|ORIGINAL RESEARCH REPORT
|Year : 2017 | Volume
| Issue : 3 | Page : 131-137
Knowledge of chemotherapy and occupational safety measures among nurses in oncology units
Sylvia E Nwagbo1, Rose Ekama Ilesanmi2, Beatrice M Ohaeri2, Abimbola O Oluwatosin2
1 Department of Clinical Nursing, University College Hospital, Ibadan, Nigeria
2 Department of Nursing, University of Ibadan, Ibadan, Nigeria
|Date of Web Publication||17-Aug-2017|
Rose Ekama Ilesanmi
Department of Nursing, University of Ibadan, Ibadan
Source of Support: None, Conflict of Interest: None
Background: The mutagenic and teratogenic effects of chemotherapeutic agents from repeated exposure during care are well documented. Nurses are among the healthcare professionals who constantly handle these agents, therefore their knowledge and pattern of occupational safety is a concern. This study sought to determine knowledge of chemotherapy and occupational safety measures of nurses in oncology units in the University College hospital, Ibadan. Materials and Methods: A cross sectional descriptive study design, based on Protection Motivation theory was conducted among 100 purposively selected nurses from oncology unit of the hospital. Data were collected using a 54-item validated questionnaire. Descriptive and inferential statistics at 0.05 level of significance was used. Results: Respondents were within 35.4 ± 5.1 years. More than half of the respondents had over 3 years practice in the oncology unit (mean 2.62, ± 1.1). Knowledge of chemotherapy among the cohort was high; mean 13.9 ± 2.2, 70 % understood the use of gloves and gowns as part of safety guidelines. On handling patients' clothes, only 57% understood that such should not be washed by hand or with other clothes. Cumulatively, 79.2% of the respondents knew about the safety guidelines, 4.7% had no knowledge while 16.1% were not sure of the correct guidelines for administering chemotherapy. Respondents' level of education was significantly associated with knowledge of chemotherapy, P<0.05; practice score was also significantly associated with respondents' cadre; P<0.05. Conclusion: Periodic and consistent update of nurses' knowledge supported by policies to enforce guidelines implementation is recommended.
Keywords: Chemotherapy, nurses' knowledge, occupational protective measures, oncology
|How to cite this article:|
Nwagbo SE, Ilesanmi RE, Ohaeri BM, Oluwatosin AO. Knowledge of chemotherapy and occupational safety measures among nurses in oncology units. J Clin Sci 2017;14:131-7
|How to cite this URL:|
Nwagbo SE, Ilesanmi RE, Ohaeri BM, Oluwatosin AO. Knowledge of chemotherapy and occupational safety measures among nurses in oncology units. J Clin Sci [serial online] 2017 [cited 2019 Jul 18];14:131-7. Available from: http://www.jcsjournal.org/text.asp?2017/14/3/131/213090
| Introduction|| |
Cancer chemotherapy is of great benefit to patients in the treatment of malignant and nonmalignant tumors. Its use is rapidly expanding with increasing complexity in schedules as opposed to other regular medications. These drugs are known to be potentially hazardous due to their unique pharmacological properties that interfere with cell division. The American Society of Health-System Pharmacists  defined hazardous drugs as those which manifest genotoxicity, carcinogenicity, teratogenicity, fertility impairment, serious organ, or any toxic manifestation at low doses in animals and humans. Researchers have confirmed that side effects associated with cancer chemotherapeutic agents can occur both in patients and those within the treatment chain, depending on the chemical and physical properties of the drugs, the quantity administered, and the available collective and personal protective measures. Other factors such as the practitioners' knowledge and skills also significantly determine the level of contamination and risk. It follows that repeated exposure to even low doses for long period of time may produce profound effects.
As far back as 1985, Selevan et al. reported that nurses who were chronically exposed to cyclophosphamide, doxorubicin, and vincristine experienced fetal losses. In addition, reports of learning disabilities were found among children of nurses who handled chemotherapeutic drugs. More recent studies on chromosomes of nurses who handled chemotherapeutic drugs confirmed chromosomal aberrations with evidence of mutagenic and carcinogenic risks in the urine samples.,,, These findings raise serious concern about knowledge of safety practices.
