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1]

ORIGINAL RESEARCH REPORT

Knowledge of chemotherapy and occupational safety

measures among nurses in oncology units
Sylvia E. Nwagbo, Rose Ekama Ilesanmi1, Beatrice M. Ohaeri1, Abimbola O. Oluwatosin1

Department of Clinical Nursing, University College Hospital, 1Department of Nursing, University of Ibadan, Ibadan, Nigeria

ABSTRACT
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
Address for correspondence: of chemotherapy, P<0.05; practice score was also significantly associated with respondents’
Dr. Rose Ekama Ilesanmi, cadre; P<0.05. Conclusion: Periodic and consistent update of nurses’ knowledge supported
Department of Nursing,
by policies to enforce guidelines implementation is recommended.
University of Ibadan, Ibadan, Nigeria.
E‑mail: [email protected] Key words: Chemotherapy, nurses’ knowledge, occupational protective measures, oncology

INTRODUCTION patients and those within the treatment chain,[3] depending

on the chemical and physical properties of the drugs,
Cancer chemotherapy is of great benefit to patients in the quantity administered, and the available collective
the treatment of malignant and nonmalignant tumors.[1] and personal protective measures. Other factors such as
Its use is rapidly expanding with increasing complexity the practitioners’ knowledge and skills also significantly
in schedules as opposed to other regular medications. determine the level of contamination and risk. It follows
These drugs are known to be potentially hazardous that repeated exposure to even low doses for long period
due to their unique pharmacological properties that of time may produce profound effects.
interfere with cell division. The American Society of
Health‑System Pharmacists[2] defined hazardous drugs As far back as 1985, Selevan et al.[4] reported that nurses
as those which manifest genotoxicity, carcinogenicity, who were chronically exposed to cyclophosphamide,
teratogenicity, fertility impairment, serious organ, or any doxorubicin, and vincristine experienced fetal losses.
toxic manifestation at low doses in animals and humans. In addition, reports of learning disabilities were found
Researchers have confirmed that side effects associated among children of nurses who handled chemotherapeutic
with cancer chemotherapeutic agents can occur both in
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DOI: How to cite this article: Nwagbo SE, Ilesanmi RE, Ohaeri BM,
10.4103/jcls.jcls_88_16
Oluwatosin AO. Knowledge of chemotherapy and occupational safety
measures among nurses in oncology units. J Clin Sci 2017;14:131-7.

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Nwagbo, et al.: Nurses’ knowledge of safety measures with chemotherapy

