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

The sample frame was the database of the American Registry of Radiologic Technologists (ARRT), which supplied a simple random sample and summary data on the characteristics of its registrants. A large sample (N = 2000) was drawn because response rates to mailed surveys are typically low. With a pessimistic estimate of a 15% return rate, a sample of 2000 would yield 300 responses. Although a larger yield was preferred, 300 responses would yield a 95% confidence level with a 6% margin of error and be sufficient for analyzing data. (16)

Questionnaire Design

The questionnaire included 32 items and solicited basic demographic information, information on the 4 independent variables (ie, type of initial professional education, participation in continuing education, years in professional practice and type of work site) and information on the 2 dependent variables (ie, knowledge of and compliance with radiologic safety practices). Of the 32 items, 10 solicited information about characteristics of the respondents, including gender, age, years in practice, years certified, primary area of professional practice, type of work site, initial radiologic technology education and participation in continuing education during the past year. Knowledge of safety practices was assessed by 3 multipart items that were used to calculate a composite score. Compliance with safety practices was assessed by 19 items; 6 were used to calculate a composite score and 13 were evaluated separately.

In a pretest of the instrument in October 2001, the questionnaire was administered to 40 radiologic technologists at 3 clinical sites. The major focus of the pretest was to determine whether self-report of radiologic practices would yield useful information regarding knowledge of and adherence to radiation safety practices. Even though a bias toward under-reporting of failure to adhere to safety practices would be expected, the results of the pretest indicated considerable variation in safety practices, which could have resulted in unnecessary exposure to patients and personnel. For example, 19% of the respondents reported never wearing a thyroid shield during a fluoroscopic procedure, and 48% of the respondents reported never or sometimes using gonadal shielding with patients when performing a pelvis x-ray on a 10-year-old boy.

Other aims of the pretest were to determine time to complete the survey, assess the clarity of items and develop a method for scoring. In addition to the pretest, 4 radiologic technologist educators, 5 practicing radiologic technologists and 1 radiation physicist reviewed the instrument. According to the field test and review by educators, technologists and the physicist, the instrument required approximately 10 minutes to complete and provided valid information about knowledge of and compliance with radiation safety practices related to portables, fluoroscopy, CT and general radiology. As a result of the pretest and review, the questionnaire was refined, some items were revised and others were deleted.

Results

Characteristics of Respondents

Of the 2000 questionnaires, 14 were sent back due to incorrect or insufficient addresses. Of the 1986 delivered questionnaires, 475 were returned for a return rate of 23.8%. However, 21 of the returned questionnaires were excluded from analyses due to incomplete responses.

Eighty-two percent of the respondents were women, and 18% were men. On average respondents had been in practice for 15.84 years (SD, 10.68) and certified for 16.04 years (SD, 11.10) (see Table 1). Primary area of practice was listed as diagnostic/general for 62.5%, computed tomography (CT) for 11.7%, magnetic resonance (MR) imaging for 8.8%, pediatric for 0.4% and other for 16.5%. Of the other category, most respondents (81%) wrote "mammography" next to "other" as the primary area of practice. The majority of respondents worked in hospitals (65%), outpatient facilities (15.4%) or imaging centers (7.5%), with the remainder working at a variety of other settings (12.3%). Of those working in hospitals, 14.5% were in hospitals with 99 or fewer beds, 29.7% were in hospitals with 100 to 299 beds and 20.5% were in hospitals with 300 or more beds (see Table 2).

Most of the respondents received their initial professional education in radiologic technology through certificate programs (41.6%) or associate degree programs (45.4%). Only 5.1% had completed bachelor's programs, 3.7% military programs and 4.8% other types of programs. Almost all of the respondents (98.9%) had participated in 1 or more continuing education programs in the past year. Twenty-three percent reported completing Directed Readings only, and 41% reported completing Directed Readings in combination with other modes of continuing education. Other continuing education activities included conferences along with or in combination with other activities (45%), employer-sponsored seminars (28%), online instruction (7%) and college- and university-sponsored programs (4%) (see Table 3). Because so few of the respondents reported having completed no continuing education in the past year, the relationship of this independent variable to the dependent variables of knowledge of and compliance with safety practices could not be examined.

