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Health Care Workers’ Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada a
b
Chun-Yip Hon , Kay Teschke & Hui Shen a
b
School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada
b
School of Population and Public Health, University of British Columbia, British Columbia, Canada Accepted author version posted online: 21 Apr 2015.Published online: 28 Aug 2015.
Click for updates To cite this article: Chun-Yip Hon, Kay Teschke & Hui Shen (2015) Health Care Workers’ Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada, Journal of Occupational and Environmental Hygiene, 12:10, 669-677, DOI: 10.1080/15459624.2015.1029618 To link to this article: http://dx.doi.org/10.1080/15459624.2015.1029618
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Occupational and Environmental Hygiene, 12: 669–677 ISSN: 1545-9624 print / 1545-9632 online c 2015 JOEH, LLC Copyright DOI: 10.1080/15459624.2015.1029618
Health Care Workers’ Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada Chun-Yip Hon,1 Kay Teschke,2 and Hui Shen2 1
Downloaded by [Florida Atlantic University] at 10:00 08 September 2015
2
School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada School of Population and Public Health, University of British Columbia, British Columbia, Canada
Although nurses are knowledgeable regarding the risk of exposure to antineoplastic drugs, they often do not adhere with safe work practices. However, the knowledge, perceptions, and behavior of other health care job categories at risk of exposure has yet to be determined. This study aimed to survey a range of health care workers from British Columbia, Canada about their knowledge, perceptions, and behaviors regarding antineoplastic drugs. A self-administered questionnaire was sent to participants querying the degree of contact with antineoplastics, knowledge of risks associated with antineoplastics, perceptions of personal risk, previous training with respect to antineoplastics, and safe work practices. Subjects were recruited from health care facilities in and around Vancouver. Fisher’s exact tests were performed to ascertain whether there were differences in responses between job categories. We received responses from 120 participants representing seven different job categories. Pharmacists, pharmacy technicians, and nurses were more knowledgeable regarding risks than other job categories examined (statistically significant difference). Although 80% of respondents were not afraid of working with or near antineoplastics, there were concerns about the suitability of current control measures and practices employed by co-workers. Only half of respondents felt confident that they could handle all situations where there was a potential for exposure. Only one of the perception questions, self-perceived risk of exposure to antineoplastic drugs, differed significantly between job categories. Not all respondents always wore gloves when directly handling antineoplastic drugs. Further, hand hygiene was not regularly practiced after glove usage or after being in an area where antineoplastic drugs are handled. The majority of responses to questions related to safe work practices differed significantly between job categories. Our results suggest that knowledge regarding risks associated with antineoplastic drugs can be improved, especially among job categories that are not tasked with drug preparation or drug administration. There is also a gap between knowledge and compliance with glove usage and hand hygiene.Training is also recommended to improve health care workers’ perceptions of the risks associated with antineoplastic drugs. Keywords
antineoplastic drugs, behaviors, health care workers, knowledge, occupational exposure, perceptions
Address correspondence to Chun-Yip Hon, School of Occupational and Public Health, Ryerson University, 350 Victoria Street, POD247C, Toronto, ON M5B 2K3, Canada; e-mail: cyhon@ ryerson.ca
INTRODUCTION
A
ntineoplastic drugs are prepared and administered to treat patients with cancer or non-malignant diseases. Unfortunately, because of their non selective mode of action, these drugs can harm healthy cells as well as cancerous cells and, in turn, can lead to adverse health effects for those tasked with handling them. Health care workers may be exposed to antineoplastic drugs through the course of their duties and documented chronic health effects include reproductive issues, genetic effects, as well as cancer.(1–3) Nurses are one of the job categories known to be at risk of occupational exposure to antineoplastic drugs because they directly handle these agents when administering to patients.(1–3) As such, a number of preventive measures designed to reduce exposure to antineoplastic drugs have been developed specifically for drug administration procedures. However, several studies have reported gaps between nurses’ knowledge of occupational exposure to antineoplastic drugs and their behavior when handling these agents, i.e., not complying with safe handling procedures or not using suggested protective equipment despite being aware of the risks.(4–8) In one such study, although 80% of respondents indicated they were aware that patient excreta may contain drug residual, only 16% of the nurses wore a gown and 12% wore a mask.(4) Ben-Ami et al. found a statistically significant disparity between nurses’ knowledge and their actual behavior with regards to the risks associated with antineoplastic drugs and their compliance with protective measures.(6) A similar discrepancy between nurses’ knowledge and precautions employed was reported by Polovich and Clark(8) as well as Kosgeroglu et al.(5) In
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one of the largest surveys of health care workers in the United States, Boiano et al. found that safe handling practices were not always followed by nurses who administer antineoplastic drugs despite the fact that guidelines have existed for some time.(7) The above findings for nurses are rather disconcerting given that they are considered a high-risk cohort with respect to occupational exposure to antineoplastic drugs. It also raises the question of the level of knowledge and compliance amongst other health care job categories that may be at risk of exposure to antineoplastic drugs. Approximately 58,000 Canadian health care workers are at risk of exposure to antineoplastic drugs;(9) however, this number is likely an underestimate as it has recently been documented that a broad range of health care job categories, besides nurses and pharmacy personnel (another known high-risk cohort), are potentially exposed. This includes, but is not limited to, porters, housekeepers, unit clerks, ward aides, and other auxiliary hospital personnel.(10–13) The objective of this descriptive study was to survey a broad range of potentially exposed health care workers from British Columbia, Canada with respect to their knowledge and perceptions regarding antineoplastic drugs as well as their behavior associated with safe work practices. The job categories surveyed were pharmacists, pharmacy receivers, pharmacy technicians, nurses, transport (includes porters and shipper/receivers), unit clerks, and others in drug administration units who are not responsible for drug administration (volunteers, oncologists, ward aides, and dieticians). These jobs were selected based on evidence from observations and exposure measurement studies that identified them as being at risk of exposure.(14) The results of this study will identify gaps in knowledge and point to where improvements can be made to promote safe handling of antineoplastic drugs and minimize occupational exposure.