drugs. [5] More recent studies on chromosomes of exclusion criteria included population without hands‑on
nurses who handled chemotherapeutic drugs confirmed experience in the oncology unit, individuals not able to
chromosomal aberrations with evidence of mutagenic and provide informed consent and/or reliable information.
carcinogenic risks in the urine samples.[3,6‑8] These findings A researcher‑developed 54‑item questionnaire based
raise serious concern about knowledge of safety practices. on literature review was used for data collection. The
questionnaire was subjected to expert review to ensure
Furthermore, the Health and Safety Executives[9] noted
content and face validity. A test–retest reliability coefficient
occupational risk and hazard as consequences of the
0.8 was obtained.
inadequate use of control measures. Hospital studies
have also reported detectable levels of cytotoxic drugs Approval for the study was obtained from the Institutional
in the air, surfaces, gloves, and different body parts of Review Board (UI/EC/15/0048) before study. Data
health‑care practitioners.[10] In addition, researchers[7,11,12] collection lasted for 3 weeks and completed questionnaires
reported differently on workplace contamination with were retrieved.
cancer chemotherapeutic agents following inadequate
occupational safety practices. In a large‑scale study of Data were analyzed using the Statistical Package for
56,000 nurses in Canada, Ratner et al.[13] concluded that the the Social Sciences 16.0 Ink. Descriptive and inferential
nurses were at risk for breast and rectal cancers following statistics were used for analysis. Items which measured
workplace exposure to antineoplastic agents. respondents’ knowledge were scored 1 for correct
responses and 0 for incorrect and “I do not know”
Nurses are key stakeholders in cancer care and responses. A maximum obtainable score was 16.0, with
fundamentally require knowledge about chemotherapy, an average rating of 8.0. The scores for knowledge were
either from nursing schools or continuing education categorized into three levels: poor (0–4), fair (4.5–6.0), and
programs. Tanghe et  al.[14] identified four main roles of
good (7.0–9.0). Patterns of utilizing occupational protective
nurses in the chemotherapy administration process. The
measures were scored as “never practice,”[1] “occasional
roles include safely administering the therapy, managing
practice,”[2] and “always practice.”[3] A maximum obtainable
side effects, educating patients and their families on the
score was 30 (if all questions were attempted).
adverse effects of chemotherapy, and providing emotional
support to patients through the process. More recently, Three hypotheses were generated, and test of association
the Cancer Nurses Society of Australia[15] confirmed that was performed using Chi‑square at 5% level of significance.
administration of chemotherapy has become the role of
nurses over the past two decades.
Table 1: Sociodemographic characteristics of the
Therefore, it is of utmost importance that nurses’ respondents (n=100)
knowledge of handling and safety measures is examined Variable Frequency (%)
because they are at risk of exposure to the drugs during Age (years)
preparation and administration. [16] Some authors [17] ≤29 16 (16.0)
have reported a high level of adherence to guidelines on 30-34 26 (26.0)
chemotherapy administration among nurses; however, 35-39 35 (35.0)
>39 23 (23.0)
similar reports have not been fully documented among
Mean±SD 35.4±5.1
nurses in Nigeria. In view of the above, this study assesses
Religion
nurses’ knowledge of chemotherapy and occupational Christian 77 (77.0)
safety practices in the oncology unit. Islam 23 (23.0)
Ethnicity
SUBJECTS AND METHODS Yoruba 70 (70.0)
Hausa 1 (1.0)
This was a descriptive, cross‑sectional study among Igbo 20 (20.0)
nurses in the oncology unit of University College Hospital, Others: Efik, Ijaw, Urhobo, Ebira, Edo 9 (9.0)
Marital status
Ibadan, who were directly involved in the administration
Single 26 (26.0)
of chemotherapeutic drugs. The hospital is a large tertiary
Married 74 (74.0)
institution with total bed occupancy of 800. The oncology Professional qualification
unit consists of radiotherapy clinic and seven wards. University education 39 (39)
Diploma education 61 (61.0)
One hundred and five nurses were purposively selected Working experience (years)
from the seven wards where patients with cancer <3 50 (50.0)
were admitted. The criteria for inclusion consisted of >3 50 (50.0)
experience in oncology wards for not <6 months, and being Mean±SD 2.62±1.11
available during the period of data collection, while the SD=Standard deviation

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Nwagbo, et al.: Nurses’ knowledge of safety measures with chemotherapy

120% of the meaning, classification, types and adverse effects

100% Good of chemotherapy; 99%, 41%, 24%, and 64% respectively
80%
Fair [Figure 1 and Table 3]. Chi‑square test was performed
60%
40%
Poor to examine the relationship between respondents’ level
20% of education and knowledge of chemotherapy. The
0% relationship between the variables was statistically
Meaning of Classification of Types of Side or adverse
Chemotherapy chemotherapy chemotherapy effects significant, χ2 = 84.1, P = 0.000
drugs drugs

