Occupational Dose Perceptions and Practices in Interventional Radiology and Interventional Cardiology By Brayden Crismon R.T.(R)(VI)(ARRT) A thesis submitted to the School of Radiologic Sciences in collaboration with a research agenda team In partial fulfillment of the requirements for the degree of MASTER OF SCIENCE IN RADIOLOGIC SCIENCES (MSRS) WEBER STATE UNIVERSITY Ogden, Utah August 13, 2025 ii THE WEBER STATE UNIVERSITY GRADUATE SCHOOL SUPERVISORY COMMITTEE APPROVAL of a thesis submitted by Brayden Crismon R.T.(R)(VI)(ARRT) This thesis has been read by each member of the following supervisory committee and by majority vote found to be satisfactory. ______________________________ Dr. Robert Walker, PhD Director of MSRS Innovation & Improvement ______________________________ Dr. Laurie Coburn, EdD Director of MSRS RA ______________________________ Dr. Tanya Nolan, EdD Chair, School of Radiologic Sciences ______________________________ Christopher Steelman, MS Director of MSRS Cardiac Specialist iii THE WEBER STATE UNIVERSITY GRADUATE SCHOOL RESEARCH AGENDA STUDENT APPROVAL of a thesis submitted by Brayden Crismon R.T.(R)(VI)(ARRT) This thesis has been read by each member of the student research agenda committee and by majority vote found to be satisfactory. Date August 12, 2025 Student Name _____________________________ Brayden Crismon iv Abstract Interventional radiology and interventional cardiology staff experience higher levels of occupational radiation exposure than other radiologic modalities. There is a lack of literature in the use of occupational radiation safety and monitoring devices, creating a discrepancy for regulating agencies ability to provide accurate dose limits and safety guidelines. The purpose of this study provides a current snapshot of radiation safety and occupational dosimetry in fluoroscopic laboratories. This quantitative study collected and analyzed data from staff members of interventional radiology and interventional radiology departments in the United States. Interventional Radiology (M = .36, SE = .105) and Interventional Cardiology (M = .41, SE = .088) staff as a whole are not aware of the effective whole body occupational radiation dose limit regulations provided by the ICRP. 70.7% of interventional radiology and interventional cardiology nurses were historically ‘never’ wearing their personal occupational dose monitoring device (Table 5). This study shows that 1.7% of radiology nurses and 0% of cardiology nurses ‘never’ wear their personal occupational dose monitoring device. This study showed that 75% of nursing staff wear thyroid shields during fluoroscopic procedures, a 5% increase from previous literature. Radiologic technologists (73.7%) wore thyroid shields in this study, a marked increase from previous literature (43%). Radiologic technologists showed a marked increase from 5.0% in previous literature to 31.6% in this study with respect to thyroid shields. The two groups that observed their occupational dose records most infrequently were Cardiology Nurses (M = 2.15, SE = .456) and Radiology Nurses (M = 2.0, SE = .426). A longer study length with the help of other societies and institutional v review boards for facilities would greatly increase participation in the study. Future research should be collected in occupational dose records, if able to gain approvals. Occupational dose records of participants will give further insight into how their perceptions of importance, radiation safety, and occupational dose monitoring practices influence their occupational dose measurements. vi Acknowledgements I would like to acknowledge Dr. Tanya Nolan, Dr. Laurie Coburn, and Christopher Steelman as mentors during the creation of this thesis. vii Table of Contents Chapter 1: Introduction ....................................................................................................... 1 Background ................................................................................................................... 1 Statement of the Problem .............................................................................................. 5 Purpose of the Study ..................................................................................................... 5 Research Questions ....................................................................................................... 6 Nature of the Study ....................................................................................................... 7 Significance of the Study .............................................................................................. 7 Summary ....................................................................................................................... 8 Chapter 2: Literature Review .............................................................................................. 9 Documentation .............................................................................................................. 9 Summary ..................................................................................................................... 24 Chapter 3: Research Method ............................................................................................. 25 Research Methods and Design(s)................................................................................ 27 Population ................................................................................................................... 28 Materials/Instruments ................................................................................................. 29 Operational Definition of Variables............................................................................ 30 Data Collection, Processing, and Analysis ................................................................. 35 Assumptions................................................................................................................ 38 Limitations .................................................................................................................. 39 Delimitations ............................................................................................................... 39 Ethical Assurances ...................................................................................................... 39 Summary ..................................................................................................................... 40 Chapter 4: Findings ........................................................................................................... 41 Results ......................................................................................................................... 42 Evaluation of Findings ................................................................................................ 63 Summary ..................................................................................................................... 