METHODS Study Design and Research Components This study was a component of a larger more comprehensive project examining health care workers’ exposure to antineoplastic drugs. A cross-sectional design was employed in the current study. Six acute care facilities in Vancouver, British Columbia participated in the study. Health care worker participants were selected based on site observations that indicated their job category was at risk of exposure.(14) Subjects were selected by either active recruitment via a letter of invitation or passive recruitment through distribution of consent to contact forms in departmental meetings. The recruitment method was dictated by the requirements of participating hospitals’ research ethics boards. The research team sent the questionnaire and a pre-paid return envelope via regular mail to each consenting subject’s preferred mailing address. The questionnaire was disseminated between May 2010 and January 2011. All respondents were given an honorarium ($25 gift card) for completing the questionnaire. 670
Study Questionnaire – Design and Pre-Testing The self-administered questionnaire was developed from multiple sources. The knowledge of risks questions (Section C) were derived from consistent findings reported in various occupational exposure studies, e.g., detectable levels of antineoplastic drugs are found on work surfaces.(15) Questions related to risk perception (Section D) were modified from a survey employed to examine facial protection use among health care workers.(16) The survey used by Geer et al. in their study examining worker knowledge, attitudes, and perceptions underlying dermal exposure was the basis for questions related to hand washing and glove usage (Section H).(17) A draft version of the questionnaire was pre-tested on a small group of health care workers who were representative of the population of interest but worked at facilities that did not participate in the research project. Where necessary, draft questions were modified based on the feedback of the pre-test group and a second version of the survey was re-tested on a smaller subset of the pre-test group. A final version of the questionnaire was vetted by the relevant research ethics boards prior to distribution to participants. A copy of the questionnaire is available online at: http://antineoexposure.spph.ubc.ca/healthcareworkers-exposure-antineoplastic-drugs/study-documents. The finalized questionnaire was divided into multiple sections as follows: (1) demographic data such as age and work experience; (2) degree of contact with antineoplastic drugs, such as frequency and duration; (3) knowledge of risks associated with antineoplastic drugs; (4) perceptions of personal risk; (5) previous training with respect to antineoplastic drugs; and (6) hand hygiene practices and use of gloves. Questions related to knowledge of antineoplastic drug hazards (Section C) had response options of “true/false/don’t know” while questions regarding knowledge of existing policies and procedures had response options of “yes/no/don’t know”. Questions related to one’s perceptions of antineoplastic drugs and individual preventive practices (Sections D and H) were on a 5-point Likert response scale of “strongly agree/agree/disagree/strongly disagree/don’t know (neutral)”. Returned questionnaires were reviewed for completeness. When questions were unanswered, the subject was contacted by a member of the research team who subsequently requested the subject respond to any unanswered questions via fax or email.
Data Analysis Descriptive statistics of frequencies were used to present the demographic results. Fisher exact tests (to account for small cell sizes of some categories) were performed to determine whether job title was associated with knowledge of risk, perception of risk, or safe work practices such as glove usage. A p-value of < 0.05 was considered statistically significant. All analyses were performed using R 3.1.2 (The R Foundation for Statistical Computing, Auckland, New Zealand).