Furthermore, the Health and Safety Executives  noted occupational risk and hazard as consequences of the inadequate use of control measures. Hospital studies have also reported detectable levels of cytotoxic drugs in the air, surfaces, gloves, and different body parts of health-care practitioners. In addition, researchers ,, reported differently on workplace contamination with cancer chemotherapeutic agents following inadequate occupational safety practices. In a large-scale study of 56,000 nurses in Canada, Ratner et al. concluded that the nurses were at risk for breast and rectal cancers following workplace exposure to antineoplastic agents.
Nurses are key stakeholders in cancer care and fundamentally require knowledge about chemotherapy, either from nursing schools or continuing education programs. Tanghe et al. identified four main roles of nurses in the chemotherapy administration process. The roles include safely administering the therapy, managing side effects, educating patients and their families on the adverse effects of chemotherapy, and providing emotional support to patients through the process. More recently, the Cancer Nurses Society of Australia  confirmed that administration of chemotherapy has become the role of nurses over the past two decades.
Therefore, it is of utmost importance that nurses' knowledge of handling and safety measures is examined because they are at risk of exposure to the drugs during preparation and administration. Some authors  have reported a high level of adherence to guidelines on chemotherapy administration among nurses; however, similar reports have not been fully documented among nurses in Nigeria. In view of the above, this study assesses nurses' knowledge of chemotherapy and occupational safety practices in the oncology unit.
| Subjects and Methods|| |
This was a descriptive, cross-sectional study among nurses in the oncology unit of University College Hospital, Ibadan, who were directly involved in the administration of chemotherapeutic drugs. The hospital is a large tertiary institution with total bed occupancy of 800. The oncology unit consists of radiotherapy clinic and seven wards.
One hundred and five nurses were purposively selected from the seven wards where patients with cancer were admitted. The criteria for inclusion consisted of experience in oncology wards for not <6 months, and being available during the period of data collection, while the exclusion criteria included population without hands-on experience in the oncology unit, individuals not able to provide informed consent and/or reliable information. A researcher-developed 54-item questionnaire based on literature review was used for data collection. The questionnaire was subjected to expert review to ensure content and face validity. A test–retest reliability coefficient 0.8 was obtained.
Approval for the study was obtained from the Institutional Review Board (UI/EC/15/0048) before study. Data collection lasted for 3 weeks and completed questionnaires were retrieved.
Data were analyzed using the Statistical Package for the Social Sciences 16.0 Ink. Descriptive and inferential statistics were used for analysis. Items which measured respondents' knowledge were scored 1 for correct responses and 0 for incorrect and “I do not know” responses. A maximum obtainable score was 16.0, with an average rating of 8.0. The scores for knowledge were categorized into three levels: poor (0–4), fair (4.5–6.0), and good (7.0–9.0). Patterns of utilizing occupational protective measures were scored as “never practice,” “occasional practice,” and “always practice.” A maximum obtainable score was 30 (if all questions were attempted).
Three hypotheses were generated, and test of association was performed using Chi-square at 5% level of significance.