65 Chapter 5: Implications, Recommendations, and Conclusions ........................................ 67 Implications................................................................................................................. 68 Recommendations ....................................................................................................... 72 Conclusions ................................................................................................................. 72 Appendices ........................................................................................................................ 81 Appendix A: Qualtrics Survey .......................................................................................... 81 Appendix B: Informed Consent ........................................................................................ 89 viii List of Tables Table 1. ICRP Recommended Dose Limits (2012) ........................................................... 11 Table 2. Annual and Estimated Annual Effective Radiation Exposure During Interventional Fluoroscopy .......................................................................................................................... 12 Table 3. IR and IC Staff Annual Effective Radiation Exposure by Staff and Department 14 Table 4. Percent Use of Radiation Monitoring Devices During Interventional Fluoroscopy ....................................................................................................... 17 Table 5. Percent Use of Personal Radiation Monitoring Devices by Staff ...................... 18 Table 6. Reporting Radiation Safety Devices that are Always Used ................................ 21 Table 7. Radiation Safety Device Use by Staff ................................................................. 23 Table 8. Respondents by Job Title or Role ....................................................................... 43 Table 9. Respondents by Primary Department ................................................................. 44 Table 10. Importance of Radiation Safety by Job Role or Title........................................ 45 Table 11. Importance of Radiation Safety by Primary Working Department .................. 46 Table 12. Devices Offered by Facility .............................................................................. 47 Table 13. Percent Personal Utilization of Radiation Safety Devices ............................... 49 Table 14. Understanding of Dose Limit Regulations........................................................ 50 Table 15. Whole Body Effective Dose Mean Value of Correct Answers by Job Role or Title................................................................................................................... 51 Table 16. Lens of the Eye Equivalent Dose Mean Value of Correct Answers by Job Role or Title .............................................................................................................. 53 Table 17. Whole Body Effective Dose Mean Value of Correct Answers by Primary Working Department .......................................................................................................................................... 54 ix Table 18. Lens of the Eye Equivalent Dose Mean Value of Correct Answers by Primary Working Department ........................................................................................ 55 Table 19. Frequencies of Observing Occupational Dose Reports ................................... 56 Table 20. Observance of Occupational Dose Record by Job Role or Title ............... Error! Bookmark not defined. Table 21. Percent Utilization of Occupational Radiation Dose Monitoring Devices ...... 58 Table 22. Capability of Conceiving and Carrying a Pregnancy to Term ......................... 59 Table 23. Importance of Radiation Safety by Ability to Conceive and Carry a Pregnancy to Term ........................................................................................................................................... 60 Table 24. Response Rates per State in the United States .................................................. 61 Table 25. Age at Time of Taking the Survey ..................................................................... 63 1 Chapter 1: Introduction Ionizing radiation is characterized by any radiation that is capable of removing electrons from atoms or molecules and can be classified as either electromagnetic or particulate (Hill & Ulrich, 2019; Puckett et al., 2023). Diagnostic and therapeutic medical imaging utilizes several types of radiation such as x-rays, gamma rays, beta particles, positrons, neutrons, and alpha particles (Donya, 2014; Puckett, 2023). Sources of ionizing radiation come from natural sources and man-made sources, as of 2023 about 46% of ionizing radiation is from a man-made source (Donya et al., 2014; Puckett et al., 2023). Among the diagnostic and therapeutic medical imaging modalities, interventional radiology (IR) and interventional cardiology (IC) hold a significant amount of occupational radiation exposure for medical workers and patients (Byrne et al, 2020; Miller et al., 2010). Over the years, the number of interventional procedures in IR and IC have significantly increased and will continue doing so (Althawadi, N., 2024, Elshami et al., 2020; Kim et al., 2012; Miller et al., 2010). This can be attributed to advancements in minimally invasive procedures and technology of fluoroscopic equipment and supplies (Vanzant & Mikhdomi, 2023). Background Since the discovery of the x-ray beam on November 8, 1895, by Wilhelm Conrad Rontgen, radiation safety guidelines were introduced in 1913 by the German Roentgen Society after several physician deaths were reported (Berger et al., 2018; Boice et al., 2020). During World War I, the use of radiography within hospitals skyrocketed due to the invention “of the hot-cathode x-ray tube by Coolidge” (Boice et al., 2020, p.3). With the invention and rapid high-density use of the hot cathode there were several x-ray 2 operators that experienced elevated levels of occupational exposure to ionizing radiation, seen by acute cases of the skin and eyes, leukemia presence, and aplastic anemia (Boice et al., 2020). In 1924 the American Roentgen Ray society created a recommendation for what they called a tolerance dose, “the level of radiation to which an individual could be continuously exposed without demonstrable ill health effect or harm” (Boice et al., 2020, p.5). The recommendation landed on what they believed was acceptable at 1/100 of the quantity of radiation that caused erythema (Boice et al., 2020). Between the years of 1934 and 2018 the International X-ray and Radium Protection Commission (IXRPC), National Council of Radiation Protection and Measurements (NCRP), and International Commission on Radiological Protection (ICRP) have created and modified recommendations for the criteria of maximum permissible doses (Boice et al., 2020). The current ICRP Publication 139 