Journal of Occupational and Environmental Hygiene
October 2015
RESULTS
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Participant Characteristics There were 120 participants representing seven different job categories (Table I). It was not possible to calculate a true response rate because of the constraints of the recruitment methods dictated by hospital ethics boards; however, the proportions of those contacted who participated in the 6 facilities ranged from 55–76%. The average job tenure of all participants was 104 months (8.6 years) with a range of 0–433 months (36 years). More than three-quarters of the participants were female and they represented the vast majority in all job categories except transport, which was predominantly male. Most participants were between the ages of 30 and 59. Knowledge of Risks and Workplace Practices Table II shows that almost all pharmacists, pharmacy receivers, pharmacy technicians, and nurses provided correct answers to the five knowledge questions. Answers by those within transport, unit clerk and other jobs in drug administration were more frequently incorrect. There was a statistically significant difference in knowledge of risk between job categories for all five questions in Table II. Perceptions of Risks and Existing Control Measures Risk of Exposure From Table III, it can be seen that for those job categories who directly handle antineoplastic drugs, i.e., pharmacists, pharmacy technicians, and nurses, at least 50% disagreed that their risk of exposure to antineoplastic drugs was very low. For the remaining job categories, a majority of respondents felt that their risk was low with unit clerks having the highest proportion of respondents feeling this way (83.3%). The difference in perception of risk of exposure between job categories was statistically significant. Pharmacy personnel and nurses were not afraid of working with or near antineoplastic drugs (>80%), whereas many in other jobs were either afraid or did not know how they felt. This difference was not statistically significant. Suitability of Safety Measures With respect to the safety measures that are currently in place to reduce antineoplastic drug contamination, a small majority of the respondents felt that they were suitable. Confidence in safety measures was higher among pharmacy personnel and nurses than among transport, unit clerk, and others in the drug administration unit but this difference was not statistically significant. Safe Work Practices of Co-Workers A small majority of participants (65%) agreed with the statement that workers around them are handling antineoplastic drugs safely. Transport had the smallest proportion of respondents who agreed with this statement; in fact, it was the only category where the majority disagreed or did not know.
The responses to this question were not significantly different between job categories. Ability to Handle Exposure Situations A little more than half the respondents (51.7%) were confident that they could handle all situations where there is a potential for antineoplastic drug exposure, including spills and contaminated urine. Nurses were most confident while transport and others in the drug administration units were least confident (difference not statistically significant). Availability of Personal Protective Equipment A large majority of respondents agreed that the required personal protective equipment (PPE) was readily available and that they were able to use the PPE properly, but transport jobs and other workers who work in the drug administration unit had a higher percentage of respondents who answered “don’t know” to both questions related to PPE. There were no statistically significant differences in responses between job categories for either of the two PPE-related questions. Regular Contact, Training History and Safe Work Behaviors Most pharmacy personnel, nurses, and unit clerks were normally required to handle, prepare, and/or administer antineoplastic drugs as part of their duties, but fewer transport and other drug administration jobs had this requirement (difference statistically significant). Most pharmacists, pharmacy technicians, and nurses had received training related to safe drug handling, but few pharmacy receivers, transport personnel or unit clerks had (difference statistically significant). In all job categories, the proportion who had received training was lower than the proportion required to handle the drugs. Not all respondents always wore gloves when directly handling, preparing, and/or administering antineoplastic drugs. Nurses, then pharmacy staff reported most compliance, whereas for other jobs, it was rarely reported (difference statistically significant).The job cohort that had the highest proportion report that they never wear gloves were unit clerks. It should be noted that many in transport and other drug administration unit jobs did not answer this question, perhaps because they felt they did not directly handle these drugs. Glove use was less frequent among pharmacy and nursing personnel when they were simply present in an area where antineoplastic drugs have been handled, prepared, and/or administered. Participants in the other three job categories answered this question more completely, and reported somewhat more glove use in this scenario. Even though glove use was more similar between job categories in this scenario, the differences between job categories remained significant. Overall, 80% of respondents always or sometimes washed their hands after glove use but responses to this question were statistically significant between job categories. Many people in job categories where glove use was rare did not answer this question. The question regarding hand washing practices after a worker has been in an area where antineoplastic drugs
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TABLE I.
Respondent Characteristics Stratified by Job Category
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Overall N (%) Mean job tenure in months (range) Gender Female (%) Male (%) Age 20 to 29 (%) 30 to 39 (%) 40 to 49 (%) 50 to 59 (%) 60+ (%)
Pharmacy Pharmacist Receiver
Pharmacy Technician
Nurse
Transport
Unit Clerk
Others in drug admin
120 (100) 21 (17.5) 7 (5.8) 24 (20.0) 33 (27.5) 11 (9.2) 12 (10.0) 12 (10.0) 104 (0–433) 124 (0–360) 121 (18–294) 116 (13–378) 87 (9–420) 141 (10–433) 75 (13–240) 76 (8–240)
78.3 21.7
76.2 23.8
71.4 28.6
79.2 20.8
90.9 9.1
18.2 81.8
100 0
83.3 16.7
10.0 27.5 29.2 24.2 9.2
9.5 33.3 28.6 23.8 4.8
0.0 28.6 28.6 28.6 14.3
8.3 41.7 41.7 8.3 0.0
15.2 27.3 24.2 21.2 12.1
0 9.1 27.3 63.6 0
25.0 33.3 16.7 25.0 0
0 0 33.3 25.0 41.7
Transport includes porters and shippers/receivers; others in drug administration include volunteers, oncologist, ward aides, and dieticians.
