Safe Handling Knowledge and Practices of Chemotherapy among Oncology Nurses in Erbil City

Background : Widespread use of chemotherapy in the treatment of cancer has lead to higher health hazards among nurses who handle and administer such drugs, so theyshould know how to protect themselves from effects of chemotherapy. Objective of study was to assess knowledge and practicesof nurses for safe handling chemotherapy in Erbil City. Methodology: A cross sectional study design was undertaken on 27 nurses in oncology units in Erbil City in 2015, to collect the data, patients who met the inclusion criteria were selected and questionnaires were filled through interviewing in 20 minutes. The questionnaire including demographic information and safe handling chemotherapy knowledge and practices and barriers of personal protective equipment. data were analysis by descriptive and inferential statistics Results: The total mean score of knowledge and practices of safe handling chemotherapy was 15.59±1.96, 8.74+1.78 respectively and more than two to third of nurses had no knowledge that chemotherapy enter the body through contaminated foods, about practices more than three quarter no change of personnel protective barriers after contact with chemotherapy . Result of this study showed that was significant negative association between knowledge and practices (r=-0.469, p=0.014). Moreover, It is showed that significant negative association between practices and barriers (r = 0. 475; P = 0. 012).


INTRODUCTION
Chemotherapy drugs include a wide range of chemical compounds because of their ability to kill tumor cell by interfering with cell division, they are extensively used to treat cancer. More than 11 million cancer cases diagnosed each year worldwide and expected to rise to 16 million by the year 2020, the rising patient's number leads to an increase in the use of chemotherapy drugs and more possibility of exposure of the health-care workers to these drugs andthe number of staff potentially exposed to hazardous effect of the chemotherapy drug was more than 5.5 million (1) . The Oncology Nursing Society recommends that in order to provide quality care and maintain safety standards, nurses must be competent in oncology nursing practices and have an awareness of risks amid their workplace. A major facet of this competency is that nurses must beremaining educated and regularly engage in standard practical safety guideline (2) .Nurses may perceive they are immune to the risks of chemotherapy exposure, as existing research concludes that poor compliance may be associated with a knowledge deficit and perceptions of a low probability of immediate injury (3) .
Knowledge is critical to safe nursing practices in all settings, but it is especially significant when a knowledge deficit of the nurse practices threatens personal safety or the safety of the patient. Past research suggests that chemotherapy may have unintentionally compromised the oncology work setting for more than thirty years (4) . An extensive review of comprehensive standards associated with hazardous drug administration and the use of personal protective equipment (PPE) may be necessary to determine if policies and regulations need to be updated to correspond with current evidence (5) . Results of this study provided information to facilitate the collaborative development of an educational plan for hospital to improve strategies and address deficits. In other words, once the study identified the presence and degree of knowledge practice's deficit to provide recommendations for a targeted intervention leading to a safer work environment in the future for patients and nurses. The objective of this study was to assess knowledge and practices of nurses for safe handling chemotherapy in Erbil City.