| Results|| |
Out of 105 questionnaires distributed, 100 were retrieved and fit for analysis. The respondents' mean age was 35.4 ± 5.1 years. There were more females (95%) than males (5%). Exactly 50% of the respondents had been working on the selected wards for over 3 years; of this, 39% were graduate nurses while 61% were diploma qualified nurses [Table 1]. The other findings are presented under the specific objectives as follows:
Nurses' knowledge of chemotherapy and the adverse effects
Questions on the meaning of chemotherapy, classification, types, and adverse effects were examined [Table 2] and [Figure 1]. Findings showed that more than 90% of the respondents understood the meaning of chemotherapy; however, only 40% possessed good knowledge of the classification and types. [Table 2] shows that respondents were knowledgeable about the common side effects of chemotherapy such as gastrointestinal distress (99%) and hair loss (100%), but only 49% indicated that obesity is not a side effect of chemotherapy while 19% were not sure. Cumulatively out of a maximum obtainable score of 16 (range 7–16), mean was 13.90 ± 2.19. The respondents had good knowledge of the meaning, classification, types and adverse effects of chemotherapy; 99%, 41%, 24%, and 64% respectively [Figure 1] and [Table 3]. Chi-square test was performed to examine the relationship between respondents' level of education and knowledge of chemotherapy. The relationship between the variables was statistically significant, χ2 = 84.1, P = 0.000
Nurses' knowledge of occupational safety practices and guidelines for chemotherapy administration
We examined nurses' knowledge of protective measures and guidelines for administration of chemotherapeutic agents [Table 4]. From the table, 96% understood the need to wear gloves for preparing and administering chemotherapeutic agents and that visible leaks and spills should be cleaned with gloved hands (92%). However, 26% were not certain of the specific recommendations about contact with body fluids of patients on chemotherapy. They were not sure if such should be washed very well with soap and water. Only 56% indicated that using condom during sex was part of recommended practice for patients. In addition, 40% were not certain of how to handle stained clothes or sheets with body fluids. Cumulatively, 91.0% scored above the average rating scale, with 30% having fair knowledge (4.5–6.0), and 61% having good knowledge (7.0–9.0). Chi-square test of association was performed to examine the association between years of practice in the oncology unit and knowledge of guideline for chemotherapy administration. The relationship between the variables was statistically significant, χ2 = 40.7, P = 0.00.
|Table 4: Respondents' knowledge of chemotherapy occupational protective measures and guidelines (n=100)|
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Safety practices of occupational protective measures during administration of chemotherapeutic agents among nurses
Practice of safety measures during the administration of chemotherapy [Table 5] indicated that 84% always used gloves for administration, 55% occasionally use face mask and goggle, and 20% never used goggles and face mask. Protective apron was also used occasionally by 53% while drug preparation in designated area was never observed by 25% of the study cohort. A percentage (73%) always observed side effects of drugs on patients and give drugs according to recommended route and dosage (88%).
|Table 5: Respondents' pattern of occupational protective measures(n=100)|
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The mean practice score was 24.40 ± 3.80, which was greater than the average rating scale (20.0). Furthermore, 95.0% of the respondents scored above the average rating scale, with 35% having fair practice while 60% had good practice.
Comparing respondents' knowledge of occupational protective measures against practice, findings indicated good knowledge of chemotherapy occupational protective measures and guidelines among the nurses, which also translated to good practice [Figure 2]. Chi-square test of association between practice score and nurses' cadre was performed. Findings were statistically significant χ2 = 46.3, P = 0.000, <0.05.
|Figure 2: Respondents Knowledge on occupational safety measures against practice|
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| Discussion|| |
Administering chemotherapy is a sensitive domain of oncology nursing practice because the slightest error or negligence may result in adverse effect for patients, staff, and the environment., Notably, the processes of preparation, administration, cleaning of spills, and handling of waste of patients on chemotherapeutic agents pose the most occupational risk to nurses in this area of practice. Verstrate  explained that knowledge is critical to safe nursing practice, and it becomes significant when knowledge deficit on the part of the nurse threatens personal safety and that of the patient. In this study, we examined nurses' knowledge of chemotherapy, and the occupational safety practices employed during care among nurses.
Respondents were within the mean age of 35 ± 5.1 years, half of whom have worked in the oncology unit for a minimum of 3 years with the mean age of 2.62 ± 1.11 years. However, Khan et al. reported that nurses possess less working experience in the oncology department. The years of practice in the oncology unit may influence knowledge and practice and maybe argued that nurses with long-term experience in oncology care are more likely to provide care in line with recommended guidelines and safety practices. To corroborate this, we found a statistically significant association between years of practice in the oncology unit with knowledge of chemotherapy (P < 0.005). It follows that nurses who have spent more years in the oncology unit would more likely demonstrate better knowledge than those who have not. It is also expected that the knowledge would eventually translate to good practice.