have been handled, prepared and/or administered was more completely answered by participants in all job categories. The vast majority reported sometimes or always washing their hands, although substantial numbers of pharmacist and unit clerks reported never doing so (difference not statistically significant). DISCUSSION
W
e attempted to understand the knowledge and perceptions of a broad range of health care workers (pharmacists, pharmacy receivers, pharmacy technicians, nurses, transport, unit clerks, and others in drug administration units who are not responsible for drug administration) with respect to occupational exposure to antineoplastic drugs and their usual behaviors when in potential contact with these hazardous agents. Our results suggest that there are opportunities to extend the reach of training as certain job categories, in particular, transport, unit clerks, and others in the drug administration unit, were much less likely to be educated regarding workplace health and safety of antineoplastic drugs (less than 25% of workers in these three cohorts had ever received training). This lack of training is evidenced by the fact that these three job categories did not fare well on questions related to knowledge of occupational exposure risk to antineoplastic drugs and the associated site practices. Training programs targeted at nurses have proven to be effective in increasing knowledge and improving compliance with both safe handling guidelines as well as personal protective equipment usage.(18–20) Our results also indicate the need to reinforce the importance of glove use and subsequent hand hygiene amongst all at-risk health care workers (Table IV). This is especially true for pharmacists and pharmacy technicians because they are regularly exposed as they are tasked with checking the doses 672
and for drug preparation, respectively. The lack of compliance among both pharmacists and pharmacy technicians was in spite of the fact that they were knowledgeable about the health risks associated with antineoplastic drugs and aware of their potential exposure. Our findings are similar to those who reported a gap between nurses’ knowledge and adherence to safe work practices.(4–8) Another disconcerting finding is that hand hygiene was not routinely practiced after glove use. This is of concern as studies have found gloves to be permeable to antineoplastic drugs(21, 22) presenting an opportunity for the skin to act as a reservoir(23) as well as the potential for exposure through accidental ingestion.(24) Not surprisingly, compliance with glove usage and subsequent handwashing was further reduced when participants were simply in an area where antineoplastic drugs are handled, prepared and/or administered as opposed to direct contact. However, because surface contamination can be found in any of these areas(25) and dermal contact is the primary route of exposure,(12,26,27) glove use, and/or hand hygiene is still suggested and this fact should be reinforced in training. With regards to health care workers’ perceptions, it was interesting to note that the proportion who believed their risk of occupational exposure to antineoplastic drugs was very low was similar to those who felt their level of risk was higher (49.2% and 45.0%, respectively). It is therefore surprising that 80% of the respondents disagreed with the statement that they are afraid of working with or near antineoplastic drugs. Perhaps this is due to the fact that there are other existing occupational hazards in which they perceive there are greater health risks compared to contact with antineoplastic drugs.(6) A small majority (63.3%) felt that the current control measures are appropriate to minimize exposure. Similarly, only 65% of respondents believed that co-workers were
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673
100
100
84.2
87.5
85.7
100
100
71.4
100
Pharmacy Receiver (%)
91.7
100
100
100
87.5
Pharmacy Technician (%)
100
100
87.9
93.9
100
Nurse (%)
54.5
54.5
54.5
45.5
72.7
Transport (%)
Transport includes porters and shippers/receivers; others in drug administration include volunteers, oncologist, ward aides, and dieticians.
100
85.7
80.8
81.7
95.2
Pharmacist (%)
81.7
Overall (%)
Knowledge of Risks and Workplace Practices Stratified by Job Category
Knew the skin is possible route of occupational exposure antineoplastic drugs Knew that work surfaces may have antineoplastic drug contamination Knew that their site had a dedicated antineoplastic drug preparation area Knew that there is a separate disposal method for antineoplastic drugs Knew that the site had a safe drug handling policy
TABLE II.
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58.3
75
83.3
66.7
41.7
Unit Clerk (%)
25.0
41.7
33.3
50.0
33.3
Others in drug admin (%)
Journal of Occupational and Environmental Hygiene Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uoeh20
Health Care Workers’ Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada a
b
Chun-Yip Hon , Kay Teschke & Hui Shen a
b
School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada
b
School of Population and Public Health, University of British Columbia, British Columbia, Canada Accepted author version posted online: 21 Apr 2015.Published online: 28 Aug 2015.
