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Knowledge, Attitudes and Practices of Safe Handling of Cytotoxic Drugs

among Oncology Nurses in Tanta University Hospitals

Article in Egyptian Journal of Occupational Medicine · January 2019

DOI: 10.21608/ejom.2019.25119

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Egyptian Journal of Occupational Medicine, 2019; 43 (1) : 75-92

KNOWLEDGE, ATTITUDES AND PRACTICES OF

SAFE HANDLING OF CYTOTOXIC DRUGS AMONG

ONCOLOGY NURSES IN TANTA UNIVERSITY

HOSPITALS

By
Zayed HA1, Saied SM2, El-Sallamy RM1 and Shehata WM2
1
Department of Occupational Medicine, 2Department of Public Health and Community Medicine,
Tanta University, Egypt
Zayed HA: [email protected] Saied SM: [email protected]
El-Sallamy RM :[email protected] Shehata WM: [email protected]

Abstract
Introduction: Occupational exposure to antineoplastic agents and safe handling of
cytotoxic drugs (CDs) had gained a high concern among oncology nursing staff due
to their potential health risks. Many organizations such as Occupational Safety and
Health Administration (OSHA), Oncology Nursing Society and National Institute
for Occupational Safety and Health (NIOSH) have recommended guidelines for
safe handling of cytotoxic drugs. Aim of work: To assess the knowledge, attitudes,
and practices (KAP) of oncology nursing staff working at Tanta University Hospitals
towards the safe handling of CDs. Materials and methods: A cross-sectional study
was conducted for 3 months (from February to April, 2018) at the Oncology department
in Tanta University Hospitals, Egypt. A pre-designed questionnaire was used to assess
nurses` KAP regarding safe handling of CDs. Results: A total of 55 oncology nurses
participated in the study. The total KAP scores of nurses towards the safe handling of
CDs were satisfactory among 63.6% of the studied group. The mean scores of responses
for knowledge, attitudes, and practices were 19.05 ± 4.8 out of 26, 13.09 ± 3.07 out of
16, and 8.87 ± 1.35 out of 12, respectively. More than half of the nurses had previous
training in the Oncology department. Defective use of personal protective equipments
(PPE) during various steps of CDs handling was noticed. Conclusion: There was
inadequate practice of safe handling of CDs and defective implementation of guidelines
among the studied oncology nurses, necessitating more frequent in-service training and
audit system to monitor and evaluate their performance after training.
75
 76 Zayed HA et al.,

Keywords: Cytotoxic drugs, Safe handling, Oncology nurses, Tanta University

Hospitals, Knowledge, Attitudes and Practices.

Introduction al., 2004 and NIOSH, 2017), (2) Dur-

Health care workers (HCWs) in ing administration by intravenous (IV)
the field of medical oncology provide routes, or during specialized procedures
medical treatment for cancer patients of administration such as intra-perito-
using chemotherapy (Shambaugh et neal, pleural or pericardial, and cere-
al., 2003). Chemotherapeutic agents in brospinal fluid (CSF) routes…. (White
this field are known as cytotoxic drugs et al., 1996; and Stuart et al., 2002).
(CDs), anti-neoplastic drugs (ADs) and (3) Transport, and (4) during cleaning
oncology drugs. They are used exten- spills and waste disposal (Vyan et al.,
sively in health care facilities to treat 2014). Thus significant amounts of CDs
cancer patients (Boiano et al., 2014). can be contaminated food absorbed via
CDs are hazardous to HCWs particu- (i) inhalation of the powder and liq-
larly nurses, clinical pharmacists and uid aerosols, (ii) unprotected skin and
cleaners who may come in contact with mucus membranes, (iii) Oral exposure
these CDs during their daily work activ- may occur from hand-to-mouth contact
ities (Clapp et al., 2007 and Dabrowski or ingestion of or drinks and (iv) nee-
et al. 2007).There are more than 11 mil- dle stick injury (Harrison et al., 2006;
lion cancer cases diagnosed each year Hedmer et al., 2008 and Mahdy et al.,
worldwide and are expected to rise to 2017).
16 million by the year 2020. Thus, the Although guidelines for safe han-
number of HCWs handling cytotoxic dling of CDs were introduced more
drugs is expected to increase with the than 20 years ago, contamination of
increase in the number of new cancer both the working environment as well
cases requiring treatment with chemo- as the HCWs is still reported in several
therapeutic agents (Mistry et al., 2011). recent studies particularly in developing
Chemotherapy drugs are adminis- countries (Crauste-Manciet et al., 2005;
tered either by injection or orally. Oc- Kopp et al., 2013 and Alehashem and
cupational exposure to CDs may occur Baniasadi, 2018). Lack of knowledge,
during (1) drug preparation and admix- economic and socio-cultural factors are
ture (Connor et al., 1999; Fransman et major determinants of unsafe behavior
 Knowledge, Attitudes, Practices and Cytotoxic Drugs 77