Characteristics of the respondents (N = 454) were compared with those of the registrants of the ARRT (N = 234 951) in 2004. The respondent group had a higher percentage of women (82% vs 74% for ARRT registrants) and a lower percentage with a bachelor's degree as the highest level of education (10% vs 15% for ARRT registrants). Hospitals were the most frequent practice site for both groups.

Knowledge of and Compliance With Radiation Protection Practices

Knowledge of and compliance with safety practices were evaluated through calculating composite scores and summarizing performance on individual items. The mean composite score for knowledge was 82.2 (N = 454; SD, 14.8), and the mean composite score for compliance with safety practices was 72.2% (N = 385; SD, 23.5). Although the distribution of both variables was skewed to the right, the skewness value was within the acceptable range of plus or minus 2. The knowledge scores had a flat distribution with a kurtosis value of 3.85. The Pearson product moment correlation value for knowledge and compliance scores was low (r = .139) and significant (P < .01, 2-tailed). Because the distributions of the dependent variables (ie, knowledge and compliance) were not normal, the relationship between them also was evaluated using Kendall tau rank correlation and the Spearman rank correlation. Again, the scores had a significant and positive relationship (see Table 4).

Performance on individual items is summarized in Tables 5 and 6. Of the 10 items, 6 assessed radiation safety practice among personnel and 5 assessed radiation safety practice with patients. The percentage of respondents complying with best practices for radiation safety practice ranged from 31.1% to 96.4% for personnel and from 40% to 95.4% with patients.

Relationships Among Independent and Dependent Variables

Because the questionnaire included areas of practice outside of some respondents' primary area of practice, not all respondents responded to every question. For example, if the respondent's primary area of practice was CT, he or she would not necessarily answer questions in the portable or fluoroscopy sections. Therefore, values were missing for most of the independent and dependent variables. Although replacing missing values could bias the results, it is acceptable to replace up to 15% of the data for each variable, according to George and Mallery. (17) An examination of the independent and dependent variables revealed that the percentage of missing values was less than 15% for all variables. Accordingly, missing values for continuous variables were replaced by the mean value for that variable.

Relationships between the independent and dependent variables were examined using the Spearman rank correlation and the Kendall tau rank correlation tests for categorical variables (see Table 4). The only independent variable that was significantly correlated with a composite knowledge score was initial education ([r.sub.s] = 0.092; P< .05). For the composite practice score significant correlations were found for years in practice ([r.sub.s] = 0.094; P< .05) and work site ([r.sub.s] = 0.108; P< .05). Although the findings are statistically significant, they are of little practical importance due to the very low value of the correlation coefficients. Tests of significance are sensitive to sample size. Thus, a significant result indicates confidence in the finding (ie, it is unlikely the finding is due to chance), but it does not necessarily mean that the observed relationship is strong enough to have practical implications. (16)

For individual items, relationships among variables were evaluated using the chi-square test of independence and the phi coefficient to determine whether the independent variables were related to performance on individual items. Before the chi-square values could be calculated, the response categories for the independent variables needed to be combined, or collapsed, in such a way that each category contained more than 5 values for at least 80% of the categories. The categories for years in practice were fewer than 5 years, 6 to 15 years, 16 to 25 years and more than 26 years. The categories for type of work site were collapsed into the categories of hospital (1 to 99 beds), hospital (100 to 299 beds), hospital (300 or more beds) and all others, including outpatient facilities and imaging centers. The categories for initial education were collapsed to college degree (associate and bachelor's degrees), hospital-based program and other.