recommends limits to whole body effective dose, eye lens dose, and skin dose of the hands and feet. The whole body effective dose limit is marked at 20 millisieverts per year (mSv/y) averaged over 5 years and no more than 50 mSv/y in any given year, an equivalent dose of 20 mSv/y for the lens of the eye over 5 years and no more than 50 mSv/y in any given year, 500 mSv/y for the skin, hands, and feet (International Commission on Radiological Protection [ICRP], 2012; ICRP, 2018). The NCRP reports dose limits to 50 mSv/y for whole body effective dose, a cumulative dose of less than 10 mSv times age in years, and 50 milli-gray per year (mGy/y) for the lens of the eye (Boice et al.; Cool et al., 2019). With the observation of occupational dose effects and implementation of dose limits, methods to reduce radiation exposure have become incorporated into medical imaging. Personal protective equipment (PPE), As Low as Reasonably Achievable 3 (ALARA) guidelines, and technological advancements of imaging equipment are all examples of radiation reduction (Bhanot et al., 2022; Frane & Bitterman, 2023, Vanzant & Mikhdomi, 2023). ALARA is a tool for practitioners to remember the fundamentals of radiation safety: time, distance, and shielding. Time relates to the duration that an individual is exposed to radiation, distance is the factor that for every time an individual doubles their distance from a radiation source, their risk is reduced to a quarter of the original distance, and shielding relates to the use of protective equipment and appropriate technical factors (Bhanot et al., 2022; Frane & Bitterman, 2023, Mukherji et al., 2020). The use of medical radiation comes with inherent risk for the operators as described by the need for dose limits and safety measures (Vanzant & Mikhdomi, 2023, ICRP, 2007, ICRP, 2018). The biological effects of radiation can be described by deterministic and stochastic effects (Bhanot et al., 2022; Frane & Bitterman, 2023; Hamada & Fujimichi, 2014; Vanzant & Mikhdomi, 2023). Stochastic effects do not require a threshold dose, meaning that they can occur at any exposure to radiation over time, and can lead to carcinogenesis and cardiovascular, gastrointestinal, and respiratory issues. The severity of a stochastic effect is independent of the dose received, based on the linear no-threshold hypothesis (LNTH), making a stochastic effect quite concerning (Bhanot et al., 2022; Frane & Bitterman, 2023; Hamada & Fujimichi, 2014; Vanzant & Mikhdomi, 2023). Deterministic effects of radiation on health have a correlation between severity and dose received, described as dose-dependent effects (Frane & Bitterman, 2023; Talapko et al., 2024). Notably, for a deterministic effect to be observed, a specific cumulative dose must be reached (Frane & Bitterman, 2023; Talapko et al., 2024; Vanzant & Mikhdomi, 2023). Deterministic effects are often called tissue reactions 4 because they are observed in tissues like the skin, eyes, bone marrow, and hair (Bhanot et al., 2022; Frane & Bitterman, 2023; Hamada & Fujimichi, 2014; Vanzant & Mikhdomi, 2023). The advancements of medical imaging have created real time fluoroscopic guidance for diagnostic and therapeutic interventions (Vanzant & Mikhdomi, 2023; Borrego et al., 2020). Modern day fluoroscopy is performed by a specific team of radiation workers, mainly interventional radiologists and interventional cardiologists assisted by the allied health professionals (radiologic technologists, nurses, cardiovascular technicians). Other medical specialties, like orthopedic surgeons, endoscopists, neurosurgeons, spine surgeons, and urologists, utilize fluoroscopic guidance but not to the extent of IR and IC physicians (Kim et al., 2012). IC in the modern world performs several cardiac procedures that include transcatheter aortic valve replacement (TAVR), transcatheter tricuspid and mitral valve interventions (TTMVI), balloon aortic valvuloplasty (BAV), percutaneous transluminal coronary angioplasty (PTCA), percutaneous coronary intervention (PCI), among others (Holmes & Alkhouli, 2020). IR practices predominantly outside of heart interventions to include non-vascular procedures such as, percutaneous needle biopsy (PNB), percutaneous drainage (PCD) with or without catheter placement, nephrostomy placement, ureteral stenting, cholecystostomy placement, and percutaneous transhepatic biliary drainage (PTBD) (Mukund et al., 2019; Mashoufi, R. & Mashoufi, R., 2023, Wilson-Steward et al. 2023b). Vascular procedures that IR performs consist of endovascular aortic repair (EVAR), arterial embolization for hemorrhage, transarterial chemoembolization (TACE), angioplasty and venoplasty for vascular stenoses, vascular stent placement, 5 thrombectomy, transjugular intrahepatic portosystemic shunt (TIPS), among several others (R. Mashoufi & R. Mashoufi, 2023; Mussmann et al., 2024; Wilson-Steward et al., 2023b). Statement of the Problem Medical radiation workers in IR and IC have higher occupational exposure to radiation compared to medical radiation workers that do not utilize fluoroscopic units (Akram & Chowdhury, 2022). The increased market for interventional radiologists, and radiologists in general, has led to novel vascular and non-vascular treatments released every year to better treat patients with minimally invasive procedures (Weiss & HafeziNejad, 2023). There is concern in the IRCP Publications that radiation monitoring may be skewed due to radiation workers not wearing personal dose monitoring devices regularly (ICRP, 2018). There is little information that is presented in how often medical radiation workers wear personal radiation dose monitoring devices, posing the question of whether dose limits and reporting are accurate. Performing a quantitative study will help delineate whether dose reporting is accurate and estimate the confidence of IR and IC staff in their dose limits and reports. It is important for regulatory commissions to have data related to correct use of personal radiation dose monitoring devices to accurately determine occupational dose limits for medical radiation workers. Purpose of the Study The purpose of this quantitative study is to determine the awareness and practices of occupational radiation exposure among staff of IR and IC labs. A Likert-Scale questionnaire will be offered with informed consent to participants of IR and IC labs to assess their awareness with occupational dose limit regulations, how often staff are 6 wearing personal radiation dose monitoring devices, what the utilization of radiation safety devices are, and the awareness of radiation workers dose reports. In addition, a question will ask what department they work in and their job title, their country/state of residence, age range, and a survey question that asks about what radiation safety devices are used in their lab. Research Questions Q1. What is the awareness of interventional radiology and interventional cardiology staff of dose limits and regulations? Q2. How often are staff of interventional labs wearing personal radiation dose monitoring devices? Q3. What is the utilization of various radiation safety devices in IR and IC laboratories? Q4. What is the awareness of medical radiation workers regarding their dose reports? Hypotheses H10. Staff are aware of all dose limits and regulations. H1a. Staff are not aware of all dose limits and regulations. H20. Staff are wearing personal radiation dose monitoring devices during all fluoroscopic procedures. H2a. Staff are not routinely or never wearing personal radiation dose monitoring devices during all fluoroscopic procedures. H30. Staff are always utilizing radiation protection equipment during all fluoroscopic procedures. 