Assessment of The Nurses’ Knowledge about Skin Care For Patients Undergo Radiotherapy of Breast Cancer at Al – Amal

Objectives : The study aims to identify the nurse’s knowledge toward skin care for patients undergo radiotherapy breast cancer Methodology: Seventy nurses were selected to achieve the objectives of the study. The study was conducted during Feb./2014 at Al – Amal National Hospital for Cancer Management in Baghdad City. The questionnaire consists of two parts first part: included demographic characteristics of the nurses and the second part: included clauses relating to the knowledge of nurses about skin care to patients undergoing radiation therapy consisted of (20) items .Data were analyzed by using Frequency, percentage and chi-squared test. Results : The study results showed that most of nurse’s Knowledge was range between low(40%) and moderate(45.7%)and there were significant differences between nurse’s knowledge and nurse’s variables age, level of education, years of experience in radiotherapy unit and number of training sessions at (p<0.05). Conclusion: The researcher concluded that the nurse’s knowledge is insufficient about skin care for patients undergoing radiotherapy of breast cancer. Recommendation: It is recommended increase the researcher to focus on the nurses knowledge about skin care for patients undergoing radiotherapy of breast cancer and to identify the symptoms of the side effects of radiation therapy and prevention.


INTRODUCTION:
Breast cancer is one of the most fearful illnesses for women.It accounts for nearly one of every three cancers diagnosed 1 .Breast cancer is the most common form of malignancy and accounts for 13% of all cancers diagnosed in the UK 2 .Carcinoma of the breast is the most prevalent cancer among Iraqi women and constitutes 29% of Iraqi Cancer Registry cases and 3٢% of all female cancers 3 .
The modalities for the treatment of breast cancer are surgery, chemotherapy, hormone therapy and radiation therapy.More than half of breast cancer patients will undergo radiation therapy, where ionizing radiation will cause cells, both normal and malignant, to be destroyed 4 .The goal of radiotherapy is to provide maximum benefit to the patient with minimal side effects 5 .However, even with the most modern radiotherapy techniques, up to 90% of patients will experience a dose-dependent skin reaction at the treated area 1 .Skin reactions to radiation can range from a mild "sunburn" effect to severe rash and swelling 4 .Skin reactions related to radiation therapy usually manifest within 1-4 weeks of radiation start, persist for the duration of radiation therapy, and may require 2-4 weeks to heal after completion of therapy.The severity of the skin reaction ranges from mild erythema (red rash) and dry desquamation (itchy, peeling skin) to more severe moist desquamation (open wound) and ulceration.After the initial dose of radiation, tissue damage occurs immediately, and every subsequent fraction of radiation generates inflammatory cell recruitment.Acute radiation dermatitis is the combined result of a decrease in functional stem cells, changes in the skin's endothelial cells, inflammation, and skin-cell necrosis and death.Potential complications of radiation dermatitis in the acute setting include local infection 5 .The pathophysiology of a radiation skin reaction is a combination of radiation injury and the subsequent inflammatory response and can occur at both the entrance and exit site of the irradiation 6,7 .The reaction's presentation will to some degree impact on the physiological, emotional and financial well-being of the patient, and can be significant enough to warrant cessation of the radiation treatment 1 .Skin care protocols are compiled by radiation therapy departments to prevent, and manage, acute and chronic skin reactions.The protocols aim to maintain cleanliness, protect skin integrity, alleviate pain, protect from trauma, prevent and control infection and odor, and promote wound healing 6,,8,9 Patients need guidance, education, and support from nurses to navigate the healthcare system and the cancer-care continuum.Provide education, encouragement, problemsolving help, and resource assistance to them and their families.Teaching is a primary responsibility of nursing care for radiation patients 10 .The vital role of the oncology nurse is assessment of skin reactions, patient education regarding skin care, prevention, and managing skin breakdown if it occurs 1,11 .Radiation oncology nurses have access to all of the information they need, to provide the excellent patient care we do so very well!Our challenge is to grow along with our specialty, keeping up with new treatment procedures and protocols, using evidencebased interventions, and taking care of ourselves so we can give necessary support and caring to patients 12 .