When calculating chi-square values, the distribution of scores for the entire study group was compared with the distribution of scores for subgroups of the study population. For example, the chi-square test could be used to compare the distribution of scores for compliance with safety practices among radiographers who received their initial training in a college-based program with the distribution of scores for all radiographers in the study. A significant chi-square score indicates that the distribution of scores for the 2 groups is significantly different and therefore not due to chance.

The phi coefficient is based on the chi-square score and measures the strength of association between variables. Chi-square and phi coefficient values were calculated for each of 11 individual items. For the 5 items related to compliance with patient safety practices, none of the chi-square values were significant and the phi coefficient scores were uniformly low. Additionally, the results for the chi-square tests were mixed, as can be seen in Tables 7 and 8. For compliance with safety practices among personnel and years in practice, 3 items had significant chi-square values, indicating that the observed distribution of scores for compliance with safety practices among personnel was different from the predicted distribution of scores. Similarly, significant chi-square and phi coefficient values were found for the same 3 items for type of work site and compliance with personnel safety practices. Further examination of the data revealed that higher levels of compliance were associated with work sites at large hospitals (300 or more beds) and for individuals with 6 to 25 years in practice.

Discussion and Conclusions

Study results indicated poor compliance with radiation safety practices, especially safety practices to reduce unnecessary exposure to personnel. The results, with regard to the relationships among the independent and dependent variables, are mixed.

Contrary to expectations and the results of the Tilson study, the type of initial professional education was not significantly related to compliance with safety practice, although it did have a small, significant association with knowledge of safety practices. Work site and years of practice had small, significant associations with compliance with safety practices. Initial education had a weak association with knowledge of safety practices; however, work site and years of employment in the radiologic sciences appeared to be important in determining compliance with safety practices.

The data indicated higher levels of compliance in large hospitals than in other types of work sites; however, the data did not provide insight into the characteristics of large hospitals that increased the likelihood of compliance. For example, why was there noncompliance with best practices such as wearing a thyroid shield? Was the reason that 1) a shield was not available, 2) the technologist was pressed for time and did not have time to look for the shield, or 3) the technologist was complacent about the need to wear a thyroid shield? It may be that in large hospitals shields are more likely to be available or that technologists are less likely to be pressed for time. Or perhaps large hospitals provide better supervision of radiation practice and have more frequent in-service training, which results in higher levels of compliance. In fact, this would be consistent with the finding by Lemley et al that larger hospitals offered more hours of formal training than smaller hospitals. (3)

Recommendations

Additional study is required to determine what aspects of work sites encourage compliance and to fully understand the relationship between compliance and years of employment in the radiologic sciences. Visual inspection of the data suggests a curvilinear relationship between compliance and years of employment in the radiologic sciences. In other words, personnel might be less compliant at the beginning and the end of their careers. If this is the case, a possible intervention could be additional supervision and in-service education for early and late careerists.

Only further study will clarify what organizations should do to increase compliance with safety practices. To date, a second study using a revised questionnaire has been completed for radiologic technologists practicing in California, and a third study to identify organizational practices to improve compliance is planned. Additional studies are needed to determine why such high levels of continuing education are being reported but are not resulting in high levels of compliance with safety practices. It also will be important to identify types and modes of effective continuing education.

Acknowledgement: The California Society of Radiologic Technologists and the California State University Northridge, Health Sciences Department provided support for this research.

Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3909, or e-mail communications@asrt.org.

References

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(3.) Lemley AA, Hedl JJ Jr, Griffin EE. A study of radiation safety education practices in acute care Texas hospitals. Radiol Technol. 1987;58(4):323-331.

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ANITA MARIE SLECHTA, MS, R.T.(R)(M), FASRT JANET THOMPSON REAGAN, PHD

Anita Slechta, MS, R.T.(R)(M), FASRT, is a professor of health science and program director of the baccalaureate program at California State University, Northridge. Her research interests and publications include licensure and education with the purpose of protecting the public and personnel from unnecessary radiation.

