An examination of factors related to radiation protection practices.

Radiation protection practices in medical imaging departments, embedded in every radiologic technology preparation program, are designed to reduce radiation dose to personnel and patients. However, the wide range of entry-level education programs in the United States, variety of educational requirements for licensure and different work site resources, policies and procedures could result in variations in adherence to radiologic protection practices. Practice ranges from strict shielding and collimation to no protective measures employed. Variations in clinical practice and adherence to protection practices are of concern because unnecessary radiation exposure to technologists and patients is a potentially serious health issue.

Literature Review

An investigation of factors related to compliance with radiation protection practices and a review of educational requirements revealed that accreditation standards for approved radiologic science curriculum mandate radiation protection practices throughout the required cognitive and psychomotor knowledge and skill sets. A comprehensive review of 5 different indices of health and medicine literature related to compliance with the practice and education of radiographers revealed only 2 studies (1,2) that examined factors related to radiation protection practices. Instead, most studies focused on exposure of the patient when the procedure was done correctly rather than on the frequency of noncompliance with safety.

A study conducted in 1976 found that certification was positively related to radiation protection practices. In 1982 Tilson (2) studied the relationship between 6 independent variables: age, sex, professional training, years since completion of training, years of professional experience and radiation safety practices. To reduce the influence of observation on performance, radiographers were not informed of the true purpose of the study. Tilson found that years of professional experience and age were positively correlated with radiation protection practices. Rate of repeat procedures was significantly related to level of training, and college-trained radiographers had a lower rate of "repeat films due to technical error" than hospital-trained radiographers. Both studies are dated, and the Tilson study was limited in that it was based on observing only 44 radiographers in 11 acute care hospitals in Northern California. In addition, it investigated only 2 patient safety practices in general radiography (ie, repeat film rate and gonad shielding), 2 safety practices for radiography personnel (ie, use of lead shields and use of lead gloves) and only 1 type of practice site (ie, acute care hospitals).

Also of interest is a study by Lemley et al (3) that included an extensive review of the literature documenting risk of exposure to low-dose radiation and a survey of radiation safety education in Texas hospitals. A survey was sent to 170 small hospitals and 135 large hospitals (305 hospitals total) to determine the types of radiation procedures provided and the nature and scope of radiation safety education. Results of the survey indicated that larger hospitals were more likely to offer radiation safety education than smaller hospitals (83% and 57%, respectively), more likely to offer it at the department level (80% and 55%, respectively) and more likely to offer formal education programs (62% and 10%, respectively). (3) The authors concluded that a need for increased safety education existed, especially in small hospitals.

The Tilson and Lemley studies identified factors related to compliance with radiation safety practices in acute care hospitals in 2 different states and provided a foundation for further research. Current research builds on the historical studies by conducting national surveys of radiologic technologists and expanding the number of independent and dependent variables.

More recently, the health care industry has been in the spotlight due to concern about escalating costs and perceived poor quality. Consequently, some reports (4-8) have focused attention on medical errors in hospitals, as well as disability, deaths and costs due to poor quality. The report "The Challenges and Potential for Assuring Quality Health Care for the 21st Century" identified the following 3 categories of medical errors: underuse, overuse and misuse of services. (4) The latter category, misuse of services, includes but is not limited to errors in diagnosis and treatment that result from lack of knowledge or complacency among personnel, excessive workload, pressure for speed, faulty or poorly designed equipment, and inappropriate or inadequate organizational and departmental processes and procedures. Misuse of services, as defined in the report, includes lack of adherence to radiation safety practices and increased risk of exposure and potential harm to patients and personnel.

To ensure adherence to safety practices, and thus reduce risk to patients and personnel, a coordinated, collaborative effort of government regulators, health care organizations, professional associations and educators is needed. (5-9) The U.S. Food and Drug Administration, through its regulation of medical equipment and devices, plays an important role in reducing exposure due to faulty or poorly designed equipment. Health care organizations are responsibile for ensuring that adequate resources are available in terms of personnel and equipment, for ensuring that workloads are appropriate and for designing effective work processes and procedures. Professional associations and educational programs are pivotal in ensuring that personnel have appropriate education and preparation for practice and that they remain competent throughout their careers.

Several recent studies (10-12) have explored the application of workplace approaches such as continuous quality improvement programs, Six Sigma programs and the International Standards Organization 9000 program for quality management and the reduction of medical errors. A recent report by the Institute of Medicine also recommended that professional societies "develop a curriculum on patient safety and encourage its adoption into training and education requirements." (4) Additionally, Lynn (13) discussed the legal and ethical duty of radiographers to provide benefit and minimize risk of harm to patients. In particular, items 4 and 7 of the American Society of Radiologic Technologists' Code of Ethics address these responsibilities, and the report "Health Professions Education: Bridge to Quality" includes evidence-based practice and quality improvement in the 5 core competencies for education in the health professions. (12)

The certified radiologic technologists' deficiencies in either knowledge of or adherence to radiation safety practices can result in increased unnecessary exposure to patients and personnel. Although a 1-time unnecessary exposure may not have a measurable adverse effect, long-term effects of radiation exposure are insidious and cumulative and can result in eventual harm to those exposed. (5,14,15)

Objective

To advance understanding of the factors related to knowledge of and adherence to radiation safety practices, this study investigated the relationship of 4 independent variables (ie, type of initial professional education, participation in continuing education, years in professional practice and type of work site) and 2 dependent variables (ie, knowledge of and compliance with radiation safety practices).

The goals of this study were to advance the education and practice of the radiologic sciences and to promote radiation safety practice. To accomplish these goals, knowledge of and compliance with radiation protection practices first needed to be assessed. It was then important to determine the relationship between the independent variables and the dependent variables.

The null hypothesis was that the independent variables would not be related significantly to either of the dependent variables. However, based on previous studies and the experience of the authors, it was predicted that education level, years of practice, participation in continuing education and work site would be related to knowledge of and compliance with radiation safety practices. Specifically, it was believed that higher education, increased years in practice, frequent continuing education and working in large acute care hospitals would be positively correlated with knowledge and compliance. Last but not least, recommendations were made based on results of the study regarding initial and continuing education in the radiologic sciences, and an agenda for future research was developed.

The assumptions underlying the study were as follows:

* Radiologic technologist participants would give accurate responses regarding safety practices.

* Any bias in responses would lead to underestimates rather than overestimates of compliance with radiation safety practice.

* The questionnaire provides a valid assessment of knowledge of and compliance with safety practices.

* The predictions of relationships among variables are reasonable based on results of previous studies (ie, the Tilson and Lemley studies).

Methods

To achieve the goals of the study, a survey of 2000 certified radiologic technologists was conducted. Questionnaires were mailed September 19, 2003, with a requested return date of October 21, 2003.

Sample Design