Factors Associated with Nurses’ Adherence to the Use of Protective
Precautions in Administering Chemotherapy Drugs
Ika Nur Pratiwi, Laily Hidayati and Mukhamad Nursalim
Faculty of Nursing Universitas Airlangga, Kampus C Mulyorejo, Surabaya, Indonesia
Keywords: Adherence, Chemotherapy Drug, Nurse, Precaution.
Abstract: Chemotherapy drugs could impose hazardous physical effects, especially on nurses administering the drug.
However, the precautions may often be of insufficient concern for practitioners. Our study was intended to
evaluate the factors associated with nurses’ adherence to using protection in administering chemotherapy
drugs. We performed a cross-sectional data collection on all nurses working at the in-hospital ward of Dr.
Soetomo General Hospital where chemotherapy is given. Results showed that of 133 nurses working in the
chemotherapy hosting, 53 participants fulfilled the criteria and completed all the questionnaires. Twenty-nine
(54.7%) of the participants were aged between 20-30 years old, 38 (71.7%) had vocational nursing
qualifications, and 28 (52.8%) had at least six years of working experience. We found factors significantly
associated with nurses’ adherence including attitude (Spearman’s rho = 0.3; P = 0.03), equipment availability
(Spearman’s rho = 0.5; P < 0.001) and accessibility (Spearman’s rho = 0.4; P = 0.004), and supervision
(Spearman’s rho = 0.5; P < 0.001). Additionally, the findings indicate that factors associated with nurses’
adherence to the use of protective precautions in giving chemotherapy include attitude, equipment availability
and accessibility, and supervision.
1 BACKGROUND
Chemotherapy, as one of the cancer treatment
modalities, uses a cytostatic agent that belongs to the
hazardous and toxic substances. Administration of
this agent puts the healthcare provider, especially the
nurses, at the risk of exposure (Huda, 2003) with a
subsequent possibility of skin rash, infertility,
pregnancy abortion, fetal malformation, or cancer
(Callahan et al., 2016a). To reduce the risk, it is
mandatory to apply protective precautions during the
process (Huda, 2003).
It is estimated that around 14 million new cases of
cancer are diagnosed each year with 48% of them in
developing countries (Callahan et al., 2016b). Data
from the Ministry of Health Indonesia in 2013
showed that the prevalence of all-type cancer is
around 1.4% of the total population (KEMENKES
RI, 2015) with the top four provinces being DI
Yogyakarta (4.1%), Central Java (2.1%), Bali (2.0%)
and East Java (1.6%).
Dr. Soetomo General Hospital, located in East
Java, is one of the top referral and teaching hospitals
in Indonesia covering the eastern part of the country.
Unpublished medical record data of the hospital
showed that in 2015 there had been 12,016
chemotherapy procedures performed on 5,795
patients.
In this study, we aimed to analyze the factors
contributing to nurses’ adherence to the use of
protective precautions while administering the
chemotherapy regimen.
2 METHODS
2.1 Study Design, Population, Sample
We performed cross-sectional data collection on all
nurses working at the in-patient ward Dr. Soetomo
General Hospital that hosts a chemotherapy
administration.
Inclusion criteria to enter the study were 1) Nurses
responsible for administering chemotherapy drugs
directly to the patients in the ward, 2) Nurses who had
received special training in chemotherapy drug
handling, administration, and management, 3) Nurses
who had working experience of more than one year
Pratiwi, I., Hidayati, L. and Nursalim, M.
Factors Associated with Nurses’ Adherence to the Use of Protective Precaution in Administering Chemotherapy Drug.
DOI: 10.5220/0008327905210526
In Proceedings of the 9th International Nursing Conference (INC 2018), pages 521-526
ISBN: 978-989-758-336-0
Copyright
c
2018 by SCITEPRESS – Science and Technology Publications, Lda. All rights reserved
521
in the institution at the time of study and 4) Nurses
who agreed to participate in the study.
As the aim of this study was to portray the entire
procedure of chemotherapy administration, we only
excluded participants if they did not agree to be
included or revoked their consent to the study.