Janet Reagan, PhD, is a professor of health administration in the Department of Health Sciences at California State University, Northridge. She has published in many professional journals; her research interests and publications include human resource management and quality improvement. Table 1 Respondent Characteristics Women 82% (n = 371) Men 18% (n = 83) Average years of practice in 15.84 yrs radiologic technology SD = 10.68 Average number of years 16.04 yrs certified SD = 11.1 Table 2 Respondent Characteristics Continued (a) Primary place of employment

(N = 454)

Hospital total 65% (n = 295)

1-99 beds 14.5% (n = 66)

100-299 beds 29.5% (n = 134)

300 or more beds 20.9% (n = 95)

Outpatient facility 15.2% (n = 69)

Imaging center 7.3% (n = 33)

Other 12.5% (n = 57) Initial radiologic technology education

Hospital-based program 41.6% (n = 189)

Two-year degree (community college) 45.4% (n = 206)

Bachelor's degree in

radiologic technology/sciences 5.1% (n = 23)

Military program 3.7% (n = 17)

Other 4.2% (n = 19) Additional education (b)

Associate degree 23.1% (n = 105)

Bachelor's degree 9.91% (n = 39)

Master's degree 1.1% (n = 4)

Doctoral degree 0.2% (n = 1)

Other 7% (n = 32) (a) Due to rounding, percentages may not add up to 100%. (b) Represents percentage of the whole sample (N = 454) because 193 respondents (42.5%) listed additional education. Table 3 Participation in Continuing Education in the Past Year (a)

% Type of Continuing Education (b) Participation Respondents who participated in 1 or more continuing education programs in the past year 98% (n = 445) Directed Readings only 23% (n = 102) Conferences only 4% (n = 18) Community college only 1% (n = 5) Other 3% (n =13) Directed Readings combined with other modes of continuing education 41% (n = 182) Conferences combined with other modes of continuing education 45% (n = 200) Employer-sponsored seminar and some other continuing education activity 28% (n = 125) Online instruction and some other continuing education activity 7% (n = 31) University-sponsored CE and some other continuing education activity 4% (n = 18) (a) Due to rounding, percentages may not add up to 100%. (b) Respondents could list more than 1 type of continuing education. Table 4 Relationship Among Dependent and Independent Variables

Independent Variables Dependent Variables Years in Practice Initial Education Composite Score: [r.sup.s] = 0.013 [r.sup.s] = -0.092 Knowledge P = NS P <.05

[tau] = 0.009 [tau] = -0.078

P = NS P <.05 Composite Score: [r.sup.s] = 0.094 [r.sup.s] = -0.088 Practice P <.05 P = NS

[tau] = 0.068 [tau] = -0.072

P <.05 P = NS

Independent

Variables Dependent Variables Work site Composite Score: [r.sup.s] = 0.038 Knowledge P = NS

[tau] = 0.030

P = NS Composite Score: [r.sup.s] = 0.108 Practice P <.05

[tau] = 0.083

P <.05 NS = not significant; [r.sup.s] = Spearman rank correlation; [tau] = Kendall tau rank correlation; P = statistical probability Table 5 Personnel Radiation Safety Practice (a) Question no. n Always Sometimes Never 7. When performing 312 31.1% (b) 62.8% 6.1% portable exams do you wear (n = 97) (n = 196) (n = 19) a lead apron(s)? 8. If you wear a lead 300 39.7% (b) 56.7% 3.7% apron during portables do (n = 119) (n = 170) (n = 11) you always stand at least 6 ft away from the patient? 12. During a fluoroscopic 270 34.1% (b) 37.4% 28.5 procedure, do you wear a (n = 92) (n = 101) (n = 77) thyroid shield? Question no. n Daily 1 /wk 9. Holds patient during a 318 4.7% 22.3% portable exam. (n = 15) (n = 71) Question no. n By the Behind