7 H3a. Staff are not routinely or never utilizing radiation protection equipment during all fluoroscopic procedures. H40. Staff are not aware of their own occupational dose reports. H4a. Staff are aware of their own occupational dose reports. Nature of the Study The study was presented to IR and IC staff in the United States. Selection of participants is not random as it is a particular group of professionals. Random assignment is not of concern as it is a variable of study within the questionnaire. The questionnaire will contain Likert-Scale questions, two demographic questions, and one survey question. The Likert-Scale questions will ask their awareness with occupational dose limit regulations, how often staff wear personal radiation dose monitoring devices, what the utilization of radiation safety devices are, and the awareness of radiation workers dose reports. These questions will answer what the observation of radiation dose limits are, what the adherence to accurate radiation dosimetry practices are, and the utilization of radiation safety devices. The demographic questions will delineate if there is a significant difference between differing staff members. The survey question on radiation protection devices will assess how well they are mitigating their occupational exposure at their facility. Significance of the Study This study is important to the field of IR as well as IC to assess radiation safety practices and perceived risk associated with radiation. This article can contribute to future primary research on dose reporting analyses in IR and IC labs. The importance overall is instrumental in assessing the need for increased monitoring, education, and awareness of 8 occupational exposure associated with an increase in the demand for fluoroscopically guided procedures. Summary Radiation safety has a long history of importance that has changed over the years due to physician deaths and other observed radiation exposure effects. This study will impact the professions that primarily utilize fluoroscopy for their procedures by assessing the awareness and perception of medical radiation workers in this area related to occupational exposure, dose reporting, and radiation safety. This study will be presented as a questionnaire with 7 Likert-Scale questions, two simple demographic questions, and a survey that asks what radiation safety devices are used at their facility. 9 Chapter 2: Literature Review Medical radiation workers in IR and IC have higher occupational exposure to radiation compared to medical radiation workers that do not utilize fluoroscopic units (Akram & Chowdhury, 2022). With an increased market for IR and IC procedures, there is concern that radiation safety monitoring may be skewed due to a lack of adherence to regular wear of dosimeters (ICRP, 2018; Weiss & Hafezi-Nejad, 2023). It is essential to start with the perception of how technologists, radiologists, nurses, and other ancillary staff view their occupational radiation exposure. Evaluating perceived dose and radiation safety practices could aid agencies in predicting annual effective dose measurements and if changes need to be made to dose limits. This literature review will provide context of what research has been performed on occupational radiation exposure among IR and IC staff. Documentation A thorough literature search strategy was used to collect existing data and information regarding occupational radiation exposure among IR and IC staff. The literary strategy included database searches in Google Scholar, EBSCOhost, and Stewart Library OneSearch. Eligibility was determined by the availability of data regarding the whole body annual or estimated annual exposure rates among staff working primarily in IR and IC. Additional eligibility incorporated any data regarding routine use of dosimeters or lack thereof. Excluded studies focused on procedural dose to occupational staff, studies outside of IR and IC, procedural dose to patients, eye lens dose, and extremity dose. Of the 86 articles found, 24 met inclusion eligibility. 10 Annual Occupational Exposure Limits Occupational radiation exposure to IR and IC staff in literature has all agreed upon the occupational dose limits established by the ICRP during the year of their study. The current ICRP Publication 139 recommends limits to whole body effective dose, eye lens dose, and skin dose of the hands and feet. The whole body effective dose limit is marked at 20 millisieverts per year (mSv/y) averaged over 5 years and no more than 50 mSv/y in any given year, an equivalent dose of 20 mSv/y for the lens of the eye over 5 years and no more than 50 mSv/y in any given year, 500 mSv/y for the skin, hands, and feet (International Commission on Radiological Protection [ICRP], 2012; ICRP, 2018). The NCRP reports dose limits to 50 mSv/y for whole body effective dose, a cumulative dose of less than 10 mSv times age in years, and 50 milli-gray per year (mGy/y) for the lens of the eye (Boice et al.; Cool et al., 2019). Prior to 2012, the guidelines for annual exposure of the lens of the eye were marked at an equivalent dose of 150 mSv/y, a stark difference to the current yearly maximum of 50 mSv/y (ICRP, 2007; ICRP, 2012; ICRP, 2018). Table 1 provides a summary of current ICRP recommendations for occupational dose limits of interventional fluoroscopy operators and staff. The ICRP has made these recommendations to “ensure that the occurrence of stochastic health effects is kept below unacceptable levels, and that tissue reactions (deterministic effects) are avoided” (ICRP, 2018). 11 Table 1 ICRP Recommended Dose Limits (2012 / 2018) Type of Limit Limit Whole Body Effective Dose 20 mSv/y averaged over 5 years 50 mSv/y Annual Equivalent Dose in Lens of the Eye 20 mSv/y averaged over 5 years 50 mSv/y Skin 500 mSv/y Hands and Feet 500 mSv/y Note. This table describes the International Commission on Radiological Protection (ICRP, 2012 and ICRP, 2018) suggestions for regulations of dose limits for the whole body and the lens of the eye in millisieverts per year (mSv/y). Annual Effective Exposure Rates The literature review included studies from 2008 to 2024 regarding annual effective whole body dose measurements or estimated annual whole body dose measurements. Table 2 provides the dose rates of several staff members involved with fluoroscopic procedures but has been limited to those working primarily in a radiology department or cardiac catheterization department. The staff members that were observed included a physician group, nurse and anesthesia group, and technician and technologist group, represented in Table 3. 