Click for updates To cite this article: Chun-Yip Hon, Kay Teschke & Hui Shen (2015) Health Care Workers’ Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada, Journal of Occupational and Environmental Hygiene, 12:10, 669-677, DOI: 10.1080/15459624.2015.1029618 To link to this article: http://dx.doi.org/10.1080/15459624.2015.1029618
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Occupational and Environmental Hygiene, 12: 669–677 ISSN: 1545-9624 print / 1545-9632 online c 2015 JOEH, LLC Copyright DOI: 10.1080/15459624.2015.1029618
Health Care Workers’ Knowledge, Perceptions, and Behaviors Regarding Antineoplastic Drugs: Survey From British Columbia, Canada Chun-Yip Hon,1 Kay Teschke,2 and Hui Shen2 1
Downloaded by [Florida Atlantic University] at 10:00 08 September 2015
2
School of Occupational and Public Health, Ryerson University, Toronto, Ontario, Canada School of Population and Public Health, University of British Columbia, British Columbia, Canada
Although nurses are knowledgeable regarding the risk of exposure to antineoplastic drugs, they often do not adhere with safe work practices. However, the knowledge, perceptions, and behavior of other health care job categories at risk of exposure has yet to be determined. This study aimed to survey a range of health care workers from British Columbia, Canada about their knowledge, perceptions, and behaviors regarding antineoplastic drugs. A self-administered questionnaire was sent to participants querying the degree of contact with antineoplastics, knowledge of risks associated with antineoplastics, perceptions of personal risk, previous training with respect to antineoplastics, and safe work practices. Subjects were recruited from health care facilities in and around Vancouver. Fisher’s exact tests were performed to ascertain whether there were differences in responses between job categories. We received responses from 120 participants representing seven different job categories. Pharmacists, pharmacy technicians, and nurses were more knowledgeable regarding risks than other job categories examined (statistically significant difference). Although 80% of respondents were not afraid of working with or near antineoplastics, there were concerns about the suitability of current control measures and practices employed by co-workers. Only half of respondents felt confident that they could handle all situations where there was a potential for exposure. Only one of the perception questions, self-perceived risk of exposure to antineoplastic drugs, differed significantly between job categories. Not all respondents always wore gloves when directly handling antineoplastic drugs. Further, hand hygiene was not regularly practiced after glove usage or after being in an area where antineoplastic drugs are handled. The majority of responses to questions related to safe work practices differed significantly between job categories. Our results suggest that knowledge regarding risks associated with antineoplastic drugs can be improved, especially among job categories that are not tasked with drug preparation or drug administration. There is also a gap between knowledge and compliance with glove usage and hand hygiene.Training is also recommended to improve health care workers’ perceptions of the risks associated with antineoplastic drugs. Keywords
antineoplastic drugs, behaviors, health care workers, knowledge, occupational exposure, perceptions
Address correspondence to Chun-Yip Hon, School of Occupational and Public Health, Ryerson University, 350 Victoria Street, POD247C, Toronto, ON M5B 2K3, Canada; e-mail: cyhon@ ryerson.ca
INTRODUCTION
A
ntineoplastic drugs are prepared and administered to treat patients with cancer or non-malignant diseases. Unfortunately, because of their non selective mode of action, these drugs can harm healthy cells as well as cancerous cells and, in turn, can lead to adverse health effects for those tasked with handling them. Health care workers may be exposed to antineoplastic drugs through the course of their duties and documented chronic health effects include reproductive issues, genetic effects, as well as cancer.(1–3) Nurses are one of the job categories known to be at risk of occupational exposure to antineoplastic drugs because they directly handle these agents when administering to patients.(1–3) As such, a number of preventive measures designed to reduce exposure to antineoplastic drugs have been developed specifically for drug administration procedures. However, several studies have reported gaps between nurses’ knowledge of occupational exposure to antineoplastic drugs and their behavior when handling these agents, i.e., not complying with safe handling procedures or not using suggested protective equipment despite being aware of the risks.(4–8) In one such study, although 80% of respondents indicated they were aware that patient excreta may contain drug residual, only 16% of the nurses wore a gown and 12% wore a mask.(4) Ben-Ami et al. found a statistically significant disparity between nurses’ knowledge and their actual behavior with regards to the risks associated with antineoplastic drugs and their compliance with protective measures.(6) A similar discrepancy between nurses’ knowledge and precautions employed was reported by Polovich and Clark(8) as well as Kosgeroglu et al.(5) In
Journal of Occupational and Environmental Hygiene
October 2015
669