Nurses’ knowledge of occupational safety

Figure 1: Respondents knowledge of the aspects of chemotherapy
practices and guidelines for chemotherapy
administration
Table 2: Knowledge of chemotherapy adverse
We examined nurses’ knowledge of protective measures
effects
and guidelines for administration of chemotherapeutic
Possible adverse effects Frequency (%)
agents [Table 4]. From the table, 96% understood the
Yes No Not certain need to wear gloves for preparing and administering
Gastrointestinal distress 99 (99.0) 1.(1.0) 0 chemotherapeutic agents and that visible leaks and spills
Hair loss 100 (100.0) 0 0
should be cleaned with gloved hands (92%). However, 26%
Infertility and abortion 99 (99.0) 1 (1.0) 0
were not certain of the specific recommendations about
Teratogenic effects 99 (99.0) 1 (1.0) 0
Obesity 32 (32.0) 49 (49) 19 (49.0) contact with body fluids of patients on chemotherapy. They
Allergy or pseudoallergic reactions 95 (95.0) 2 (2.0) 3 (3.0) 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.
Table 3: Respondents cumulative knowledge of In addition, 40% were not certain of how to handle
chemotherapy stained clothes or sheets with body fluids. Cumulatively,
Aspects of chemotherapy Good (%) Fair (%) Poor (%) 91.0% scored above the average rating scale, with 30%
Meaning of chemotherapy 99 0 1 having fair knowledge (4.5–6.0), and 61% having good
Classification of chemotherapeutic agents 41 34 35 knowledge (7.0–9.0). Chi‑square test of association was
Types of chemotherapy drugs 24 44 32
performed to examine the association between years of
Adverse effects of chemotherapy drugs 64 23 13
practice in the oncology unit and knowledge of guideline
for chemotherapy administration. The relationship
RESULTS between the variables was statistically significant,
χ2 = 40.7, P = 0.00.
Out of 105 questionnaires distributed, 100 were retrieved
and fit for analysis. The respondents’ mean age was Safety practices of occupational protective
35.4 ± 5.1 years. There were more females (95%) than measures during administration of
males (5%). Exactly 50% of the respondents had been chemotherapeutic agents among nurses
working on the selected wards for over 3 years; of this, 39% Practice of safety measures during the administration of
were graduate nurses while 61% were diploma qualified chemotherapy [Table 5] indicated that 84% always used
nurses [Table 1]. The other findings are presented under gloves for administration, 55% occasionally use face mask
the specific objectives as follows: and goggle, and 20% never used goggles and face mask.
Nurses’ knowledge of chemotherapy and the Protective apron was also used occasionally by 53% while
drug preparation in designated area was never observed
adverse effects
by 25% of the study cohort. A percentage (73%) always
Q u e s t i o n s o n t h e m e a n i n g o f c h e m o t h e ra p y,
observed side effects of drugs on patients and give drugs
classification, types, and adverse effects were examined
according to recommended route and dosage (88%).
[Table 2 and Figure 1]. Findings showed that more
than 90% of the respondents understood the meaning The mean practice score was 24.40 ± 3.80, which was
of chemotherapy; however, only 40% possessed good greater than the average rating scale (20.0). Furthermore,
knowledge of the classification and types. Table 2 95.0% of the respondents scored above the average rating
shows that respondents were knowledgeable about scale, with 35% having fair practice while 60% had good
the common side effects of chemotherapy such as practice.
gastrointestinal distress (99%) and hair loss (100%),
but only 49% indicated that obesity is not a side effect of Comparing respondents’ knowledge of occupational
chemotherapy while 19% were not sure. Cumulatively out protective measures against practice, findings indicated
of a maximum obtainable score of 16 (range 7–16), mean good knowledge of chemotherapy occupational protective
was 13.90 ± 2.19. The respondents had good knowledge measures and guidelines among the nurses, which also

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Nwagbo, et al.: Nurses’ knowledge of safety measures with chemotherapy

Table  4: Respondents’ knowledge of chemotherapy occupational protective measures and

guidelines (n=100)
Protective measures/guidelines True (%) False (%) Not certain (%) Mean±SD
Nurses should wear gloves when preparing and giving chemotherapy 96 (96.0)* 2 (2.0) 2 (2.0) 7.12±2.13
Nurses should wear facemask when preparing and administering chemotherapy 76 (76.0)* 12 (12.0) 12 (12.0)
If there are any visible leaks or spills, gloves should be worn to clean up the drugs 92 (92.0)* 5 (5.0) 3 (3.0)
Use of protective gowns for chemotherapy administration 85 (85.9)* 9 (9.1) 5 (5.1)
Chemotherapy drugs should be prepared in the treatment room or special treatment area 88 (88.0)* 4 (4.0) 8 (8.0)
If a caregiver or relative comes in contact with any body fluids they should wash the area very well 72 (72.0)* 2 (2.0) 26 (26.0)
with warm soap and water
Patients should use a condom during sex and do so for about 2 weeks because the drugs can still 56 (56.0)* 4 (4.0) 40 (40.0)
be found in semen and vaginal secretions
Any clothes or sheets that have body fluids on them should be washed in washing machine ‑ not 57 (57.0)* 3 (3.0) 40 (40.0)
by hand. Wash twice in hot water with regular laundry detergent. Do not wash them with other
clothes. If they cannot be washed right away, sealed in a plastic bag
Protect food from chemotherapy agents 90 (90.0)* 1 (1.0) 9 (9.0)
*
P<0.05. SD=Standard deviation