2.2 Study Procedure
Participants were recruited by performing total
sample collection on all nurses satisfying the criteria.
Prior to the study, each participant was given
complete information regarding the study and
procedure involved. After the participants agreed and
signed the consent form, they were then asked to fill
in the questionnaires measuring knowledge, attitude,
the availability and accessibility of instruments for
administering chemotherapy drugs. Along with those
questionnaires, we also collected the basic
demographical information of each participant
including age, sex, education background and length
of working experience. Following the questionnaire
step, participants were then observed during their
daily activities performing chemotherapy
administration.
Since this study involving the everyday tasks of
each nurse and may compromise their career, the
anonymity and confidentiality of the results are
highly appreciated.
Study was conducted at the in-hospital ward of
Dr. Soetomo General Hospital Surabaya involving
paediatrics, obstetrics and gynaecology, surgery, and
medicine ward.
2.3 Questionnaires
To measure the factors that may have an association
with the nurses’ adherence to protective precautions
we used several questionnaires as explained below:
2.3.1 Knowledge Questionnaire
Instrument for measuring knowledge according to
Chemotherapy Handling Questionnaire developed by
Martha Polovich (Polovich, 2016) adapted to Bahasa
Indonesia.
2.3.2 Knowledge Questionnaire
Instrument for measuring attitude adapted from
Polovich et al. (Callahan et al., 2016a). The
questionnaire is presented in a 5-grade Likert scale.
2.3.3 Availability Questionnaire
Using assessment tools developed by Yuliana
(Callahan et al., 2016b) written in Bahasa Indonesia.
This questionnaire contains six yes/no questions. The
parameters assessed include instrument
completeness, condition, and quantity.
2.3.4 Accessibility Questionnaire
We developed a questionnaire with six short yes/no
answers. This was measuring instrument location and
distance from the chemotherapy administration site.
2.3.5 Supervision Questionnaire
This was assessed with a questionnaire developed by
the authors. The parameters measure were policy in
using protective precautions, monitoring, and
evaluation. There were six questions with yes/no
answers.
The forms and questionnaires were standardized
and used throughout the study. All questionnaires
were tested for validity and reliability before the
study on 20 participants (nurses). The results showed
that the questionnaires were at least acceptable to use
as shown by a Cronbach Alpha score of above 0.700.
2.4 Data Analysis
The data obtained from the study was processed by
using Microsoft Excel (Microsoft Inc, California,
USA) and analyzed by using SPSS v22 (SPSS Inc.,
Chicago, Illinois, USA). Participants’ baseline
demographics were expressed as either categorical
data with frequency and percentage or continuous
data with mean and one standard deviation.
Correlation analysis results were analyzed using
Spearman’s correlation test due to the skewed
distribution of data.
2.5 Ethical Clearance
The protocol of this study was reviewed and approved
by the ethics committee of Dr. Soetomo General
Hospital with registration number:
53/Panke.KKE/I/2017. The author asserts that all
procedures performed within and related to this study
conformed to the basic principles of research
involving humans. Participation was voluntary, and
all participants were free to withdraw at any stage.
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
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3 RESULTS
There were 133 nurses working in the chemotherapy-
hosting ward. Of those, 53 participants fulfilled the
criteria and completed all the questionnaires, with 13
males and 40 females. Twenty-nine (54.7%) of the
participants were aged between 20-30 years old, 38
(71.7%) had vocational nursing qualification, and 28
(52.8%) had at least 6 years of working experience.
Table 1 shows participants’ demographic
distribution. More than half of the respondents were
female, had a vocational education background, and
had less than 10 years of experience. However, 77.4%
of them were giving chemotherapy more than four
times in a week.
Table 2 explains that most participants have
positive attitues toward protective precaution tools
and good knowledge. However, more than 88% of
them were non-adherent to the use of protective
precautions when administering the drugs.
As shown in Table 3, knowledge, age, education,
and experience of nurses did not significantly
correlate with adherence in using protective
precautions. However, we found that attitude,
instrument availability and accessibility, and
supervision were significantly correlated with nurses’
adherence.