related to handling of CDs by HCWs increased risks of leukemia and breast

(Waheida et al., 2015; and Alehashem cancer among nurses handling CDs and
and Baniasadi, 2018). An epidemiologi- not following safety guide lines (Skov
cal study in 2016 determined the imme- et al.,1992 and Ratner et al., 2010).
diate and contributing causes of expo-
Aim of work
sure of HCWs to anti-neoplastic drugs.
These were classified into 4 categories To assess the knowledge, attitude,
for immediate causes such as: direct and practice (KAP) of oncology nurses
contact with CDs without personal pro- towards the safe handling of cytotoxic
tective equipments, needle stick injury, drugs (CDs).
spills, and other unintended exposures; Materials and methods
and 3 categories of contributing causes
Study design: A cross-sectional
such as: lack of training, inadequate
study.
controls and poor communication (Hon
and Abusitta, 2016). Place and duration of the study:
The study was conducted among adult
Acute health hazards associated
Oncology department nurses, in Tanta
with occupational exposure to CDs in-
University Hospitals, Egypt; for a peri-
clude skin rashes, sore throat, cough,
od of 3 months (from February to April,
dizziness, headache, eye irritation, hair
2018)
loss, and allergic reactions (Valanis et
al., 1993). Chronic health effects in Study sample: The target group
unprotected HCWs who handle these was all registered nurses (55 nurses)
drugs without following safety mea- working in the adult Oncology depart-
sures include genotoxicity, mutagenic- ment of Tanta University Hospitals. In-
ity, carcinogenicity, adverse reproduc- clusion criteria: All nurses who were in-
tive outcomes such as: spontaneous volved in handling cytotoxic drugs with
abortion, infertility and poor neonatal work experience equal to or more than
outcome (Talamanca, 2006; Moga et al., one year at the same hospital. Exclusion
2011 and Mahdy et al., 2017) and organ criteria: Nurses who were not involved
toxicity such as bone marrow, liver, kid- in handling of cytotoxic drugs, and
ney, lung, and cardiac toxicity (Boiano those with work experience less than
et al., 2014). Several studies reported one year.
 78 Zayed HA et al.,

Study methods: Scoring: The knowledge score

All study participants were subject- ranged from 0 to 26. Nurses who
achieved ≥ 75% of the score (i.e. ≥
ed to the following:
20) were classified as having satisfac-
1- Predesigned self-administered tory knowledge, those who scored
questionnaire sheet developed by <75%were considered to have unsatis-
Alehashem and Baniasadi (2018) was factory knowledge.
used for data collection. It consisted of
Regarding the attitude, the score
four sections: the first section included
ranged from 0 to 16. Nurses who
some socio-demographic and occupa-
achieved ≥ 75% of the attitude score
tional data of the studied nurses; the
(i.e. ≥ 12) were considered to have a
second section consisted of 13 items
positive attitude, while score less than
which measured the nurses’ knowledge
75% was considered as a negative one.
regarding protocols and guidelines for
preparation, administration, waste dis- For practice, the score ranged from
posal, and storage of CDs; the third sec- 0 to 12. Nurses who obtained ≥ 75%
tion consisted of 8 items which were of the score (i.e. ≥ 9) were classified as
used to assess the participant’s attitudes having adequate practice while those
towards the importance of safe handling who achieved less than < 75% were
of CDs. The fourth section consisted of classified as having inadequate practice.
12 items to assess the participant’s prac- Total KAP ranged from 0-54, nurses
tice in various steps of handling CDs. who achieved ≥ 75% of the total score
Coding: Knowledge items required (≥ 41) were classified as having a satis-
an ordinal response (NO=0, Somewhat factory KAP, while obtaining less than
=1, Yes =2), attitude item responses were 75% was considered as an unsatisfac-
(Disagree=0, Neutral=1, Agree=2), tory KAP.
and responses to practice points were 2. A performance observational
(NO=0, Yes=1). The KAP scores were checklist, which was developed by the
calculated for each nurse based on their researchers, after reviewing related lit-
answers. The mean scores were calcu- erature, to assess the practice of the
lated and a higher mean score indicated study participants and their compliance
greater agreement with the statements. with guidelines while handling CDs,
 Knowledge, Attitudes, Practices and Cytotoxic Drugs 79