OBJECTIVES OF STUDY:
1-To identify the nurse's knowledge toward skin care of breast cancer patients undergo radiotherapy.2-To find an association between nurses knowledge level And their sociodemographic characteristics

METHODOLOGY
Design of the study: Descriptive analytical study was used in this study.Table 2 shows the nurses' knowledge about skin care for patients undergo radiotherapy of breast cancer were low with items, (Smoking worsens mucositis during radiation therapy) (Continuing effects on the skin from 1-4 weeks after radiation therapy), (Using powder kids cause fungal skin infections),( Using of cosmetics (make-up and perfume) increases skin irritation),( Rubbing the region exposed to radiation therapy to irritation) , (Using Deodorant that does not contain chemicals manufactured),(Using of hats and cotton clothing that covers all parts of the body from the sun's rays) was(78.8%)and(putwarm compresses on the treat area).*knowledge score (less than 70%) was poor and (70-85%) was fair and (85-100%) was good.

RESULTS:
Table 5 revealed that there were significant differences between nurses' knowledge score about breast cancer toward skin care under radiotherapy and their years of experience in the radiation therapy unit (p <0.05).The majority of percentage (31.4%) of the sample in years of experience in the radiation therapy unit at(6-10) were poor level and(24.3%)ofsample (1-5) were fair.

DISCUSSION:
The demographic characteristics of the nurses in the present study was 65.7% were males, the majority of them (30%) at age (25-29) years and (40-45 ), most of nurses were secondary Nursing School graduated were of (54.3%), 44.3% of nurse's were have (6-10) years of experience in the radiation therapy unit and the majority of the nurses were have(38.6%)where have (1-5) of training session table1.
The findings of the present study revealed that the nurse's Knowledge assessment were low mean of score with items (Smoking worsens mucositis during radiation therapy) was (67.6%) (Continuing effects on the skin from 1-4 weeks after radiation therapy)was(68.3%),(Using powder kids cause fungal skin infections) was(71.9%),(Using of cosmetics (make-up and perfume) increases skin irritation) was(72.4%),( Rubbing the region exposed to radiation therapy to irritation) was(73.3%),(Using Deodorant that does not contain chemicals manufactured) was (75.7%),(Using of hats and cotton clothing that covers all parts of the body from the sun's rays) was(78.8%),(putwarm compresses on the treat area was(72.4%)table2.Many literature and studies mention about general nurses instructions to patients who will undergo radiation therapy such as: Do not use thick creams because creams that have a high content of paraffin or petroleum jelly.Daily washing of the skin with mild soap and water.Cosmetics, perfume and powder increases skin irritation.Deodorants may continue to be used unless these are found to irritate the skin.Avoid rubbing the area .Use an electric shaver rather than a wet razor.Do not use wax to remove hair or other hair removing creams or product.Smoking during radiotherapy may have a negative influence on prognosis, Smoking limits the oxygen carrying capacity of hemoglobin.Elevated carboxyhemoglobin levels have been associated with changes to the epithelium and increased platelet stickiness.Nicotine affects macrophage activity and reduces epithelialization.Don't expose the treatment area to sun.If you can't avoid sun exposure, use sunscreen with a sun protection factor of at least 30, and wear a hat.Patients are encouraged to avoid direct application of heat or cold to the irradiated area i.e. ice or electric heating pads. 6,7,10,13,14.Wengström, (2000)stated that, the nurses identified several areas of priority related to nursing care."Poor follow-up of patients who have completed the course of radiation therapy" (76%) was perceived as the greatest nursing problem 8 .D 'Haese, et al.,  (2005) presented in their study on Sixty-seven nurses, identified through nine Belgian radiotherapy departments, responded to a questionnaire survey consisting of 58 items regarding prevention and management of erythema, dry desquamation and moist desquamation.Consensus for a given advice was categorized as small if less than 50% of the nurses gave the same answer, as moderate if between 50% and 75% and as large when more than 75%.Overall, 33% of the items showed small consensus, 29% showed moderate consensus and 38% showed large consensus.The highest consensus was seen for advice in cases of moist and dry desquamation.There was less agreement in the case of erythema and it decreased further for preventive advice 11.This study presented that the nurse's Knowledge score was (45%) felt that nurses played a moderate level and (40%) of the sample was poor level, and reveal that significant differences between knowledge score about breast cancer toward skin care under radiotherapy and nurse's variables age, level of education, years of experience in radiotherapy unit and number of training sessions (p <0.05) table3,4,5,6.
The College needs to urgently publish new guidelines based on the current evidence available to provide a foundation and radiotherapy departments need to routinely monitor, assess and document skin reactions using grading systems and noting intrinsic and extrinsic related factors, thus assisting in the overall data collection and management of irradiated skin2,12.Ruppert, (2011) mention that, the body of evidence is insufficient to provide clinicians with comprehensive guidelines for the prevention and management of radiation induced skin reactions 10 .Oncology nurses need to increase their awareness of the evidence or lack of evidence when recommending interventions to their patients 14 .

