” TS 2:08  “[Nurses] can use the sections to guide their teaching and instruction to patients, particularly about dosing and any tests that will be done to monitor for adverse reactions and any needed changes in the dosing, like whether they need to hold the medication or take less of it. They can also use the information to describe what the expected and serious adverse reactions for the drug are and how frequently they occurred in clinical trials.” TS 9:12  “The patient package inserts and medication guides that I mentioned are written in patient-friendly language and are good resources for nurses to use to educate patients and their caregivers or family members about what the product is used for, what its main and most serious side effects are, as well as what to expect in terms of the need for any special tests.” TS 11:04  “In the FDA’s public Prescribing Information Resources page, there are several excellent resources for healthcare providers to learn more about specific sections of the label, as well as to find good educational material for patients and their caregivers. There are also several presentations and videos available related to many sections of the label that are excellent resources for oncology nurses.” TS 14:26

Episode 78: Ethical Distress Impacts Nursing Practice

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