and to assess their application of knowl- Data management

edge into the actual practice as hand
The collected data were coded,
hygiene and PPE utilization during the
double-checked for completeness, and
various steps of handling CDs.
entered into Microsoft Excel data sheet,
Consent
and then analyzed using SPSS software
Verbal consent was obtained from (version 25.0 for Windows; SPSS Inc.,
all study participants who accepted to Chicago, IL, USA). Descriptive vari-
participate in the study prior to distri-
ables were expressed as frequency,
bution of the questionnaire sheet. No
percentages, and mean ± S.D. Pearson
personal identifiers were incorporated
into the sheet. Nurses were informed chi-square and Fisher Exact tests were
about the aim of the study, and that the used to test for association between
collected data will be used for research categorical variables. Spearman’s cor-
purposes only. relation analysis was done to determine
Ethical approval whether any of the occupational fac-
tors significantly predicted the knowl-
The Research Ethics Committee
(REC) of the Faculty of Medicine, Tanta edge, attitude, and practice scores, and
University approved the study protocol. to test the correlation between these
Ethical considerations and confidential- scores. The statistical significance level
ity were guaranteed. was set at p≤ 0.05.
 80 Zayed HA et al.,

Results
Table (1): Socio-demographic and occupational characteristics of the studied
oncology nurses correlated with their total KAP score.
Mean total KAP score 41.36 ±8.7 (out of 52)
Unsatisfactory KAP Satisfactory KAP r
Characters (No=55) p
% No %
No
20 36.4 35 63.6

•• Age in years Mean ± SD (years): 34.38±9.5 - Range (years): 22-55

20- 34 (61.8%) 19 55.9% 15 44.1%
30- 13 (23.6%) 3 23.1% 10 76.9% 0.368
0.006*
40-55 8 (14.5%) 1 12.5% 7 87.5%
•• Marital status
Unmarried@ 16 (29.1%) 10 62.5% 6 37.5%
0.269
Married 39 (70.9%) 13 33.3% 26 66.7% 0.047*
•• Educational level
Bachelor degree 12 (21.8%) 1 8.3% 11 91.7%
Health Technical 23 (41.8%) 2 8.7% 21 91.3% 0.798
Institute 0.000**
Nursing school 20 (36.4%) 20 100.0% 0 0.0%
•• Years of experience
< 2 Year 2 (3.6%) 2 100.0% 0 0.0%
2<3 years 20 (36.4%) 13 65.0% 7 35.0% 0.503
0.000**
3-5 Years 8 (14.5%) 4 50.0% 4 50.0%
>5 Years 25 (45.5%) 4 16.0% 21 84.0%
•• Ever received any formal training regarding CDs handling
Yes 30 (54.5%) 8 26.7% 22 73.3% 0.336
NO 25 (45.5%) 15 60.0% 10 40.0% 0.012*
@
Un-married including single, divorced, and widowed
*
Statistically significant ** Highly statistically significant
 Knowledge, Attitudes, Practices and Cytotoxic Drugs 81