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one of the largest surveys of health care workers in the United States, Boiano et al. found that safe handling practices were not always followed by nurses who administer antineoplastic drugs despite the fact that guidelines have existed for some time.(7) The above findings for nurses are rather disconcerting given that they are considered a high-risk cohort with respect to occupational exposure to antineoplastic drugs. It also raises the question of the level of knowledge and compliance amongst other health care job categories that may be at risk of exposure to antineoplastic drugs. Approximately 58,000 Canadian health care workers are at risk of exposure to antineoplastic drugs;(9) however, this number is likely an underestimate as it has recently been documented that a broad range of health care job categories, besides nurses and pharmacy personnel (another known high-risk cohort), are potentially exposed. This includes, but is not limited to, porters, housekeepers, unit clerks, ward aides, and other auxiliary hospital personnel.(10–13) The objective of this descriptive study was to survey a broad range of potentially exposed health care workers from British Columbia, Canada with respect to their knowledge and perceptions regarding antineoplastic drugs as well as their behavior associated with safe work practices. The job categories surveyed were pharmacists, pharmacy receivers, pharmacy technicians, nurses, transport (includes porters and shipper/receivers), unit clerks, and others in drug administration units who are not responsible for drug administration (volunteers, oncologists, ward aides, and dieticians). These jobs were selected based on evidence from observations and exposure measurement studies that identified them as being at risk of exposure.(14) The results of this study will identify gaps in knowledge and point to where improvements can be made to promote safe handling of antineoplastic drugs and minimize occupational exposure.
METHODS Study Design and Research Components This study was a component of a larger more comprehensive project examining health care workers’ exposure to antineoplastic drugs. A cross-sectional design was employed in the current study. Six acute care facilities in Vancouver, British Columbia participated in the study. Health care worker participants were selected based on site observations that indicated their job category was at risk of exposure.(14) Subjects were selected by either active recruitment via a letter of invitation or passive recruitment through distribution of consent to contact forms in departmental meetings. The recruitment method was dictated by the requirements of participating hospitals’ research ethics boards. The research team sent the questionnaire and a pre-paid return envelope via regular mail to each consenting subject’s preferred mailing address. The questionnaire was disseminated between May 2010 and January 2011. All respondents were given an honorarium ($25 gift card) for completing the questionnaire. 670
Study Questionnaire – Design and Pre-Testing The self-administered questionnaire was developed from multiple sources. The knowledge of risks questions (Section C) were derived from consistent findings reported in various occupational exposure studies, e.g., detectable levels of antineoplastic drugs are found on work surfaces.(15) Questions related to risk perception (Section D) were modified from a survey employed to examine facial protection use among health care workers.(16) The survey used by Geer et al. in their study examining worker knowledge, attitudes, and perceptions underlying dermal exposure was the basis for questions related to hand washing and glove usage (Section H).(17) A draft version of the questionnaire was pre-tested on a small group of health care workers who were representative of the population of interest but worked at facilities that did not participate in the research project. Where necessary, draft questions were modified based on the feedback of the pre-test group and a second version of the survey was re-tested on a smaller subset of the pre-test group. A final version of the questionnaire was vetted by the relevant research ethics boards prior to distribution to participants. A copy of the questionnaire is available online at: http://antineoexposure.spph.ubc.ca/healthcareworkers-exposure-antineoplastic-drugs/study-documents. The finalized questionnaire was divided into multiple sections as follows: (1) demographic data such as age and work experience; (2) degree of contact with antineoplastic drugs, such as frequency and duration; (3) knowledge of risks associated with antineoplastic drugs; (4) perceptions of personal risk; (5) previous training with respect to antineoplastic drugs; and (6) hand hygiene practices and use of gloves. Questions related to knowledge of antineoplastic drug hazards (Section C) had response options of “true/false/don’t know” while questions regarding knowledge of existing policies and procedures had response options of “yes/no/don’t know”. Questions related to one’s perceptions of antineoplastic drugs and individual preventive practices (Sections D and H) were on a 5-point Likert response scale of “strongly agree/agree/disagree/strongly disagree/don’t know (neutral)”. Returned questionnaires were reviewed for completeness. When questions were unanswered, the subject was contacted by a member of the research team who subsequently requested the subject respond to any unanswered questions via fax or email.
Data Analysis Descriptive statistics of frequencies were used to present the demographic results. Fisher exact tests (to account for small cell sizes of some categories) were performed to determine whether job title was associated with knowledge of risk, perception of risk, or safe work practices such as glove usage. A p-value of < 0.05 was considered statistically significant. All analyses were performed using R 3.1.2 (The R Foundation for Statistical Computing, Auckland, New Zealand).