Table  5: Respondents’ pattern of occupational protective measures  (n=100)

Patterns Never Occasionally Always Mean±SD
Use of gloves 6 (6.0) 10 (10) 84 (84) 24.40±3.80
Use of face mask and goggles 20 (20.0) 55 (55.0) 25 (25.0)
Protective aprons or overall 26 (26.0) 53 (53.0) 21 (21.0)
Preparation of drugs in designated treatment room 25 (25.0) 55 (55.0) 20 (20.0)
Prevention of spills 3 (3.0) 24 (24.0) 73 (73.0)
Handle spills by cleaning 5 (5.0) 32 (32.0) 73 (73.0)
Assessment of side effects in patients 4 (4.0) 23 (23.0) 73 (73.0)
Administer chemotherapy in line with guideline 4 (4.0) 8 (8.0) 88 (88.0)
Administration in line with recommended route 5 (5.0) 7 (7.0) 88 (88)
SD=Standard deviation

70%
or negligence may result in adverse effect for patients,
staff, and the environment.[18,19] Notably, the processes
Knowledge of of preparation, administration, cleaning of spills, and
60%
chemotherapy
occupational protective handling of waste of patients on chemotherapeutic agents
50% measures and guidelines pose the most occupational risk to nurses in this area of
practice. Verstrate[20] explained that knowledge is critical
40%
to safe nursing practice, and it becomes significant when
30% Practice of occupational
knowledge deficit on the part of the nurse threatens
protective measures personal safety and that of the patient. In this study, we
20% examined nurses’ knowledge of chemotherapy, and the
occupational safety practices employed during care among
10%
nurses.
0% Respondents were within the mean age of 35 ± 5.1 years,
Good Fair Poor
half of whom have worked in the oncology unit for a
Figure 2: Respondents Knowledge on occupational safety measures minimum of 3 years with the mean age of 2.62 ± 1.11 years.
against practice However, Khan et al.[21] reported that nurses possess less
working experience in the oncology department. The years
translated to good practice [Figure 2]. Chi‑square test of of practice in the oncology unit may influence knowledge
association between practice score and nurses’ cadre was and practice and maybe argued that nurses with long‑term
performed. Findings were statistically significant χ2 = 46.3, experience in oncology care are more likely to provide care
P = 0.000, <0.05. in line with recommended guidelines and safety practices.
To corroborate this, we found a statistically significant
DISCUSSION association between years of practice in the oncology unit
with knowledge of chemotherapy (P < 0.005). It follows
Administering chemotherapy is a sensitive domain of that nurses who have spent more years in the oncology
oncology nursing practice because the slightest error unit would more likely demonstrate better knowledge than

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Nwagbo, et al.: Nurses’ knowledge of safety measures with chemotherapy