Spearman’s rho coefficient for attitude,
instrument availability and accessibility, and
supervision were 0.298, 0.498, 0.386, and 0.511
respectively.
4 DISCUSSION
Most hazardous drugs (HDs) are chemotherapy drugs
used in the treatment of cancer, making occupational
HD exposure a significant problem for oncology
nurses. Nurses may be exposed to HDs during
preparation, administration, or handling of patient
Table 1: Participant demographics.
No.
Characteristics
N
%
1.
Age
20-30 years
29
54.7
31-41 years
12
22.6
.
> 41 years
12
22.6
2.
Sex
Male
13
24.5
Female
40
75.5
3.
Education
Vocational
38
71.7
Bachelor
15
28.3
4.
Years experience
< 6 years
25
47.2
6-10 years
15
28.3
> 10 years
13
24.5
5.
Frequency
administering drug
1-3/week
12
22.6
4-6/week
17
32.1
> 6/week
24
45.3
Table 2: Interview results.
No.
Characteristics
N
%
1.
Knowledge
23
43.4
21
39.6
9
17.0
2.
Attitude
48
90.6
5
9.4
3.
Instrument
Availability
26
50.9
27
49.1
4.
Instrument
Accessibility
24
45.3
29
54.7
5.
Supervision
29
54.7
24
45.3
6.
Adherence
6
11.3
47
88.7
Table 3: Spearman correlation test.
No.
Parameter
P value
1.
Knowledge
vs. Adherence
0.470
2.
Attitude
vs.
Adherence
0.030*
3.
Instrument
Availability
vs. Adherence
< 0.001*
4.
Instrument
Accessibility
vs. Adherence
0.004
5.
Supervision
vs. Adherence
< 0.001*
6.
Age vs. Adherence
0.322
7.
Education vs.
Adherence
0.328
8.
Experience vs.
Adherence
0.642
*. Significant result
Factors Associated with Nurses’ Adherence to the Use of Protective Precaution in Administering Chemotherapy Drug
523
excreta following their use (American Society of
Health-System Pharmacists, 2006). This study
analyzed the factors contributing to nurses’ adherence
in using protective precautions when administering
chemotherapy drugs. Our results indicated that the
only predisposing factors significantly correlated
with adherence to using protective precautions was
attitude, while other factors such as age, education,
and working experience did not significantly
correlate. Instrument availability and accessibility as
the enabling factors on the other hand plays an
important role in nurses’ adherence showing a
moderate yet significant correlation supporting the
reinforcing factors, supervision.
4.1 Predisposing Factors and Adherence
Predisposing factors play a role in determining the
pre-existing condition of the subject prior to the
process. Lawrence Green (Notoatmojo, 2007))
explains that predisposing factors can be shown in
knowledge, attitude, beliefs, and values. The factors
may also be associated as the factors that could
facilitate people in taking particular actions.
Our study indicates that age, as a “solid”
predisposing factor, did not correlate with the
adherence of performing important procedures such
as using protective precautions. Our result was at
odds with the theory proposed by Wawan and Dewi
(Wawan & Dewi, 2010) that the increase in age may
facilitate someone to think constructively, enable
them to cope with the problems and thus adhere to
rules and regulations. Our in-depth interviews with
senior nurses may suggest that they maintain the
practice of low adherence due to lack of consistent
good practice, and it later becomes a habit. Other
study by Nurcahyanti (Nurcahyanti, K.K., Siswanto,
Y. & Ariesti, N.D., 2014) confirms our result in an
adherence study on midwives.
Our results on education and working experience
also did not show a significant correlation to
adherence. The results could not confirm
Notoatmojo’s (Notoatmodjo, S., 2010) and Wawan &
Dewi’s (Wawan & Dewi, 2010) theories that
education and working experience could improve the
knowledge insight and the familiarity with the
working environment. A significant correlation was
also lacking between knowledge and adherence,
although most of the nurses exhibit a fair to good level
of understanding of the risk of chemotherapy drugs.