Table (1) showed that a total of 55 nurses from the oncology department, par-
ticipated in the present study; their mean age was 34.38±9.5 years, and all of them
(100%) were females. More than two thirds of the respondents (70.9%) were mar-
ried. Less than one quarter (21.8%) of participants had a Nursing Bachelor Degree.
Nearly half of the participants (45.5%) had work experience more than five years.
Only 54.5% of nurses had previous training on safe handling of CDs. Regarding the
correlations of the total KAP score with participants` characteristics ; the results of
Spearman test indicated that there were significant correlations between age, mari-
tal status, educational level, years of experience, and receiving training and total
KAP score, as higher percentages of satisfactory KAP were found among the older
age groups, Bachelor Degree holders, more than 5 years’ experience, and those
who received previous training (87.5%, 91.7%, 84.0%, and 73.3%, respectively,
p< 0.05).
 82 Zayed HA et al.,

Table (2): The numbers and percentages of responses to the KAP items.
Knowledge items NO Somewhat Yes
No % No % No %
1. Anti-cancer drugs are cytotoxic 0 0 16 29.1 39 70.9
2. I am aware of all routes of exposure to CDs 11 20.0 23 41.8 21 38.2
3. I am aware of adverse health effects of exposure 12 21.8 20 36.4 23 41.8
to CDs
4. I know the management of adverse health effects 2 3.6 23 41.8 30 54.5
of CDs
5. I know guidelines and standards for safe 0 0 12 21.8 43 78.2
preparation of CDs
6. I know safe administration of CDs 0 0 14 25.5 41 74.5
7. I know safe transport and storage of CDs 14 25.5 15 27.3 26 47.3
8. I have to use biological safety cabinet (BSC) for 16 29.1 23 41.8 16 29.1
all preparations
9. I know correct use of BSC 16 29.1 23 41.8 16 29.1
10. I know the management of accidents in handling 11 20.0 23 41.8 21 38.2
of CDs
11. I know all required PPE 0 0 0 0 55 100
12. I know how to use PPE correctly 0 0 0 0 55 100
13. I know safe CD waste disposal methods 0 0 10 18.2 45 81.8
Attitude items Disagree Neutral Agree

No % No % No %
1. Safe handling of CDs makes me sure that I am 7 12.7 14 25.5 34 61.8
not at risk
2. Use of PPE in handling of CDs is essential 0 0 0 0 55 100
3. Handling of CDs in work overload condition is 10 18.2 14 25.5 31 56.4
unacceptable
4. Adverse health effects of CDs exposure are worrying 0 0 15 27.3 40 72.7
5. I should handle CDs without hurry 0 0 10 18.2 45 81.8
6. I should pay attention to precautions in guidelines 0 0 0 0 55 100
7. I started my work in oncology with my willing 10 18.2 14 25.5 31 56.4
8. I wish to continue my work in oncology with my 4 7.2 20 36.4 31 56.4
willing
 Knowledge, Attitudes, Practices and Cytotoxic Drugs 83

Practice items NO Yes

No % No %
1. I always prepare CDs in preparation room 14 25.5 41 74.5
2. I always prepare CDs in BSC 37 67.3 18 32.7
3. I never do risky behaviour (eat, drink, smoke,..) in 10 18.2 45 81.8
preparation room
4. I don’t store CDs in preparation room 7 12.7 48 87.3
5. I follow standard guidelines for handling of CDs 6 10.9 49 89.1
6. I always wear PPE during preparation of CDs 0 0 55 100
7. I always wear PPE during administration of CDs 0 0 55 100
8. I always wear PPE during transport and storage of CDs 8 14.5 47 85.5
9. I manage accidents as spills based on standard protocols 11 20.0 44 80.0
10. I record and report all accidents in handling of CDs 18 32.7 37 67.3
11. I consult clinical pharmacist about safe handling 23 41.8 32 58.2
12. I consult occupational medicine specialist about related 48 87.3 7 12.3
health problems

