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

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Global Health


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

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

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


Design and participants

Ethical approval for the study was obtained from the National Ribat University, Faculty of Graduate Studies and Scientific research with approval number 269930. This cross-sectional study was conducted to determine the knowledge of safe handling, administration, and waste management of chemotherapeutic drugs among oncology nurses working at Khartoum Oncology Hospital, Sudan.

Nurses who work in Oncology department at Khartoum Oncology Hospital were eligible to participate. Founded in 1967 in the state of Khartoum, Sudan, Khartoum Oncology Hospital has a well-established oncology department. It is a 172-bed hospital with approximately 200 nursing staff. We used purposive sampling to invite participants to our study. Of the 92 nurses who work in Oncology department, 78 nurses having one year of work experience in the Oncology department fulfilled the criteria for inclusion. The eligible nurses were requested to provide a written consent form. We excluded nurses on vacation (n = 10) and those in administrative positions (n = 4).

Operational definitions of variables

Knowledge, safe handling, and barriers were the dependent variables assessed through a questionnaire. Experience, education, and training of oncology nurses were the independent variables.

The knowledge of the oncology nurses was assessed in three sections. Questions in the first section were related to the preparation, use, and precautions of chemotherapeutic drugs. The questions in the second section were related to knowledge regarding safe handling and administration of chemotherapy and identifying exposure risks. The questions in the third section were related to knowledge regarding the disposal of chemotherapeutic waste and managing side effects. The questionnaire consisted of true/false questions and multiple-choice questions (MCQs) with one correct answer out of four options.

Questionnaire development and description

We used a questionnaire developed by a team of experts in oncology nursing (two professors, two clinical nurses with more than 10 years of experience, one medical doctor, and one English language expert). A first draft was created by the first author of this study based on the recommendation from the previous research (Idris, 2014; Okobia et al., 2006; Sharour, 2018). It was emailed independently to all six experts. Their recommendations were discussed and implemented by the second author of this study. The second draft was emailed again to all six experts. Any conflict was resolved among the experts through meetings and discussions. The final copy of the questionnaire was piloted among 10 oncology nurses from other states of Sudan who were not part of the current study.

The questionnaire was developed to assess the knowledge and barriers toward practice among oncology nurses. The questionnaire consisted of 35 questions divided into four sections. The first section consisted of nine questions to collect demographic data from the participants. The second section consisted of eight MCQs related to knowledge regarding chemotherapy uses and types, as well as precautions used during preparation. The third section consisted of three MCQs and seven true/false statements related to knowledge regarding the safe handling and administering of chemotherapy and identifying exposure risks. The fourth section consisted of eight MCQs related to knowledge regarding the disposal of chemotherapeutic waste and managing side effects (Appendix 1). Total points obtained from each section were converted to percentages by dividing the points obtained in each section by the total points of that section, and then multiplying the result by 100. The nurse’s knowledge was considered poor if the scoring percentage was between 0–40%, fair between 41–60%, good between 61–80%, and excellent between 81–100%.

Sample size calculation

The RaoSoft Sample Size Calculator was utilized in the calculate the sample size for this study (Raosoft, Inc. RaoSoft Sample Size Calculator, 2004, online at as of June 1, 2017). The power level was 0.95, and the error margin was 0.05. With a total of 92 oncology nurses in Khartoum Oncology Hospital, a sample size of 75 was sufficient. In total, 92 nurses were invited to participate, and 78 completed the questionnaire, with a response rate of 81.5%.

Statistical analysis

For data analysis, the SPSS software package (SPSS Inc., Chicago, IL, USA, 2020) was used. The data were summarised by frequency and percentages. Scoring for knowlwdge of handling, disposal and adminstration of cytotoxic drugs were calculated by dividing the points obtained by the total points, and then multiplying the result by 100. One-sample chi-square and binomial tests were used to compare significance between categories of demographic data. The mean and standard deviation were used to show the dispersion of data. Linear regression analysis was used to determine the predictive value of demographic characteristics for the knowledge of oncology nurses.


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

Table 1:
Demographic data (n − 78).
Variables Frequency
Age (years)
20–30 10 12.8 0.001*
31–40 55 70.5
41–50 13 16.7
Male 31 39.7 0.089**
Female 47 60.3
Diploma degree 71 91.0 0.001*
Bachelor degree 6 7.7
Master degree 1 1.3
General experience (years)
1–5 56 71.8 0.001*
5–10 16 20.5
10–15 1 1.3
More than 15 5 6.4
Chemotherapeutic experience (years)
1–3 years 22 28.2 0.174*
4–7 years 23 29.5
8–11 years 11 14.1
Above 11 years 22 28.2
Training in chemotherapy during academic years
Not sufficient 75 96.2 0.001**
Not received 3 3.8
Training in chemotherapy after graduation
Once 15 19.2 0.001*
Twice 17 21.8
More than two 3 3.8
Never 43 55.1
Hospital has policy on safe handling of chemotherapy drugs
yes 0 0 ND
no 78 100
Do you have spill kit at your workplace
yes 0 0 ND
no 78 100
DOI: 10.7717/peerj.14173/table-1


One Sample Chi-Square Test.
One Sample Binomial Test.