On the other hand, one predisposing factor,
attitude, was found to have positive weak yet
significant correlation to nurses’ adherence. Our
result was in line with a similar study at RSUD
Zainoel Abidin, Banda Aceh by Hasan and colleagues
(Hasan, 2016). Other study by Riyanto et al. (Riyanto,
2016) confirms the positive correlation of attitude
toward adherence; although the latter study was not
specifically conducted in the chemotherapy unit.
4.2 Enabling Factors and Adherence
Two important enabling factors that were evaluated
and found to have a positive correlation with
adherence were protective instrument availability and
accessibility including aprons, head caps, plastic
boots, gloves, masks, and protective spectacles within
the working area.
The results are in line with Yuliana (Yuliana,
2012) and a study by Nurkhasanah and Sujianto
(Nurkhasanan, 2014) which confirm that nurses
equipped with sufficient instruments in performing
daily tasks support the adherence to standards in
using protective precautions. Other studies from
Chaerunnisa et al. (Chaerunnisa, 2014) and Erlina and
colleagues (Erlina, R., Larasati, T. & Kurniawan,
2013) support the results that instrument accessibility
plays an important role in adherence. The latter two
studies were performed on pregnant women when
accessing antenatal care. Polovich et al. (2011) also
confirm that personal protective equipment (PPE) is
available in most settings where chemotherapy is
handled; however, chemotherapy-designated PPE is
not always provided by employers. At least 20% of
nurses reported that chemotherapy gowns were not
available for their use. Eye protection and respirators
were available less often than other PPE (Polovich, M
& Marthin, 2011).
In-depth interviews with nurses in the unit
suggested that not all units were equipped with
complete instruments for performing chemotherapy
administration. This may be one reason contributing
to nurses’ adherence in using protective equipment.
Lawrence Green (Notoatmodjo, S., 2010) explained
that instrument accessibility influences people in
using the facilities and supports their behavior.
4.3 Reinforcing Factors and Adherence
We found that the supervision strategy in the unit
performing chemotherapy administration
significantly correlated with nurses’ observance in
using protective equipment. Riyanto’s studies
evaluating nurses’ adherence to protective equipment
use in daily practices support our results. They found
that head nurse supervision in the ward could improve
nurse-in-charge behavior in using protective
apparatus (Riyanto, 2016).
INC 2018 - The 9th International Nursing Conference: Nurses at The Forefront Transforming Care, Science and Research
524
Supervision from senior nurses may have a direct
impact on the willingness to perform proper
procedures. Head nurses have the role of supervising
their juniors or nurse-in-charge in performing daily
activities (Nursalam, 2013). Lawrence Green
(Notoatmodjo, S., 2010) also describes how
supervision functions as the strengthening factor in
affecting people’s behavior.
Follow-up interviews with the head nurses in this
study also revealed that the nurse-in-charge
performing chemotherapy administration tends to
continually perform the procedures while there is a
senior or supervisor overseeing their work.
4.4 Study Limitations
The inherent limitation of cross-sectional studies is
indivisible in this study. The one-off data collection
may limit observation of the whole picture of the
daily practice of using protective equipment in a
chemotherapy ward. In addition, the observational
nature of this study may also exhibit some bias in
deducing correlation of factors.
5 CONCLUSIONS
Chemotherapy drugs could pose a serious risk to
healthcare providers administering the substances,
and this is especially so for the nurse-in-charge of
chemotherapy. Therefore, the use of protective
precaution equipment is mandatory in every step of
the procedure and often involves applying multiple
protective apparatus.
Our study indicates that predisposing factors
(attitude), enabling factors (instruments availability
and accessibility), and reinforcing factors
(supervision) correlate significantly with nurses’
adherence to using protective precaution equipment
while administering chemotherapy drugs.
Further improvements may need to be
emphasized by stakeholders, especially involving the
factors associated with nurses’ adherence. Follow-up
studies such as qualitative investigation could be
conducted to elaborate the results of this
investigation. Alternative methods of disseminating
safety recommendations are needed.
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