patient's the

head doctor 10. Where do you stand 264 10.6% 70.4% (b) during a typical upper GI (n = 28) (n = 186) fluoroscopic procedure? 11. Where do you stand 263 3.4% 61.9% (b) during a typical lower GI (n = 9) (n = 163) fluoroscopic procedure? Question no. 7. When performing portable exams do you wear a lead apron(s)? 8. If you wear a lead apron during portables do you always stand at least 6 ft away from the patient? 12. During a fluoroscopic procedure, do you wear a thyroid shield? Question no. 1 / mo 1 / yr Never 9. Holds patient during a 24.5% 26.7% (b) 21.7% (b) portable exam. (n = 78) (n = 85) (n = 69) Question no. In the At the Other

control foot of

room the table 10. Where do you stand 11.7% (b) 2.6% 4.5% during a typical upper GI (n = 31) (n = 7) (n = 12) fluoroscopic procedure? 11. Where do you stand 7.6% (b) 22.4% 5.3% during a typical lower GI (n = 18) (n = 59) (n = 14) fluoroscopic procedure? (a) Due to rounding, percentages may not add up to 100%. (b) Represents best practice. Table 6 Table Patient Radiation Safety Practice (a) Question no. n As far As close The

away from to the distance/

the patient position

patient as does not

as possible matter

possible 13. During fluoroscopy, 131 15.3% 80.9% (b) 3.8% with an under the table (n = 20) (n = 106) (n = 5) x-ray tube, where do you place the image intensifier (II)? Question no. n Always Sometimes Never 14. Do you use gonadal 136 40.4% (b) 36.8% 22.8% shielding on women of (n = 55) (n = 50) (n = 31) child-bearing age during a CT of the chest? 16. Have you told any 412 9.9% 50.1% 40.0% (b) patients who are nervous (n = 41) (n = 206) (n = 165) about their radiation exposure that they will receive more radiation from the sun at the beach in 1 day than from their diagnostic x-rays? 19. In a coned down L5/S1 351 1.1% 3.4% 95.4% (b) lateral radiograph, do you (n = 4) (n = 12) (n = 335) use fluoro before exposure to ensure the disc space is open and decrease repeating radiographs? Question no. n On top of Around Under the

the the patient

patient entire

pelvis 15. Where do you place the 142 9.2% 70.4% (b) 2.1% gonadal shielding during a (n = 13) (n = 100) (n = 3) CT exam of the chest? Question no. 13. During fluoroscopy, with an under the table x-ray tube, where do you place the image intensifier (II)? Question no. 14. Do you use gonadal shielding on women of child-bearing age during a CT of the chest? 16. Have you told any patients who are nervous about their radiation exposure that they will receive more radiation from the sun at the beach in 1 day than from their diagnostic x-rays? 19. In a coned down L5/S1 lateral radiograph, do you use fluoro before exposure to ensure the disc space is open and decrease repeating radiographs? Question no. No gonadal

shielding

is

necessary 15. Where do you place the 18.3% gonadal shielding during a (n = 26) CT exam of the chest? (a) Due to rounding, percentages may not add up to 100%. (b) Represents best practice. Table 7 Summary Data Analysis of Years in Practice vs Safety Practices for Personnel Using Chi Square ([chi square]) and Phi ([PHI])

[chi Items n square] df P [PHI] 7 309 13.76 6 -0.05 0.211 9 343 37.30 12 -0.01 0.343 10 263 5.81 6 NS (a) 0.150 11 249 6.50 6 NS (a) 0.162 12 268 24.61 6 -0.01 0.303 (a)NS = not significant. Table 8 Summary Data Analysis of Work Site vs Safety Practices for personnel Using Chi Square ([chi square]) and Phi ([PHI])

[chi Items n square] df P [PHI] 7 310 40.35 6 -0.01 0.361 9 318 39.45 12 -0.01 0.352 10 263 6.27 6 NS (a) 0.154 11 260 3.43 6 NS (a) 0.115 12 268 23.21 6 -0.01 0.294 (a)NS = not significant.