Table (3): Knowledge, attitudes and practices grades of the studied nurses
and their correlations.
No % No %
Knowledge Grade [Mean Knowledge score 19.05 ±4.8 (out of 26)]
Unsatisfactory Satisfactory
18 32.7 37 67.3
Attitude Grade [Mean Attitude score 13.09 ±3.07 (out of 16)]
Negative Positive
15 27.3 40 72.7
Practice Grade [Mean Practice score 8.87 ±1.35 (out of 12)]
Inadequate Adequate
35 63.6 20 36.4
Correlation
Knowledge Practice
Knowledge r p 0.041 0.767
Attitude 0.927 0.000** 0.025 0.859
** :
Highly statistically significant
 84 Zayed HA et al.,

Tables (2 and 3) showed the per- dling of CDs. Concerning Practice: All
centages of the responses to each KAP nurses (100%) wore PPE during prepa-
item, and the correlations between ration and administration of CDs. The
KAP scores. Concerning Knowledge: majority (89.1%) followed standard
All nurses (100%) reported that they guidelines for safe handling of CDs.
knew all required PPE, and how to use Only, near one-third (32.7%) always
them correctly. The majority of them prepared CDs in BSC and 18.2% of
(81.8%) reported that they knew the nurses did some risky behaviours as eat-
safe method of disposal of CDs waste. ing or drinking in the preparation room.
In addition, the majority (78.2%) men- Other faulty behaviours were found, as
tioned that they knew guidelines and one-fourth (25.5%) of nurses did not
adhere to prepare CDs in the prepara-
standards for safe preparation of CDs,
tion room, one-third of them (32.7%)
while only one third (29.1%) knew
did not record and report all accidents
about using BSC during preparation of
during handling of CDs. Only 58.2% of
CDs. The mean score of responses for
them consulted the clinical pharmacist
knowledge was 19.05 ±4.8. More than
about safe handling, and the majority
two-thirds (67.3%) of participants had
(87.3%) did not consult an occupational
a satisfactory knowledge grade. Con-
medicine specialist about related health
cerning Attitude: All nurses (100%)
problems. The mean score of responses
agreed that the use of PPE in handling for practice was 8.87 ±1.35, and only
of CDs was essential, and that they paid (36.4%) of participants had an adequate
attention to safety precautions. The ma- practice grade. The study showed that
jority of nurses agreed that they handle there was only a strong positive cor-
CDs without hurry, and that the adverse relation between knowledge and at-
health effects of CDs exposure were titude regarding safe handling of CDs
worrying (81.8%, and 72.7%, respec- (r=0.927, p<0.001), and respondents
tively). Of the respondents, (61.8%) who had higher knowledge scores had
had a positive attitude towards safe han- better attitude scores.
Table (4): Association between knowledge, attitude and practices of nurses and their occupational
characteristics.
Knowledge Attitude Practice
No % No % χ2 No % No % χ2 No % No % χ2
p
Unsatisfactory Satisfactory Negative Positive p Inadequate Adequate p

Character
Experience
≤5 Ys 15 50.0 15 50.0 8.94 12 40.0 18 60.0 5.39 21 70.0 9 30.0 1.56
>5 Ys 3 12.0 22 88.0 0.003** 12.0 22 88.0 0.020* 11 44.0 0.283
3 14
56.0
Previous training
Yes 3 10.0 27 90.0 15.49 2 6.7 28 93.3 14.13 16 53.3 14 46.7
NO 15 60.0 10 40.0 0.000** 52.0 12 48.0 0.000** 6 24.0 3.03
13 19
76.0 0.082
*
Statistically significant ** Highly statistically significant Ys: Years

Table (4) revealed that work experience more than five years was associated with higher percentages of
satisfactory knowledge grade, positive attitude, and adequate practice (88%, 88%, and 44%, respectively), and
Knowledge, Attitudes, Practices and Cytotoxic Drugs

the difference was statistically significant in knowledge and attitude (p< 0.05). Previous training was associ-
ated with higher percentages of satisfactory knowledge grade, positive attitude, and adequate practice (90%,
93.3%, and 46.7%, respectively), with a statistically significant difference concerning knowledge and attitude
(p< 0.05).
85
 86 Zayed HA et al.,

