Knowledge of safe handling, administration, and waste management of chemotherapeutic drugs among oncology nurses working at Khartoum Oncology Hospital, Sudan

Introduction

Cancer is a deadly disease, accounting for nearly 10 million deaths in 2020 alone (Hulvat, 2020; Turner et al., 2020). The most common are breast, lung, colon, rectum, and prostate cancers (Boakye et al., 2021). Cancer mortality has been reduced due to advancements in medicine and early detection technology (Boakye et al., 2021). Many types of treatments are available for patients with cancer, including chemotherapy, radiotherapy, hormone therapy, immunotherapy, and surgeries (Abbas & Rehman, 2018). Chemotherapy uses drugs to stop or slow the growth of cancer cells. It is administered by various routes, including oral, intravenous, intrathecal, intraperitoneal, and intra-arterial (Tanay, 2020).

In Sudan, national population-based Cancer Registry was established in 2009 (Saeed et al., 2014). In the years 2009–2010, 6,771 new cancer cases were reported, with 3,646 (53.8%) female and 3,125 (46.2%) male cases (Saeed et al., 2014). The most commonly diagnosed among women was breast cancer, followed by leukemia, cervical, and ovarian cancer. Prostate cancer was the most common among men, followed by leukemia, lymphoma, oral, colon, and hepatocellular carcinoma. Leukemia was the most frequent cancer in children under the age of 15, followed by lymphoma and cancers of the eye, bone, kidney, and brain (Saeed et al., 2014).

 Nurses are responsible for the safe and effective administration of cancer therapy medications also known as chemotherapuetic drugs or cytotoxic durgs (CD) (Kav et al., 2008). Oncology nurses are health care professionals who are trained to administer cancer therapy medications such as chemotherapy (Neuss et al., 2016). These nurses must have in-depth knowledge and skills to handle CD and patient safety. Oncology nurses must keep their knowledge and skills current with advances in cancer treatment to reduce the risk of error and promote best practices in cancer care (Rubin et al., 2015). Oncology nurses must attend regular workshops and in-service education (Khalil et al., 2017). It was reported that nurses exposed to cytotoxic drugs are more likely to have children with learning disabilities (Martin, 2005). A large-scale study conducted among (n = 56, 213) oncology nurses in Canada reported a significant increased risk of breast cancer, rectal cancer and congenital anomalies in their offspring’s (Ratner et al., 2010). A study reports that the inadequate knowledge among nurses about extravasation of cytotoxic drugs causes severe damage to patients as well as healthcare professionals (Hussin & Razaq Ahmed, 2020). Little research has been conducted related to knowledge, safe handling, and practice of oncology nurses in Sudan. Therefore, the goal of this study was to assess the knowledge of administration and waste management of chemotherapeutic drugs by nurses who work in Oncology department at Khartoum Oncology Hospital.

Methods

Results

This study involved 78 oncology nurses and had an 81.5% response rate. The majority of participants (n = 55, 70.5%) were between the ages of 31 and 40 years. There were approximately equal numbers of male and female participants, and most had a diploma in nursing. The majority of participants reported more than 5 years of general nursing experience with insufficient training in chemotherapy during their academic years. Fewer than 20% of participants reported having undergone training in chemotherapy, and 55.1% reported having never having undergone any training in chemotherapy (Table 1).

The mean score of knowledge on chemotherapy uses and types and the precautions used during preparation was 2.0 (poor), and the standard deviation was 1.5 (out of 8). The scores obtained for each question are given in Table 2.

The mean score of knowledge regarding safe handling and administering of chemotherapy and identifying exposure risks was 6.2 (good), with a standard deviation of 1.7 (out of 10). The scores obtained for each question are given in Table 3.

The mean score of knowledge regarding the disposal of chemotherapeutic waste and managing side effects was 4.4 (fair), with a standard deviation of 1.5 (out of 8). The scores obtained for each question are given in Table 4.

The mean of the combined knowledge scores for all the sections was 12.7 (fair), with a standard deviation of 3.9 (out of 27).

A simple linear regression was carried out to test whether demographic variables significantly predicted knowledge of CD among nurses. The results of the regression indicated that the model explained 16.3% of the variance and that the model was significant, F (7, 70) = 3.150 (p = .006). Nursing education level and chemotherapy training significantly predicted chemotherapeutic knowledge among nurses (β = 3.715, p = 0.008 and β = 0.969, p = 0.004, respectively). Participants with bachelor’s degrees had a mean knowledge score of 19.67 (SD = 4.59), compared to a mean of 12.17 (SD = 3.334) for nurses with diplomas (Table 5).