Journal of Occupational and Environmental Hygiene
October 2015
RESULTS
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Participant Characteristics There were 120 participants representing seven different job categories (Table I). It was not possible to calculate a true response rate because of the constraints of the recruitment methods dictated by hospital ethics boards; however, the proportions of those contacted who participated in the 6 facilities ranged from 55–76%. The average job tenure of all participants was 104 months (8.6 years) with a range of 0–433 months (36 years). More than three-quarters of the participants were female and they represented the vast majority in all job categories except transport, which was predominantly male. Most participants were between the ages of 30 and 59. Knowledge of Risks and Workplace Practices Table II shows that almost all pharmacists, pharmacy receivers, pharmacy technicians, and nurses provided correct answers to the five knowledge questions. Answers by those within transport, unit clerk and other jobs in drug administration were more frequently incorrect. There was a statistically significant difference in knowledge of risk between job categories for all five questions in Table II. Perceptions of Risks and Existing Control Measures Risk of Exposure From Table III, it can be seen that for those job categories who directly handle antineoplastic drugs, i.e., pharmacists, pharmacy technicians, and nurses, at least 50% disagreed that their risk of exposure to antineoplastic drugs was very low. For the remaining job categories, a majority of respondents felt that their risk was low with unit clerks having the highest proportion of respondents feeling this way (83.3%). The difference in perception of risk of exposure between job categories was statistically significant. Pharmacy personnel and nurses were not afraid of working with or near antineoplastic drugs (>80%), whereas many in other jobs were either afraid or did not know how they felt. This difference was not statistically significant. Suitability of Safety Measures With respect to the safety measures that are currently in place to reduce antineoplastic drug contamination, a small majority of the respondents felt that they were suitable. Confidence in safety measures was higher among pharmacy personnel and nurses than among transport, unit clerk, and others in the drug administration unit but this difference was not statistically significant. Safe Work Practices of Co-Workers A small majority of participants (65%) agreed with the statement that workers around them are handling antineoplastic drugs safely. Transport had the smallest proportion of respondents who agreed with this statement; in fact, it was the only category where the majority disagreed or did not know.
The responses to this question were not significantly different between job categories. Ability to Handle Exposure Situations A little more than half the respondents (51.7%) were confident that they could handle all situations where there is a potential for antineoplastic drug exposure, including spills and contaminated urine. Nurses were most confident while transport and others in the drug administration units were least confident (difference not statistically significant). Availability of Personal Protective Equipment A large majority of respondents agreed that the required personal protective equipment (PPE) was readily available and that they were able to use the PPE properly, but transport jobs and other workers who work in the drug administration unit had a higher percentage of respondents who answered “don’t know” to both questions related to PPE. There were no statistically significant differences in responses between job categories for either of the two PPE-related questions. Regular Contact, Training History and Safe Work Behaviors Most pharmacy personnel, nurses, and unit clerks were normally required to handle, prepare, and/or administer antineoplastic drugs as part of their duties, but fewer transport and other drug administration jobs had this requirement (difference statistically significant). Most pharmacists, pharmacy technicians, and nurses had received training related to safe drug handling, but few pharmacy receivers, transport personnel or unit clerks had (difference statistically significant). In all job categories, the proportion who had received training was lower than the proportion required to handle the drugs. Not all respondents always wore gloves when directly handling, preparing, and/or administering antineoplastic drugs. Nurses, then pharmacy staff reported most compliance, whereas for other jobs, it was rarely reported (difference statistically significant).The job cohort that had the highest proportion report that they never wear gloves were unit clerks. It should be noted that many in transport and other drug administration unit jobs did not answer this question, perhaps because they felt they did not directly handle these drugs. Glove use was less frequent among pharmacy and nursing personnel when they were simply present in an area where antineoplastic drugs have been handled, prepared, and/or administered. Participants in the other three job categories answered this question more completely, and reported somewhat more glove use in this scenario. Even though glove use was more similar between job categories in this scenario, the differences between job categories remained significant. Overall, 80% of respondents always or sometimes washed their hands after glove use but responses to this question were statistically significant between job categories. Many people in job categories where glove use was rare did not answer this question. The question regarding hand washing practices after a worker has been in an area where antineoplastic drugs
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TABLE I.