Table (5): Use of PPE and hand washing during the different steps of CDs
handling.
CDs handling Preparation Administration Transport Cleaning of Waste
steps & store of spills handling
(No=12) ( No =35) CDs ( No =5) ( No =55)
( No =5)
Measures % No % No % No % No %
Gloves 10 83.33 29 82.86 4 80.00 5 100.00 23 41.82

Gown 7 58.33 9 25.71 2 40.00 3 60.00 10 18.18

Use of PPE

Mask 9 75.00 31 88.57 2 40.00 3 60.00 19 34.55

Eye 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00

protector
Before 10 83.33 27 77.14 2 40.00 0 0.00 0 0.00
washing

any step
Hand

After any 11 91.67 23 65.71 3 60.00 5 100.00 41 74.55

step
PPE: Personnel protective equipment CDs: Cytotoxic drugs

Table (5) revealed that gloves were the most commonly used PPE especially
during cleaning of spills (100%), while eye protectors (Goggles) were totally not
available. Defective pre-step hand wash was found except before preparation and
administration steps (83.33%, and 77.14%, respectively).
 Knowledge, Attitudes, Practices and Cytotoxic Drugs 87

Discussion ers handling CDs have adequate knowl-

Cytotoxic drugs (CDs) result in dis- edge.
ruption of the growth of both normal High levels of knowledge concern-
and diseased cells, and lead to toxic side ing the CDs and associated adverse
effects for both patients receiving these health effects are extremely vital to im-
drugs and health care workers involved prove nurses’ compliance with safety
in different steps of handling them such measures (Elshamy et al., 2010).
as preparation, administration, trans-
port, cleaning of spills and handling of As reported in the previous studies,
wastes. Nurses are the health care work- training of nurses significantly enhanc-
ers most exposed to the toxic effects of es their knowledge (Turk et al., 2004;
these drugs so they are in need for spe- Kyprianou et al., 2010, Chaudhary;
cialized knowledge, skills and attitude 2012, Shahrasbi et al.; 2014 and Ale-
to ensure their own safety as well as hashem and Baniasadi, 2018) the pres-
patients’ safety (Public Services Health ent study also showed significant cor-
and Safety Association, 2013 and Gazal relation between knowledge scores and
et al., 2015). previous training of nurses (Table 1).
Regarding knowledge about safe Concerning the attitude of nurses
handling of CDs, the results of the pres- towards safe handling of CDs, the cur-
ent study indicated that about two-thirds
rent study showed that the attitude score
(67.3%) of the nurses had a satisfactory
was positive in about three quarters
level of knowledge (Table 1). This level
of nurses (Table3) ,which is different
is higher than the levels reported in pre-
from Alehashem and Baniasadi results
vious studies done by Turk et al. (2004)
(2018) which showed that the attitude
and Alehashem and Baniasadi (2018)
(58% and 52.5%, respectively), and score was sufficient in only 60% of
much higher than Bolbol et al. (2016) their nurses. Also, there was a statisti-
who found that only 4% of nurses had cally significant association between
adequate knowledge, but lower than the nurses’ attitude and their previous train-
results of Sheikh study (2016) done at ing (Table 4), which is consistent with
Kenyatta National Hospital units who the findings of Alehashem and Baniasa-
found that 95.4% of health care work- di , 2018.
 88 Zayed HA et al.,