12 Table 2 Annual and Estimated Annual Effective Radiation Exposure During Interventional Fluoroscopy Author Alkhorayef, et al., 2021 Staff Interventional Radiologist Mean (mSv/y) Range (mSv/y) 4.50 0.10-14.0 4.70 0.10-25.5 4.60 0.10-22.5 5.60 0.10-25.5 Althawadi, Abuzaid, & Interventional Cardiologist 1.79 0.04-9.50 Elshami, 2024 Radiologic Technologist 0.83 0.01-1.80 Cardiovascular Technologist 0.71 0.10-0.99 IC Nurse 0.94 0.03-2.79 Interventional Cardiologist 0.65 0.15-1.50 Cardiac Technician 1.10 0.43-1.65 IC Nurse 1.13 0.10-2.01 Interventional Radiologist 3.00 - IR Nurse 1.34 - Radiologic Technologist 0.60 - Interventional Radiologist - 0.20-9.30 Neuroradiologist - 0.10-4.60 Radiologic Technologist - <0.10-1.20 IR Nurse - 0.10-2.00 Alyami & Nassef, 2024 Chida, et al., 2013 Creti, 2018 Interventional Ko, et al., 2021 Interventional Radiologist 5.92 - Korir, Wambani, & Korir, Radiologist 2.18 - 2011 Radiologic Technologist 2.52 - 13 Nurses 1.77 - Kuipers, et al., 2008 Interventional Radiologist 1.56 0.0-10.79 Nassef & Kinsara,2017 Radiologist 0.39 0.09-1.49 Radiologic Technologist 0.63 0.37-0.88 Cardiac Technician 2.20 1.51-2.76 IC Nurse 4.70 0.98-8.32 Radiology Nurse 0.84 0.59-1.02 0.02 0.02-0.03 0.72 0.14-1.35 0.92 0.21-2.30 0.82 0.44-1.66 0.67 0.12-3.23 0.65 0.42-2.23 Radiologist 0.30 0.04-0.76 Interventional Cardiologist 0.39 0.10-1.14 Radiologic Technologist 0.30 0.04-0.67 Cardiac Radiographer 0.31 0.14-0.62 IC Nurse 0.40 0.11-1.43 Radiology Nurse 0.28 0.04-0.33 Interventional Cardiologist 3.30 2.00-19.6 Electrophysiologist 4.30 3.50-6.10 IC Nurse and Technician 2.60 2.00-14.9 Ramanathan, Almeida, & Cardiac Radiographer Fernando, 2021 Shbeer, 2024 Soliman, et al., 2021 Venneri, et al., 2009 IC Anesthesia Note. This table describes the observed staff mean and range of occupational dose rates, in 14 millisieverts per year, by author. Estimated dose rates were obtained from partial data extrapolated into a yearly dose rate. IR and IC refer to Interventional Radiology and Interventional Cardiology, respectively. The symbol ‘-‘ indicates that the author did not provide the specific data. Table 3 IR and IC Staff Annual Effective Radiation Exposure by Staff and Department IR and IC Staff Mean (mSv/y) Min (mSv/y) Max (mSv/y) Physician 2.44 0.44 8.24 Nurse / Anesthesia 1.21 0.25 2.12 Technician / Technologist 0.93 0.41 2.22 IC Staff Mean (mSv/y) Min (mSv/y) Max (mSv/y) Physician 2.09 1.16 7.57 Nurse / Anesthesia 1.27 0.29 2.90 Technician / Technologist 0.91 0.55 2.77 IR Staff Mean (mSv/y) Min (mSv/y) Max (mSv/y) Physician 2.61 0.08 8.58 Nurse / Anesthesia 1.15 0.21 1.34 Technician / Technologist 0.98 0.13 1.14 Note. Interventional Radiology (IR) and Interventional Cardiology (IC) staff mean, minimum, and maximum annual dose rates, in millisieverts per year (mSv/y) are observed in this table. This table is a condensed version of what is seen in Table 2. Of the physician group, interventional radiologists, interventional neuroradiologists, radiologists, and interventional cardiologists were shown to have the 15 highest occurrence of occupational whole body effective dose (M = 2.44 mSv/y). The nurse and anesthesia group represented the sedation staff in the procedure room and included IR nurses, IC nurses, radiology nurses, and anesthesiologists with occurrence of occupational dose (M = 1.21 mSv/y). The technician/technologist group included radiologic technologists, cardiovascular technologists, cardiac technicians, and cardiac radiographers with occurrence of occupational dose (M = 0.93 mSv/y). Comparing the groups in the literature, physicians had the highest occupational dose, followed by the nurse/anesthesia group, and lastly the technician/technologist group. Inconsistency of provided data on how many procedures the staff member participates in, the complexity of the procedures, dose area product, fluoroscopy time, proportion of staff distribution, etc. can be sources of future direction for accurate occupational dose reporting systems. Personal Dose Monitoring Device Use Literature surrounding the use and proper wear of personal dose monitoring devices is sparse and inconsistent in data collection methods. The conducted literature review found articles from 2018 to 2025 that included data related to the adherence of using personal dose monitoring devices. The studies were presented as a Likert Scale questionnaire or survey for participants that were selected, though the Likert Scales were different between many of the studies. Collection of data in this literature review aimed to create a uniform data spread that can be evaluated as: wearing the personal dose monitoring device, always, inconsistently, or never. Any data in existing literature that was presented as ‘sometimes,’ ‘often,’ ‘rarely,’ etc. were grouped as inconsistent. Data represented in existing literature as ‘always’ or ‘never’ are reported as such in this literature review. 16 Table 4 provides an overview of all data extrapolated from existing literature. Evaluation of the literature shows that primary operators (physicians, radiologists, interventional cardiologists, etc.) and other staff (nurses and radiologic technologists) working in IR and IC do not always wear their dosimeters when working around fluoroscopic units. As seen in Table 5, of these groups it appears that radiologists (95.7%) always wear their personal dose monitoring device far more than their IC peers (27.5%). The lack of adherence to proper wear of radiation monitoring devices can cause gaps and a lack of data for annual effective dose rate capture. 17 Table 4 Percent Use of Personal Radiation Monitoring Devices During Interventional Fluoroscopy Author Staff Always Inconsistent Never Abdelrahman, et al., 2018 Radiologist 93.5% - - Abuzaid, Elshami & Hasan, Physician 95.7% - 4.3% 2019 Nurse 84.0% - 16.0% 32.3% 37.3% 30.5% Interventional Alharbi, et al., 2025 Cardiologist Interventional Ghallab, et al., 2024 Cardiologist 0.0% 100.0% 0.0% Lim, et al., 2016 Radiologic Technologist ~80%* - - Shivute & Shilumba, 2025 Non-Radiology HCW - - 70.7% Tefera, Qureshi & Mazhani, Interventional 2020 Cardiologist 37.7% 39.4% 23.0% Interventional Uthirapathy, et al., 2022 Cardiologist 40.0% 37.0% 23.0% Lee, et al., 2022 IR and IC Physician 44.50% 55.50% - Radiologic Technologist 57.80% 42.20% - Nurse 52.00% 48% - Note. This table illustrates the percent use of personal radiation monitoring devices worn by various staff members during interventional fluoroscopic procedures by author. The symbol ‘-‘ indicates that that author did not provide the specific data. IR refers to Interventional Radiology, IC refers to Interventional Cardiology, and HCW refers to healthcare