Not determined

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

Table 2:
Knowledge of chemotherapy uses and types, precautions used during preparation.
Multiple-choice questions in the questionnaire Frequency (n) Percentage (%)
A place to prepare chemotherapeutic drugs
Correct answer 0 0
Incorrect answer 78 100
Meaning of adjuvant drugs
Correct answer 9 11.5
Incorrect answer 69 88.5
Knowledge of action of cytotoxic drugs on the cell cycle phase
Correct answer 9 11.5
Incorrect answer 69 88.5
Use of chemotherapy drugs
Correct answer 27 34.6
Incorrect answer 51 65.4
Related to intravenous delivery of cytotoxic drugs
Correct answer 26 33.3
Incorrect answer 52 66.7
Pre-administration precaution before administration of cytotoxic drugs
Correct answer 21 26.9
Incorrect answer 57 73.1
The recommended sequence of the cytotoxic drugs
Correct answer 16 20.5
Incorrect answer 62 79.5
What types of gloves are worn while preparing chemotherapy
Correct answer 48 61.5
Incorrect answer 30 38.5
DOI: 10.7717/peerj.14173/table-2

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

Table 3:
Knowledge regarding safe handling and administering chemotherapy, identifying exposure risks.
Questions Frequency
Use of Personal protective equipment (PPE) 15 19.2
Correct answer 63 80.8
Incorrect answer
Pre-medication administration time
Correct answer 27 34.6
Incorrect answer 51 65.4
Related to minimize exposure to chemotherapeutic agents
Correct answer 20 25.6
Incorrect answer 58 74.4
Related to the use of recommended type gloves
Correct answer 68 87.2
Incorrect answer 10 12.8
Statement related to labeling the chemotherapy drug
Correct answer 61 78.2
Incorrect answer 17 21.8
Related to safe handling of cytotoxic drugs
Correct answer 51 65.4
Incorrect answer 27 34.6
Chemotherapy can enter the body through inhalation
Correct answer 30 38.5
Incorrect answer 48 61.5
Chemotherapy can more easily enter the body through damaged skin.
Correct answer 28 35.9
Incorrect answer 50 64.1
Chemotherapy tablets can be chewed, cut, or crush
Correct answer 72 92.3
Incorrect answer 6 7.7
Administering/handling chemotherapy is no different from administering/ handling intravenous antibiotics.
Correct answer 73 93.6
Incorrect answer 5 6.4
DOI: 10.7717/peerj.14173/table-3

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

Table 4:
Related to knowledge regarding disposal of chemotherapeutic waste and managing side effects.
Questions Frequency
Related to disposal of Cytotoxic waste
Correct answer 27 34.6
Incorrect answer 51 65.4
Management of spillage of chemotherapy drugs
Correct answer 23 29.5
Incorrect answer 55 70.5
Scenario related to extravasation chemotherapy drugs
Correct answer 30 38.5
Incorrect answer 48 61.5
Actions taken during allergic reaction to chemotherapy drug
Correct answer 22 28.2
Incorrect answer 56 71.8
Knowledge of side effects of chemotherapy
Correct answer 43 55.1
Incorrect answer 35 44.9
Related to re-use of gown after handing cytotoxic drugs
Correct answer 77 98.7
Incorrect answer 1 1.3
Related to management of general and cytotoxic waste management
Correct answer 61 78.2
Incorrect answer 17 21.8
Related to education of patient about side effects of cytotoxic drugs.
Correct answer 63 80.8
Incorrect answer 15 19.2
DOI: 10.7717/peerj.14173/table-4

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

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

Table 5:
Linear regression analysis between demographic variables and knowledge as dependent variable.
Demographic variables Unstandardized coefficients Standardized coefficients t Sig. 95.0% Confidence Interval for B Correlations Collinearity statistics
B Std. error Beta Lower bound Upper bound Zero- order Partial Part Tolerance VIF
Age −0.446 1.078 −0.062 −0.414 0.680 −2.597 1.705 −0.074 −0.049 −0.043 0.487 2.051
Gender −0.240 0.857 −0.030 −0.280 0.780 −1.948 1.469 −0.030 −0.033 −0.029 0.946 1.057
Education 3.715 1.355 0.326 2.743 0.008 1.013 6.417 0.401 0.311 0.286 0.770 1.298
General nursing experiences 0.277 0.633 0.057 0.437 0.663 −0.986 1.540 0.199 0.052 0.046 0.634 1.578
Experience in chemotherapy administration 0.333 0.530 0.100 0.629 0.531 −0.723 1.390 −0.193 0.075 0.066 0.432 2.315
Training course in chemotherapy 0.969 0.386 0.307 2.508 0.014 0.198 1.739 0.362 0.287 0.261 0.726 1.377
DOI: 10.7717/peerj.14173/table-5


Dependent Variable: Total sum scores of knowledge.


Variance inflation factor


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

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

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

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

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

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

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

Barriers towards safe handling of cytotoxic drugs.

Figure 1: Barriers towards safe handling of cytotoxic drugs.


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


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


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

Supplemental Information

Questionnaire with answers

DOI: 10.7717/peerj.14173/supp-2

Questionnaire used in the study

DOI: 10.7717/peerj.14173/supp-3
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