those who have not. It is also expected that the knowledge 85.9% of nurses were aware that protective gowns should
would eventually translate to good practice. be worn during preparation and administration, only
21% always wear it, and 53% do that very occasionally.
Nurses who provide care to patients receiving Unfortunately, 26% have never worn protective gowns.
chemotherapy require specialized knowledge to These findings further support the fact that the nurses
ensure safety of patients and themselves as well as the do not adhere to the guideline, and the reasons may
environment. This particularly impacts care. Several be partly due to inadequate provision of personal
studies reported findings which suggest that nurses’ protective equipment (PPE) by some employers as well as
knowledge of chemotherapy was insufficient. For example, nonenforcement of use. It is very critical that employers
Yu et al.[22] in a descriptive study of 203 nurses concluded provide the necessary PPE in the oncology units.
that nurses fundamentally require more education about
chemotherapy. In the same vein, a pre‑post study among Safe handling of chemotherapy also requires that the
nurses reported that knowledge was poor in specific drugs should be prepared in designated treatment
areas such as the types, classification of antimicrotubules, areas. In the current study, 25% have never prepared
topoisomerase inhibitors, and cytotoxic antibiotics.[21] medication in a designated area, suggesting high
However, the level of knowledge significantly increased risk of environmental contamination. Polovich and
with educational training in that study. In our study, only Clark [25] reported environmental contamination with
55% of the respondents demonstrated good knowledge chemotherapeutic drugs, partly due to poor nursing
of the meaning, classification, types, risk, and side effects compliance to guidelines. This indicates a gap between
of drugs. This suggests less than optimal knowledge in evidence‑based recommendation and actual practice.
this specific area among the study cohort, which may put Literature explained that although policies regarding
individual nurse at risk for adverse effects. safety standards are in place in some facilities, they are
not usually mandatory and therefore may not be enforced.
The findings of this study also indicated that 41% of the
This may possibly explain the variability in practice among
nurses possessed a fair knowledge of chemotherapy.
nurses in our study. In addition, it is possible that some
Therefore, there is a strong indication for on‑the‑job
nurses may not fully appreciate their own health risk when
continuing training/professional development for nurses.
handling chemotherapy or maybe having perceptions of a
It should be noted that for a very long time, there was no
low probability of immediate injury.[26] Moreover, authors
certified oncology nursing program in Nigeria. However,
have observed that most policies and protocols in practice
very recently, a diploma program commenced in Abuja,
are geared toward patient safety and not personnel.[27,28]
Nigeria, making this center the only one for now in the
A common example is the American Society of Clinical
country. It suggests therefore that most nurses in Nigeria
Oncology and the Oncology Nursing Society standards for
who practice in the oncology units were prepared for this
chemotherapy administration. These protocols focus on
role “on the job” or may have obtained an oversea training.
patients’ safety and not nursing exposure. It can, therefore,
Assessment of respondents’ knowledge of safety measures be inferred from different studies that inadequate
for the administration of chemotherapeutic agents education and experience may contribute to unnecessary
indicates high knowledge of some aspects of care. While exposure.
79.2% demonstrated good knowledge of the guidelines,
The current study was based on protection motivation
16.1% were not sure of what constitutes the correct
theory.[29] The theory postulates that the intention to protect
recommendations for administering chemotherapy. This
is quite worrisome given the fact that a slight medication oneself depends on an individual’s perceived severity
error with chemotherapy may cause a very significant of the threat, perceived vulnerability, perceived efficacy,
adverse effect. It is important to note that 96% of and perceived self‑efficacy. It follows that an appraisal of
respondents understood the need to wear gloves during one’s vulnerability and estimation (threat appraisal) of
preparation, administration, and cleaning of spills. This the seriousness of a disease determines the protective
corroborates the findings of Al‑Azzam et al.[23] in a study on actions and the response efficacy and self‑efficacy (coping
compliance with safe handling guidelines of antineoplastic appraisal). In relation to nurses’ knowledge of chemotherapy
drugs in Jordanian hospitals. In that study, although and patterns of occupational safety, the theory suggests that
46.4% reported full knowledge and compliance with the a negative health condition or side effect can be avoided if
guideline, only 10.7% reported full compliance with eye nurses have an adequate understanding of the principles,
protection (goggles), shoe cover, and hair cover. practice, and safe handling protocols of chemotherapeutic
agents. Nurses’ appraisal of their perceived vulnerability
Similarly, Polovich and Martin [24] in a study among and severity of side effects also greatly determines their
nurses (n = 330) concluded that while nurses have motivation to protect self (protective motivation). Connor
adopted gloving for handling hazardous drugs, the use and Eisenberg[26] explained that inadequate use of protective
of protective gown remained low. In our study, while measures among nurses is a reflection of perceptions of

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Nwagbo, et al.: Nurses’ knowledge of safety measures with chemotherapy

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