workers. *Lim, et al, 2025 reported protective measurement devices used at 75-100% of the time 18 Table 5 Percent Use of Personal Radiation Monitoring Devices by Staff Mean Staff Always Inconsistent Never Physician 95.7% - 4.3% Radiologist 93.5% - - Interventional Cardiologist 27.5% 53.4% 19.1% IR and IC Physician 30.9% 53.8% 15.3% Nurse 68.0% 24.0% 8.0% Radiologic Technologist ~80%* - - 57.8% 42.2% - - - 70.7% Non-Radiology HCW Note. This table is a condensed table derived from Table 4, illustrating the percent use of personal radiation monitoring devices by staff. The symbol ‘-‘ indicates that the specific data was not provided, nor able to be condensed from previous tables. IR refers to Interventional Radiology, IC refers to Interventional Cardiology, and HCW refers to healthcare worker. *Lim, et al, 2025 reported protective measurement devices used at 75-100% of the time The study by Shivute & Shilumba (2025) was included in the study to show a lack of radiation safety understanding in non-radiation utilizing healthcare workers. Their study showed that 70.7% of all non-radiation utilizing healthcare workers do not wear their personal dose measurement devices if one is provided. Lee, et al. (2022) compared annual radiation doses before and after complying with proper adherence to personal dose measuring device recommendations. In their study, it was found that those that wore 19 devices less than 25% of the time before proper adherence had a 700% increase in annual radiation dose measurement when worn properly. Of all participants in their study an 89.4% increase in annual occupational radiation dose was observed when all personal dose measurement devices were worn properly. This data specifically shows that a lack of adherence to recommendations will not provide accurate information to governing bodies that create and maintain occupational dose limits. Radiation Safety Practices Patterns in radiation safety practices appear to have changed between 1970 and 2009 in a U.S cohort of radiologic technologists (Lim, et al., 2016). Between those years the use of lead aprons increased from about 80% to 90%, thyroid shields 2% to 43%, tube or table shield about 15% to 25%, and ceiling mounted shields from about 2% to 10% (Lim, et al., 2016). The data of concern in this article is that the percentage increase of use in lead goggles or glasses and mobile shields did not increase significantly, posing a significant risk to operators and staff regarding cataractogenesis risk. Table 6 shows the representation of always using radiation protection devices from several authors from 2013 to 2025. The studies were presented as a Likert Scale questionnaire or survey for participants that were selected, though the Likert Scales were different between many of the studies. Collection of data in this literature review aimed to create a uniform data spread that can be evaluated as: wearing radiation safety devices as always, inconsistently, or never. Any data in existing literature that was presented as ‘sometimes,’ ‘often,’ ‘rarely,’ etc. were grouped as inconsistent. Data represented in existing literature as ‘always’ or ‘never’ are reported as such in this literature review. The article by Abuzaid, Elshami, & Hasan (2019) was included to show the use of radiation 20 protection devices in operators that do not primarily work in a fluoroscopic laboratory and consist of urologists, orthopedic physicians, and other operating room staff. The use of lead aprons is promising in IR and IC staff when looking at the overall mean use of all staff members with greater than 90% compliance observed in the literature. The use of thyroid shield and attenuating eyewear shows a large lack of compliance between authors and can be attributed to a lack of radiation safety education of staff members on thyroid cancers and cataract occurrence of IR and IC staff. 21 Table 6 Reporting Radiation Safety Devices that are Always Used Radiation Protection Device Use (Always) Lead Thyroid Attenuating Other Author Apron Shield Eyewear Devices Lim, et al., 2016 90.0% 43.0% 5.0% 14.0% Lynskey, et al., 2013 99.0% 94.0% 54.0% 15.3% 87.9% 70.0% - - Ghallab, et al., 2024 100.0% 0.0% - - Uthirapathy, et al., 2022 100.0% 87.0% 35.0% 33.0% Tefera, et al., 2020 95.1% 77.0% 16.4% 4.9% O'Rourke, et al., 2024 99.0% 92.0% - Alharbi, et al., 2025 98.3% 72.9% 15.3% - - - 3.2% - 93.6% 82.7% 21.7% 14.0% Abuzaid, Elshami, & Hasan, 2019* Abelrahman, et al., 2018 Lee, et al., 2022 Other Devices include hanging lead shields, patient mounted shields, attenuating gloves, mobile floor shields, etc. Note. Table 6 describes previous literature reporting of radiation safety devices that are always used by Interventional Radiology and Interventional Cardiology staff members. The symbol ‘-‘ indicates that the author did not provide the specific data. *Reports from non-radiation HCWs 22 Table 7 represents the occurrence of radiation safety device by staff and the mean overall ‘always’ use for all staff members. Total compliance of adherence for ‘always’ wearing lead aprons, thyroid shield, and attenuating eyewear is 95.1%, 70.1%, and 22.5%, respectively. It appears all staff members see the use of lead aprons as mandatory and common place with about 4.9% either not wearing them or wearing them inconsistently. Thyroid shields show less compliance but maintain 70.1% adherence to guidelines, promising if the data rise that was presented in Lim, et al., 2016 continues into future studies. The literature representing the use of attenuating eyewear has large variations of use, especially among the studies compared in interventional cardiologists, ranging from 15.3% to 35% of always using them. The limitations of this literature review on the use of radiation safety devices are apparent in the non-uniform Likert scale questionaries and studies that are performed on the topic and lack of abundance of research. There is a lack of specific data on non-radiology HCWs, interventional radiologists, radiologic technologists, and nurses, making comparisons difficult between and within staff members. 23 Table 7 Radiation Safety Device Use by Staff Lead Apron Use Thyroid Shield Use Attenuating Eyewear Staff Always Inconsistent Never Always Inconsistent Never Always Inconsistent Never Non-Radiology HCW 95.7% - - 82.6% - - - - - Radiologic Technologist 90.0% - - 43.0% - - 5.0% - - Radiologist 99.0% - - 94.0% - - 54.0% - - Interventional 100.0 Cardiologist % 0.0% 0.0% 0.0% 44.4% 55.5% - - - % 0.0% 0.0% 87.0% - - 35.0% - - 95.1% 3.3% 1.6% 77.0% 18.0% 4.9% 16.4% 24.6% 59.0% 98.3% 1.7% 0.0% 72.9% 23.7% 3.4% 15.3% 23.7% 61.0% 80.0% - - 70.0% - - - - - 99.0% - - 92.0% - - 10.0% - - 93.6% 6.4% - 82.7% 17.3% - 21.7% 14.0% - - - Interventional 100.0 Nurses Generalized IR and IC Staff 70.1 Mean 95.1% - - % 22.5 - - % Note. This table describes various roles percent use of radiation safety devices by staff from previous literature. The symbol ‘-‘ indicates that the specific data was not provided. IR refers to Interventional Radiology, IC refers to Interventional Cardiology, and HCW refers to healthcare worker. 