Respondent Characteristics Stratified by Job Category
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Overall N (%) Mean job tenure in months (range) Gender Female (%) Male (%) Age 20 to 29 (%) 30 to 39 (%) 40 to 49 (%) 50 to 59 (%) 60+ (%)
Pharmacy Pharmacist Receiver
Pharmacy Technician
Nurse
Transport
Unit Clerk
Others in drug admin
120 (100) 21 (17.5) 7 (5.8) 24 (20.0) 33 (27.5) 11 (9.2) 12 (10.0) 12 (10.0) 104 (0–433) 124 (0–360) 121 (18–294) 116 (13–378) 87 (9–420) 141 (10–433) 75 (13–240) 76 (8–240)
78.3 21.7
76.2 23.8
71.4 28.6
79.2 20.8
90.9 9.1
18.2 81.8
100 0
83.3 16.7
10.0 27.5 29.2 24.2 9.2
9.5 33.3 28.6 23.8 4.8
0.0 28.6 28.6 28.6 14.3
8.3 41.7 41.7 8.3 0.0
15.2 27.3 24.2 21.2 12.1
0 9.1 27.3 63.6 0
25.0 33.3 16.7 25.0 0
0 0 33.3 25.0 41.7
Transport includes porters and shippers/receivers; others in drug administration include volunteers, oncologist, ward aides, and dieticians.
have been handled, prepared and/or administered was more completely answered by participants in all job categories. The vast majority reported sometimes or always washing their hands, although substantial numbers of pharmacist and unit clerks reported never doing so (difference not statistically significant). DISCUSSION
W
e attempted to understand the knowledge and perceptions of a broad range of health care workers (pharmacists, pharmacy receivers, pharmacy technicians, nurses, transport, unit clerks, and others in drug administration units who are not responsible for drug administration) with respect to occupational exposure to antineoplastic drugs and their usual behaviors when in potential contact with these hazardous agents. Our results suggest that there are opportunities to extend the reach of training as certain job categories, in particular, transport, unit clerks, and others in the drug administration unit, were much less likely to be educated regarding workplace health and safety of antineoplastic drugs (less than 25% of workers in these three cohorts had ever received training). This lack of training is evidenced by the fact that these three job categories did not fare well on questions related to knowledge of occupational exposure risk to antineoplastic drugs and the associated site practices. Training programs targeted at nurses have proven to be effective in increasing knowledge and improving compliance with both safe handling guidelines as well as personal protective equipment usage.(18–20) Our results also indicate the need to reinforce the importance of glove use and subsequent hand hygiene amongst all at-risk health care workers (Table IV). This is especially true for pharmacists and pharmacy technicians because they are regularly exposed as they are tasked with checking the doses 672
and for drug preparation, respectively. The lack of compliance among both pharmacists and pharmacy technicians was in spite of the fact that they were knowledgeable about the health risks associated with antineoplastic drugs and aware of their potential exposure. Our findings are similar to those who reported a gap between nurses’ knowledge and adherence to safe work practices.(4–8) Another disconcerting finding is that hand hygiene was not routinely practiced after glove use. This is of concern as studies have found gloves to be permeable to antineoplastic drugs(21, 22) presenting an opportunity for the skin to act as a reservoir(23) as well as the potential for exposure through accidental ingestion.(24) Not surprisingly, compliance with glove usage and subsequent handwashing was further reduced when participants were simply in an area where antineoplastic drugs are handled, prepared and/or administered as opposed to direct contact. However, because surface contamination can be found in any of these areas(25) and dermal contact is the primary route of exposure,(12,26,27) glove use, and/or hand hygiene is still suggested and this fact should be reinforced in training. With regards to health care workers’ perceptions, it was interesting to note that the proportion who believed their risk of occupational exposure to antineoplastic drugs was very low was similar to those who felt their level of risk was higher (49.2% and 45.0%, respectively). It is therefore surprising that 80% of the respondents disagreed with the statement that they are afraid of working with or near antineoplastic drugs. Perhaps this is due to the fact that there are other existing occupational hazards in which they perceive there are greater health risks compared to contact with antineoplastic drugs.(6) A small majority (63.3%) felt that the current control measures are appropriate to minimize exposure. Similarly, only 65% of respondents believed that co-workers were
Journal of Occupational and Environmental Hygiene
October 2015
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October 2015
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100
100
84.2
87.5
85.7
100
100
71.4
100
Pharmacy Receiver (%)
91.7
100
100
100
87.5
Pharmacy Technician (%)
100
100
87.9
93.9
100
Nurse (%)
54.5
54.5
54.5
45.5
72.7
Transport (%)
Transport includes porters and shippers/receivers; others in drug administration include volunteers, oncologist, ward aides, and dieticians.
100
85.7
80.8
81.7
95.2
Pharmacist (%)
81.7
Overall (%)
Knowledge of Risks and Workplace Practices Stratified by Job Category
Knew the skin is possible route of occupational exposure antineoplastic drugs Knew that work surfaces may have antineoplastic drug contamination Knew that their site had a dedicated antineoplastic drug preparation area Knew that there is a separate disposal method for antineoplastic drugs Knew that the site had a safe drug handling policy
TABLE II.
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58.3
75
83.3
66.7
41.7
Unit Clerk (%)
25.0
41.7
33.3
50.0
33.3
Others in drug admin (%)