Nurses who provide care to patients receiving chemotherapy require specialized knowledge to ensure safety of patients and themselves as well as the environment. This particularly impacts care. Several studies reported findings which suggest that nurses' knowledge of chemotherapy was insufficient. For example, Yu et al. in a descriptive study of 203 nurses concluded that nurses fundamentally require more education about chemotherapy. In the same vein, a pre-post study among nurses reported that knowledge was poor in specific areas such as the types, classification of antimicrotubules, topoisomerase inhibitors, and cytotoxic antibiotics. However, the level of knowledge significantly increased with educational training in that study. In our study, only 55% of the respondents demonstrated good knowledge of the meaning, classification, types, risk, and side effects of drugs. This suggests less than optimal knowledge in this specific area among the study cohort, which may put individual nurse at risk for adverse effects.
The findings of this study also indicated that 41% of the nurses possessed a fair knowledge of chemotherapy. Therefore, there is a strong indication for on-the-job continuing training/professional development for nurses. It should be noted that for a very long time, there was no certified oncology nursing program in Nigeria. However, very recently, a diploma program commenced in Abuja, Nigeria, making this center the only one for now in the country. It suggests therefore that most nurses in Nigeria who practice in the oncology units were prepared for this role “on the job” or may have obtained an oversea training.
Assessment of respondents' knowledge of safety measures for the administration of chemotherapeutic agents indicates high knowledge of some aspects of care. While 79.2% demonstrated good knowledge of the guidelines, 16.1% were not sure of what constitutes the correct recommendations for administering chemotherapy. This is quite worrisome given the fact that a slight medication error with chemotherapy may cause a very significant adverse effect. It is important to note that 96% of respondents understood the need to wear gloves during preparation, administration, and cleaning of spills. This corroborates the findings of Al-Azzam et al. in a study on compliance with safe handling guidelines of antineoplastic drugs in Jordanian hospitals. In that study, although 46.4% reported full knowledge and compliance with the guideline, only 10.7% reported full compliance with eye protection (goggles), shoe cover, and hair cover.
Similarly, Polovich and Martin  in a study among nurses (n = 330) concluded that while nurses have adopted gloving for handling hazardous drugs, the use of protective gown remained low. In our study, while 85.9% of nurses were aware that protective gowns should be worn during preparation and administration, only 21% always wear it, and 53% do that very occasionally. Unfortunately, 26% have never worn protective gowns. These findings further support the fact that the nurses do not adhere to the guideline, and the reasons may be partly due to inadequate provision of personal protective equipment (PPE) by some employers as well as nonenforcement of use. It is very critical that employers provide the necessary PPE in the oncology units.
Safe handling of chemotherapy also requires that the drugs should be prepared in designated treatment areas. In the current study, 25% have never prepared medication in a designated area, suggesting high risk of environmental contamination. Polovich and Clark  reported environmental contamination with chemotherapeutic drugs, partly due to poor nursing compliance to guidelines. This indicates a gap between evidence-based recommendation and actual practice. Literature explained that although policies regarding safety standards are in place in some facilities, they are not usually mandatory and therefore may not be enforced. This may possibly explain the variability in practice among nurses in our study. In addition, it is possible that some nurses may not fully appreciate their own health risk when handling chemotherapy or maybe having perceptions of a low probability of immediate injury. Moreover, authors have observed that most policies and protocols in practice are geared toward patient safety and not personnel., A common example is the American Society of Clinical Oncology and the Oncology Nursing Society standards for chemotherapy administration. These protocols focus on patients' safety and not nursing exposure. It can, therefore, be inferred from different studies that inadequate education and experience may contribute to unnecessary exposure.