24 Summary Literature on the topic shows that operators and other staff working in IR and IC labs have reportedly low annual effective doses. Though annual effective dose remains low there is data suggesting that dose reduction strategies, tighter adherence to radiation safety monitoring, and regular use of radiation safety devices will reduce fluoroscopy operator’s annual effective dose. 25 Chapter 3: Research Method Statement of the Problem Medical radiation workers in IR and IC have higher occupational exposure to radiation compared to medical radiation workers that do not utilize fluoroscopic units (Akram & Chowdhury, 2022). The increased market for interventional radiologists, and radiologists in general, has led to novel vascular and non-vascular treatments released every year to better treat patients with minimally invasive procedures (Weiss & HafeziNejad, 2023). There is concern in the IRCP Publications that radiation monitoring may be skewed due to radiation workers not wearing personal dose monitoring devices regularly (ICRP, 2018). There is little information that is presented in how often medical radiation workers wear personal radiation dose monitoring devices, posing the question of whether dose limits and reporting are accurate. Performing a quantitative study will help delineate whether dose reporting is accurate and estimate the confidence of IR and IC staff in their dose limits and reports. It is important for regulatory commissions to have data related to correct use of personal radiation dose monitoring devices to accurately determine occupational dose limits for medical radiation workers. Purpose of the Study The purpose of this quantitative study is to determine the awareness of occupational radiation exposure among staff of IR and IC labs. A Likert-Scale questionnaire will be offered with informed consent to participants of IR and IC labs to assess their awareness with occupational dose limit regulations, how often staff wearing personal radiation dose monitoring devices, what the utilization of radiation safety devices are, and the awareness of radiation workers dose reports. In addition, a question 26 was asked about what department they work in and their job title, and a survey question that asks about what radiation safety devices are used in their lab. Research Questions Q1. What is the awareness of interventional radiology and interventional cardiology staff of dose limits and regulations? Q2. How often are staff of interventional labs wearing personal radiation dose monitoring devices? Q3. What is the utilization of various radiation safety devices in IR and IC laboratories? Q4. What is the awareness of IR and IC staff regarding their dose reports? Hypotheses H10. Staff are aware of all dose limits and regulations. H1a. Staff are not aware of all dose limits and regulations. H20. Staff are wearing personal radiation dose monitoring devices during all fluoroscopic procedures. H2a. Staff are not routinely or never wearing personal radiation dose monitoring devices during all fluoroscopic procedures. H30. Staff are always utilizing radiation protection equipment during all fluoroscopic procedures. H3a. Staff are not routinely or never utilizing radiation protection equipment during all fluoroscopic procedures. H40. Staff are not aware of their own occupational dose reports. H4a. Staff are aware of their own occupational dose reports. 27 Research Methods and Design(s) The research design for this quantitative study will assess the awareness of dose limits and regulations, adherence to radiation monitoring devices, and utilization of personal radiation safety equipment. Quantitative study is appropriate because it correlates to prior studies on this topic. The literature review in this study shows a quantitative representation of occupational dose, utilization of personal dose monitoring devices, and utilization of radiation safety devices. This study aims to present the current status of what was previously observed piecewise in the literature review in a quantitative design. This research method is effective in identifying trends, generalizing based on numerical data, and allows for reproducibility to further investigation into the topic of radiation safety perceptions and practices. Descriptive design will be utilized in this study. The descriptive design allows for analysis of utilization of devices, whether or not devices are offered and perception of dose limit regulations. Correlation may be used to identify the relationships between dependent variables (device utilization and dose limit perception) and independent variables (job role and demographic features). Identification of patterns through correlational analysis could allow for an understanding of how perceptions of dose limit regulations and utilization of radiation dose monitoring devices and safety devices are between independent variables. A qualitative design was not chosen because this study aims to get a current status of the perception of occupational dose limits and utilization of radiation protection equipment and dose monitoring equipment. Qualitative research design could be sought after this initial research is performed to understand the why behind the data. 28 The sampling method chosen for this study is that of convenience through word of mouth and social media posts. The population for this study is small and distribution among the individuals that work in IR and IC labs is sufficient in data collection. Other sampling methods are not dependable on this specific population because of its size and specificity regarding inclusion criteria. Population The sample will be collected by means of a Qualtrics survey that will be sent out to various professionals working in IR and IC laboratories. The sample of individuals within IR and IC laboratories hopes to encompass interventional radiologists, interventional cardiologists, electrophysiologists, vascular interventional radiologic technologists, cardiac interventional radiologic technologists, cardiovascular invasive specialists (RCIS), registered nurses (RN), and others that may be pertinent but are not listed. Knowing that the population of these individuals is small it was determined that a maximum of 50 respondents is adequate for data collection and analysis. Participants of the study will be asked to voluntarily complete the Qualtrics survey. Qualifications to be included in the study will be limited to working professionals in IR and IC laboratories, between the ages of 18 and 70, and those that hold adequate credentials. The study will contain a random convenience sample compiled from social media resources and word of mouth. Social media posts were organized in Facebook and Instagram with a direct link to the survey. Word of mouth distribution of the survey includes either sharing the direct link or a QR code that links to the online survey. Encouragement of those that have taken the survey to distribute it to others is encouraged but not required. 