Contrary to the findings about the As regards wearing PPE, the pres-
level of nurses’ practice of Alehashem ent study found that gloves were the
and Baniasadi study in Iran (2018) and most commonly used PPE especially
Sheikh study in Nairobi (2016), but in during cleaning of spills (100%), fol-
accordance with findings from the pre- lowed by wearing during preparation of
vious studies in Pakistan, Malaysia, and CDs (83.33%) then during administra-
Nepal (Chaudhary et al., 2012; Khan tion (82.86%) (Table 5). This is nearly
et al., 2012 and Keat et al., 2013), the similar to Al-Azzam et al. study (2015)
current study showed that the practice who declared that 97.6% of nurses who
grade was generally inadequate and not were involved in preparation and ad-
strictly following the international stan- ministration of anti-neoplastic drugs
dards (Table 3). in a Jordanian hospital wore double
The current study showed that there gloves, and is in line with Turk et al.
was a strong correlation between at- results (2004) that 97.4% used them
titude and knowledge regarding safe during CDs preparation. However, it
handling of CDs (Table 3). This is simi- differs from Elshamy et al. results in
lar to other studies, which showed that Mansoura University Hospitals, Egypt
increasing the knowledge levels of the (2010), who reported that a lower per-
nurses is important to improve their at- cent of oncology nurses wore gloves
titude (Ben-Ami et al., 2001 and Ale- throughout the different stages of CDs
hashem and Baniasadi, 2018). handling (28.6% during preparation and
Also, contrary to Alehashem and administration and 25.7% while clean-
Baniasadi study (2018) who detected ing up spills). Goggles (Eye protector)
significant correlation between the were used by 33% of the nurses includ-
scores of different sections (knowledge, ed in Al-Azzam et al., study (2015), and
attitude and practice), the current study in 5.3% of nurses of Turk et al. study
did not find any significant correlation (2004); our results were different, as
between knowledge and practice or be- eye protectors (Goggles) were not at all
tween attitude and practice (Table 3), used during nursing care activity which
which is in agreement with Sheikh re- is similar to Elshamy et al. findings
sults (2016). (2010).
 Knowledge, Attitudes, Practices and Cytotoxic Drugs 89

Concerning hand washing before with involvement of the clinical phar-

CDs handling, the present study found macists and occupational medicine
it defective except before preparation specialists on the guidelines and safe
and administration steps (83.33%, and practice methods especially the Occu-
77.14%, respectively) (Table 5), which pational Safety and Health Administra-
is nearly similar to results of Al-Azzam tion (OSHA), National Institute for Oc-
et al., (2015), who reported that 75.2% cupational Safety and Health (NIOSH),
of the nurses included in their study and American Society of Hospital Phar-
were found performing good hand hy- macist (ASHP): (1) protecting health
giene while handling CDs but it is dif- care workers from health hazards as-
ferent from Elshamy et al., (2010) who sociated with CDs exposure; and (2)
found that contaminated hands and keeping exposures As Low As Reason-
poor hand washing while preparing ably Achievable (ALARA) (Boiano et
and administrating CDs was detected in al., 2014).The guidelines for preventing
51.4% of the studied nurses. occupational exposures to CDs cover
(1) engineering solutions, (2) adminis-
Conclusion and recommendations
trative controls and safe work practices
It was clear from our study that the through specified methods used to per-
practice of the nurses while dealing form work tasks from shipping/receiv-
with cytotoxic drugs (CDs) was mostly ing, transport and distribution, com-
inadequate. Oncology is a branch of pounding, administration, and waste
medicine which needs specialized, and disposal, to specialized worker training
efficient nursing work, so nurses em- (Boiano et al., 2014) and (3) use of spe-
ployed for oncology work should be cific personal protective equipments to
selected from those with high educa- minimize drug contact with the skin,
tional level, long experience and high eye or respiratory tract (Mahdy et al.,
performance. Raising the awareness 2017). In spite of the presence of these
of the nurses regarding safe handling guidelines, several researchers found
of CDs is of marked importance. On- that guidelines are not being universal-
the-job training and supervision is also ly followed (Boiano et al., 2014).Thus,
important. Pre-employment and ongo- the guideline plan should be readily
ing refreshing training programmes are available and accessible to all HCWs
highly recommended for those nurses (Occupational Health and Safety Ad-
 90 Zayed HA et al.,

ministration (OSHA), 2017). Nurses at Zagazig university hospitals. EJOM; 40 (2):

219-35.
must be aware of the existing hazards 6. Chaudhary R and Karn BK (2012):
and methods of safe handling practices Chemotherapy-knowledge and handling
of cytotoxic drugs because this benefits practice of nurses working in a Medical
University of Nepal. J Cancer Ther; 3 (1):110–4.
both patients and nurses. The higher the 7. Clapp RW, Howe GK and Jacobs MM (2007):
nurses’ awareness, the more they adhere Environmental and occupational causes of
cancer: A call to act on what we know. Biomed
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