The current study was based on protection motivation theory. The theory postulates that the intention to protect oneself depends on an individual's perceived severity of the threat, perceived vulnerability, perceived efficacy, and perceived self-efficacy. It follows that an appraisal of one's vulnerability and estimation (threat appraisal) of the seriousness of a disease determines the protective actions and the response efficacy and self-efficacy (coping appraisal). In relation to nurses' knowledge of chemotherapy and patterns of occupational safety, the theory suggests that a negative health condition or side effect can be avoided if nurses have an adequate understanding of the principles, practice, and safe handling protocols of chemotherapeutic agents. Nurses' appraisal of their perceived vulnerability and severity of side effects also greatly determines their motivation to protect self (protective motivation). Connor and Eisenberg  explained that inadequate use of protective measures among nurses is a reflection of perceptions of their low probability of immediate injury when handling these agents.
Another study among nurses  who mix and administer antineoplastic agents (n = 632) corroborates this position. According to the authors, 25% were not using PPE because they did not believe they were exposed to danger. In yet another study (n = 500) among nurses in oncology outpatients, findings indicated that 50% believed that the drugs were minimally hazardous while 5% described the drugs as not hazardous. In our study, although we did not examine directly the nurses' perception of their vulnerability to exposure to hazard, our findings suggest a low perception of their vulnerability. This is because assessment of pattern of the use of PPE indicated that only 21% always use protective aprons and gowns during preparation and administration.
It may be argued therefore that when nurses possess adequate knowledge of chemotherapy preparation, handling, and administration processes, it will facilitate effective appraisal of extent of vulnerability and severity of the potential side effects. This, therefore, drives a positive coping appraisal that will culminate into appropriate motivation for consistent personal protection.
| Conclusion|| |
The findings of the study correctly accentuate the need for continuous and periodic update of knowledge about chemotherapy and its administration guidelines. Findings in this setting indicate an urgent need for prevention of exposure and adverse effects among nurses and patients through consistent supply of occupational protective measures and monitoring in all oncology units.
We recommend that the future research should explore oncology nursing training of respondents as well as involve more centers, to provide evidence to support policy enactment.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Neuss MN, Polovich M, McNiff K, Esper P, Gilmore TR, LeFebvre KB, et al.
2013 updated American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards including standards for the safe administration and management of oral chemotherapy. J Oncol Pract 2013;9 2 Suppl: 5s-13s.
American Society of Hospital Pharmacists (ASHP). ASHP technical assistance bulletin on handling cytotoxic drugs in hospitals. Am J Hosp Pharm 1985;42:131-7.
Shahrasbi AA, Afshar M, Shokraneh F, Monji F, Noroozi M, Ebrahimi-Khojin M, et al.
Risks to health professionals from hazardous drugs in Iran: A pilot study of understanding of healthcare team to occupational exposure to cytotoxics. EXCLI J 2014;13:491-501.
Selevan SG, Lindbohm ML, Hornung RW, Hemminki K. A study of occupational exposure to antineoplastic drugs and fetal loss in nurses. N Engl J Med 1985;313:1173-8.
Martin S. Chemotherapy Handling and Effects among Nurses and their Offspring. The Oncology Nursing Society 30th
Annual Congress, April 28-May 1, 2005, Orlando, Florida; 2005.
Terui K, Okajima H, Nakajima Y. Safety evaluation of new anticancer chemotherapy administration system: Compared to the results from a former study. Gan To Kagaku Ryoho 2011;38:1483-7.
Moretti M, Bonfiglioli R, Feretti D, Pavanello S, Mussi F, Grollino MG, et al.
A study protocol for the evaluation of occupational mutagenic/carcinogenic risks in subjects exposed to antineoplastic drugs: A multicentric project. BMC Public Health 2011;11:195.
Suspiro A, Prista J. Biomarkers of occupational exposure do anticancer agents: A minireview. Toxicol Lett 2011;207:42-52.
Fransman W, Vermeulen R, Kromhout H. Occupational dermal exposure to cyclophosphamide in Dutch hospitals: A pilot study. Ann Occup Hyg 2004;48:237-44.
Connor TH, McDiarmid MA. Preventing occupational exposures to antineoplastic drugs in health care settings. CA Cancer J Clin 2006;56:354-65.