CONCLUSION:
The study concluded that the nurse's knowledge is insufficient about skin care during radiotherapy, and there were significant differences between nurse's knowledge and nurse's and age, level of education, years of experience in radiotherapy unit and number of training sessions.

RECOMMENDATION:
1-Increase body of nurse's knowledge by lectures and focus on special courses of these nurses who had experience in radiotherapy unit toward skin care of breast cancer patient under radiotherapy to prevent skin reactions and to limited patient symptoms from radiotherapy effects and identify the skin care should entail formulating a protocol that combines knowledge gained from current literature with consideration for each patient's comfort and preferences.2-Encourage the nurses to use further work is required to develop and validate assessment tools that are sensitive to changes in skin damage resulting from radiation over time.Prevention and treatment interventions will likely require different tools.3-Motivate the nurses to doing study or research about nurse's knowledge and nursing practice about management of skin reactions during radiotherapy 4-Further study is required to determine differences in the risk of radiation-induced skin toxicity for various tumor types and anatomic areas.A variety of assessment tools may need to be developed, depending the level, or risk and severity, of the expected reaction.5-Provide more levels of institutes and colleges of nursing to work in the radiation units.
6-Published guidelines provide a sound basis for evidence-based supportive care.

Sample of the study: The
total number of participants recruited for the study was 70 nurses Setting

of the study: Data
were collected from at Al -Amal National Hospital for Cancer Management in Baghdad City and conducted during Feb./2014.

66.66-77.7%) was
low, (77.8-88.9%)was moderate, (89-100%) was high Validity of the instrument: validity determined for questionnaire through the use of panel experts who are faculty members from College of Nursing.Statistical methods: The data were analyzed by using, frequency, percentage, mean of score, relative sufficiency and were tabulated and association between variables was measured with the chi-squared test.

Table 1 : Distribution of the Nurses by Socio-Demography Characteristics
Table1showsthat the highest percentages (65.7%) of nurses were males and (30.0 %) and at the age (2٥-3٩) and (٤٠-٤5) years respectively.According to the educational level, the highest percentage (54.3%) of the nurses were secondary nursing school, and (44.3%) of the sample was related to (11-15) years of employment.Concerning to the years of experience in the radiation therapy unit (45.7%) of the sample was related to (6-10) years and (38.6%) of nurses had (1-5) training session.

Table 2 : Nurse's knowledge assessment about skin care for patients undergo radiotherapy of breast cancer
M.S. =Mean of score, R.S%=Relative Sufficiency, Ass.= assessment.

Table 3 : Association between the nurse's age and their knowledge score about skin care for patients undergo radiotherapy of breast cancer
*knowledge score (less than 70%) was poor and (70-85%) was fair and (85-100%) was good.

Table 3
revealed that there were significant differences between nurses' knowledge score about skin care for patients under radiotherapy of breast cancer and their age (p <0.05).The majority of age (35-39)years were poor level were (21.4%), and (17.1%) of those with age( 40-45)years were fair level.

Table 4 : Association between nurses' educational level and their knowledge score about skin care for patients undergo radiotherapy of breast cancer
*knowledge score (less than 70%) was poor and (70-85%) was fair and (85-100%) was good.

Table 4
revealed that there were significant differences between nurses 'knowledge score about skin care for patients under radiotherapy of breast cancer and their level of education (p <0.05).The majority at educational level in Secondary Nursing School were (24.2%)were poor and (21.4%) were fair level.

Table 6
revealed that there were significant differences between nurses' knowledge score about skin care for patients under radiotherapy of breast cancer and their training session (p <0.05).While the majority of percentage (21.4%)had(1-5)training session were fair and (20%) had(11-15)training session of knowledge score were poor levels.