Discussion

The purpose of this study was to evaluate the knowledge of nurses regarding the safe handling, administration, and waste disposal of CD in the oncology department. The nurses working in the oncology department at Khartoum Oncology Hospital in Sudan had poor knowledge about safe handling and cytotoxic waste disposal and fair knowledge about CD administration. The knowledge scores obtained in this study were low compared to studies conducted among oncology nurses in Egypt (Zayed et al., 2019), Nepal (Chaudhary & Karn, 2012), the United states (Callahan et al., 2016), Iran (Orujlu et al., 2016), Malaysia (Keat et al., 2013), and Cyprus (Kyprianou et al., 2010). The difference may be due to variations in standard cancer guidelines at the hospital and the availability of in-service training.

All the participants reported that they were not aware of the availability of spill kits or policy on the safe handling of CD at the hospital. Similarly, research conducted in Egypt among 50 nurses reported health hazards such as skin irritation, chest allergy, irregular menstruation, and abortion (Aziza, 2019). Further, the authors of that study reported that the nurses did not use biological safety cabinets for CD preparation and storage, as well as non-compliance with personal protective equipment (PPE) and the absence of safe handling chemotherapy guidelines (Aziza, 2019). This can be attributed to a lack of strict guidelines and regulations in hospitals.

One quarter of the oncology nurses in our study gave the correct answer to questions related to the sequence of drug administration, pre-administration, and preparation, although more than half knew about the type of gloves needed for chemotherapy. Increased usage of gloves has also been reported in other countries such as Nepal and Turkey. This similarity may be due to the availability of gloves being high compared to other PPE. The lack of knowledge about the sequence of drug administration and pre-administrative precautions could cause potential harm to patients receiving cancer therapy (Cohen & Erickson, 2006; Rosenzweig et al., 2012; Schwappach, Hochreutener & Wernli, 2010).

Only a quarter of the nurses in this study reported using PPE at all stages of chemotherapy. These results could be attributed to the limited resources and lack of training at the hospital. However, more than half of the oncology nurses had fair knowledge about the recommended chemotherapy gloves, labeling of chemotherapeutic drugs, and administration of chemotherapeutic drugs. A study among 35 Egyptian oncology nurses reported good knowledge and unsatisfactory practice (Zakaria, Alaa & Desoky, 2022). Another study conducted in Iran among 225 rotational nurses reported a high level of knowledge about cytotoxic drugs and high compliance with PPE (Ali Shahrasbi et al., 2014).

More than three quarters of oncology nurses in this study could not correctly answer the questions related to the disposal of cytotoxic waste, while nurses had good knowledge related to gown re-use, patient education, and adverse effects of chemotherapy. In line with the results of our study 203 nurses from China reported insufficient knowledge of chemotherapy (Yu et al., 2013). The authors further reported that the participants gained knowledge about chemotherapy from colleagues and in-service training (Yu et al., 2013). Another study conducted among Italian oncology nurses (n = 287) showed insufficient knowledge and incorrect beliefs about cancer pain that could affect pain management (Bernardi et al., 2007). Improper disposal of cytotoxic drugs could lead to environmental contamination and harm to healthy individuals (Padmanabhan & Barik, 2019). Other possible reasons for the improper disposal of cytotoxic waste could be lack of time and work overload. Khartoum Oncology Hospital is a renowned facility, and people come to visit this hospital from various states of Sudan.

Regression analysis showed that qualifications and training significantly predicted knowledge. The mean knowledge scores of participants with a bachelor’s degree in nursing were significantly higher than of those with a diploma. This discrepancy could be due to the difference in the training and curriculum between a diploma and a bachelor of nursing. However, surprisingly, participants with no post-academic training showed higher mean knowledge scores than those with such training. This discrepancy may be due to poor quality of training and may eventually question the credibility of this training. Robust research is needed to determine the most effective training to improve the knowledge of oncology nurses.

The majority of nurses reported a shortage of available PPE, and the rest reported a lack of PPE awareness, lack of time for it, discomfort associated with PPE, and concern that PPE may upset patients (Fig. 1). A study conducted among 353 healthcare workers from 24 Greek hospitals reported a significant proportion of the sample did not use PPE (Constantinidis et al., 2011). The authors further reported that healthcare workers were not aware of the dangers of cytotoxic drugs (Constantinidis et al., 2011). The main reason for non-compliance with PPE in our study might be limited resources at Khartoum Oncology Hospitalay eened hospital peutic drugs.

Limitations

The cross-sectional study contains reporting bias. Additionally, the sample size in this study was small and drawn from a single hospital. This potentially limits the generalizability of the study.

Conclusion

There is a significant need to enhance the knowledge and safe handling skills of CD among oncology nurses in Sudan. Implementation of strict guidelines to manage cytotoxic waste to reduce health risks and contamination.

Recommendation

Oncology nurses need urgent training to safely handle CD to improve the quality of patient care and prevent cytotoxic drug contamination.

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