METHODOLOGY
A cross sectional study design was used to assess knowledge andpracticesof safe handling chemotherapy in Erbil City,in order to obtain the accurate data and representative sample, a nonprobability (purposive) sample was used to select among 27 nurses in Rizgary Teaching Hospital and Nanakaly Hospital form 28 June 2015 to 2 October 2015 according to the following criteria, patients who agreed to participate the study and worked in oncology units.Data were collected through the use of questionnaire; which was developed by the researchers.
The questionnaire consist of two part: first part compose of demographic data of the nurses such as age, gender, professional qualification, total years of experience and training course and the second part consist of safe handling chemotherapy about knowledge12 items and practices 7 itemsand also 10 items for thebarriersof personal protective equipment for using chemotherapy drug and each part were rated two point scales (no 1 score and yes2 score). Lower score would reflect poor knowledge and practices to safe handling chemotherapy.Data analysis was performed using SPSS 19 version information was summarized using frequency tables and cross tabulation. bivariate correlation (Pearson correlation) analysis was done to find out relationship between knowledge, practices and barriers of safe handling chemotherapy. P-value of equal or less than 0.05 was considered a statistically significant.  Table 1 shows the distribution of the sample according to demographic data. Concerning to the working area more than half of total (59.26%) was in the Nanakally Hospital and (40.74%) was in Rizgary Teaching Hospital. The age of the nurses ranged from 20-46 yearsold, the highest percentage (40.74%) of total sample was within age group (38-46) and lowest percentage (22.22) was within age group (20-28). Moreover, male and female were nearly equal percentages (51.85 and48.15) respectively. Furthermore, more than half percentage (55.56%) of nurses duration of experience less than one years while (44.44%) of them duration of experience more than one years. Regarding the professional qualification, the highest percentage (70.37%) of the study samplehad diploma and lowest percentage (11.11%) hadbachelor'squalification. In relation, to the program training for chemotherapy, the highest proportion of nurses (81.43%) was no training course and (18.52%) of nurses have training course.  Table 2. Concerning the knowledge of nurse of safe handling chemotherapy, more than three quarter of nurses don't know that chemotherapy can enter the body through breathing. While, less than three quarter of nurses correctly responded to chemotherapy can't enter the body through contact with contaminated surfaces. Also, the highest percentage (92.6 %) of nurses was correctly respond to chemotherapy can enter the body through contaminated foods. While, more than half of nurses know a surgical mask provides protection from chemotherapy aerosols.  Table 3. Regarding, the practices of nurse of safe handling chemotherapy, the highest percentage(40.7%, 37.34) of nurses were washing hands thoroughly after any contact with chemotherapy and no eating, drinking, smoking or doing make up at areas of drug administration respectively. While, concerning not safe handling practices 88%, 85% of nurses were not immediate change of any contaminated personnel protective barriers after contact with chemotherapy and wearing personnel protective barriers consequently.  Table 4 present the barriers of safe handling chemotherapy, nearly three quarter of nurses perceived main barrier of PPE is not always available and others around me don't use PPE.While,more than half of nurse not perceived barrierI don't think PPE is necessary and I was not trained to use PPE.  Table 5. Revealed that the relationship among knowledge, practices and barriers of safe handling chemotherapy showed that there was significant negative association between knowledge and practices (r=-0.469, p=0.014) and non significant positive association between knowledge and barriers (r = 0. 102; P = 0. 612). Moreover, It was showed that significant negative association between practices and barriers (r = 0. 475; P = 0. 012).

DISCUSSION
Today cancer patients are diagnosed earlier than the past and many receive multiple courses of chemotherapy treatment for a longer period of time (6) .The poor compliance of nurses with the safety measures of chemotherapy were consistently associated with several barriers including the incomplete facility, multitasking and work pressure, insufficient knowledge and techniques, lack of awareness and wrong beliefs as well as insufficient in-service training (7) .
In current study most of nurses don't know that chemotherapy can enter the body through contaminated foods and breathing. In the study which was done by Mason in the United Kingdom, significant concentrations of several drugs in both personal and area air samples were reported, drug particulates can become airborne after the drying of contaminated areas. Inadvertent ingestion may be an additional route of exposure. When food or beverages are prepared, stored, or consumed in work areas, they may easily become contaminated with airborne particles of antineoplastic drugs (8) .
In present study more than two to third of nurses were not immediate change of contaminated personnel protective barriers after contact with chemotherapy and wearing personnel protective barriers consequently this findings agree with this study showed that none of the nurses were using the protective equipment's necessary during the handling of chemotherapy. Nurses who had higher knowledge scores reported using at least one personal protective equipment significantly more frequently than the nurses who had lower knowledge scores (9) . Elshamy et al, (2010) showed that poor use of gloves, gowns and personal protective equipment by nurses when handling patient waste and when cleaning up spills which was supported the present study for handling chemotherapy, revealed that very small number of nurses used all of the recommended protective equipment (10) .
With regard, the barriers of safe handling chemotherapy about three quarter of nurses perceived main barrier of PPE is not always available and others around me don't use PPE, these findings are supported to those of a recent National Institute for Occupational Safety and Health (NIOSH) study where 80% of nurses reported they do not always use the recommended two pairs of gloves when handling chemotherapy (11) .
The current result showed that overall scores of knowledge and practices of nurses for safe handling chemotherapy were fair while, nurses caring for patients receiving chemotherapy require specialized knowledge in order to ensure safety for both patients life and for their own safety of the jobs. Many nurses have been fired from their job due to medication errors (12) . In this respect, the results of the present study also, supported by the finding which was concluded that the totaloverallresult of the study indicated that the participants have poor knowledge and skills, it is important for nursing care to cancer patients because if oncology nurses did not have advance knowledge and not competent in their skills will be considered as unsafe for providing chemotherapy administration to cancer patients and chances for medication errors can be high (13) .Nurses' knowledge about the handling of chemotherapy drugs remains a concern linked to improvement in safety standards and the higher the nurses' knowledge the more they use the safety measures in their practices (14) .

CONCLUSION
In general, the findings of the study shows that majority of nurses were fair knowledge and practices of safe handling chemotherapy.