Kiffmeyer T, Hadtstein C. Handling of chemotherapeutic drugs in the or: Hazards and safety considerations. Cancer Treat Res 2007;134:275-90.
Ratner PA, Spinelli JJ, Beking K, Lorenzi M, Chow Y, Teschke K, et al.
Cancer incidence and adverse pregnancy outcome in registered nurses potentially exposed to antineoplastic drugs. BMC Nurs 2010;9:15.
Tanghe A, Evers G, Vantongelen K, Paridaens R, Van der Schueren E, Aerts R, et al.
Role of nurses in cancer chemotherapy administration. Retrospective record analysis to improve role performance. Eur J Cancer Care (Engl) 1994;3:169-74.
NOISH, National Institute for Occupational Safety and Health (NIOSH). Alert: Preventing Occupational Exposure to Antineoplastic and Other Hazardous Drugs in Healthcare Settings. Publication No 2004.165. Cincinnati, OH: U.S Department of Health and Human Services, Centre for Disease Control and Prevention, National Institute of Occupational Safety and Health DHHS (NIOSH); 2004.165.2014.
Kim K, Lee HS, Kim Y, Kim BJ, Kim MH, Choi SC, et al.
Guideline adherence to chemotherapy administration safety standards: A survey on nurses in a single institute. J Gynecol Oncol 2011;22:49-52.
Considine J, Livingston P, Bucknall T, Botti M. A review of the role of emergency nurses in management of chemotherapy-related complications. J Clin Nurs 2009;18:2649-55.
Verity R, Wiseman T, Ream E, Teasdale E, Richardson A. Exploring the work of nurses who administer chemotherapy. Eur J Oncol Nurs 2008;12:244-52.
Verstrate CA. Exploration of Chemotherapy Safe-handling Practices and Identification of Knowledge Deficits among Oncology Nurses in the Ambulatory Care Setting. A Published Doctoral Dissertation, Grand Valley State University. Available from: http://www.scholarworks.gvsu.edu/cgi
. [Last accessed 2016 Apr 12].
Khan N, Zulfiqar K, Khowaja A, Ali TS. Assessment of knowledge, skill and attitude of oncology nurses in chemotherapy administration in tertiary hospital, Pakistan. Open J Nurs 2012;2:97-103.
Yu HY, Yu S, Chen IJ, Wang KW, Tang FI. Evaluating nurses' knowledge of chemotherapy. J Contin Educ Nurs 2013;44:553-63.
Al-Azzam SI, Awawdeh BT, Alzoubi KH, Khader YS, Alkafajei AM. Compliance with safe handling guidelines of antineoplastic drugs in Jordanian hospitals. J Oncol Pharm Pract 2015;21:3-9.
Polovich M, Martin S. Nurses' use of hazardous drug-handling precautions and awareness of national safety guidelines. Oncol Nurs Forum 2011;38:718-26.
Polovich M, Clark PC. Factors influencing oncology nurses' use of hazardous drug safe-handling precautions. Oncol Nurs Forum 2012;39:E299-309.
Connor T, Eisenberg S. Safe handling of hazardous drugs: Risk and Practice Considerations. In B. Faiman & T Dolan (Eds), Spotlight on Symposia from ONS 35th
Annual Congress (21-22). San Diego, CA: Oncology Nursing Society; 2010.
Stone DS. Health surveillance for health care workers. A vital role for the occupational and environmental health nurse. AAOHN J 2000;48:73-9.
Jacobson JO, Polovich M, Gilmore TR, Schulmeister L, Esper P, LeFebvre KB, et al
. Revisions to the 2009 American Society of Clinical Oncology/Oncology Nursing Society chemotherapy administration safety standards: Expanding the scope to include inpatient settings. Oncol Nurs Forum 2012;39:31-8.
Rogers RW. A protection motivation theory of fear appeals and attitude change1. J Psychol 1975;91:93-114.
Valanis B, Shortridge L. Self protective practices of nurses handling antineoplastic drugs. Oncol Nurs Forum 1987;14:23-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]