29 Materials/Instruments The Qualtrics survey tool accessed through Weber State University was utilized to create a survey for this study. Choosing this instrument is dependable and trusted in that it is password protected to collect and store data from survey responses. The survey, see Appendix A, includes a qualifying question to answer the informed consent disclosure. Demographic questions were introduced at the start of the survey to ask job title and role that fit them best, what department they primarily work in, their perception of how important radiation safety is to them, and what radiation safety devices are offered at their facility. These questions are important to set up the survey to identify qualifications necessary. The next grouping of questions was made to assess their knowledge passed from their education on dose limit regulations regarding whole body effective dose and equivalent dose to the lens of the eye. Asking perceptions on the annual dose limits will assess the knowledge of those working in fluoroscopic procedures of dose limit regulations. Its goal is to assess what knowledge is held by each credential or department. The third grouping of questions asked how often dose records are reviewed and how often individuals are wearing personal dose monitoring devices. These questions were grouped in this way because it assesses how active the individual is at reviewing their dose in correlation to how often they are wearing the dose monitoring device. Additionally, data is collected on the observation of their peer’s utilization of dose monitoring devices to assess if individual perception varies from observed practice. The fourth group of questions asks the personal utilization of radiation safety devices. An assessment of how often the individual is wearing any combination of radiation safety devices will aid in determining how conscious they are of mitigating their occupational 30 radiation dose. This data will identify what each credential and department utilize during fluoroscopic procedures. The last group of questions are presented as questions to enrich the study. Because of radiation-related risks to fetal development during childbearing years, a question is asked if the participant has the biological capacity to conceive and carry a pregnancy to term. This observation will show if those that have the biological capability to carry a pregnancy are more likely to adhere to personal dose monitoring and utilization of radiation safety devices. To assess the reach of this study, it is asked if an individual resides inside or outside of the United States. Those that live outside the United States are encouraged to print the full name of the country they reside in and those that live inside the United States are encouraged to print the full name of the state they reside. Though it is assumed that the participants are between the age of 18 and 70 there is a survey question to observe how perceptions and practices vary between age groups. All data that is collected from the survey is analyzed to support or reject the hypotheses of the researcher. Data is analyzed with the IBM SPSS software. Operational Definition of Variables Perceptions of Dose Limit Regulations / Dependent Variable 1 Measurements were taken in IR and IC laboratories in relation to the individual’s perception of occupational dose limit regulations based on their education and knowledge. The questions were presented as multiple-choice questions to evaluate the accuracy of IR and IC staff in regard to dose limit regulations. Statistical descriptive analysis will determine the overall perception of dose limit regulations. Correlations may be made with demographic information to study whether distinct roles, departments, ages, and location of residence show any statistical differences in responses. 31 Perception of the Importance of Radiation Safety / Dependent Variable 2 Measurement of the perception of radiation safety to the individual taking the survey was asked one question. The question was designed in a Likert Scale asking the individual to rate the importance of radiation safety from ‘not important’ (0) to ‘very important’ (10). The scale ranged from 1 to 10 with 10 possible options available on the scale. The data will be descriptively analyzed for overall importance of radiation safety perceptions among IR and IC staff. Correlations may be made with demographic information to study whether distinct roles, departments, ages, and location of residence show any statistical differences in responses. Occupational Dose Record Review / Dependent Variable 3 A question asks how often an individual reviews their occupational dose record. The question was presented as a multiple-choice question with answers from never, weekly, monthly, quarterly, semiannually, and annually. This question will allow the researcher to descriptively analyze how often individuals working in IR and IC laboratories review their occupational dose records. Correlations may be made with demographic information to study whether distinct roles, departments, ages, and location of residence show any statistical differences in responses. Utilization of Personal Dose Monitoring Devices / Dependent Variable 4 Measurements were taken to assess the utilization of personal dose monitoring devices within the survey. The question was offered as a Likert Scale question with 0 as ‘never’, 1-2 as ‘sometimes’, 3-4 as ‘most of the time’, and 5 as ‘always’. An option was offered as ‘not applicable’ as IR and IC laboratories have various staff members that may not work together and thus cannot be observed by the individual. The Likert Scale was 32 divided in responses to ‘yourself’, and observations of ‘interventional radiologist’, ‘interventional cardiologist’, ‘radiology nurse’, ‘cardiology nurse’, ‘radiologic technologist, vascular interventional (VI)’, ‘radiologic technologist, cardiac interventional (CI)’, ‘radiologic technologist’, and ‘registered cardiovascular technologist (RCIS)’. The measurements of this question regarding the observation of the individual will aid in grasping the full picture of what is observed by others in addition to one’s individual perception of themselves. Statistics of this data will include descriptive analysis to show what the utilization of personal dose monitoring devices of the individual and other staff they work with. Correlations may be made with demographic information to study whether distinct roles, departments, ages, and location of residence show any statistical differences in responses. Presence of Radiation Safety Devices / Dependent Variable 5 Observation of what radiation safety devices are offered by facilities is important to the research in that it can show the effort of institutions in mitigation of occupational dose. Measurement of what devices are offered was collected by a multiple-choice question that allowed for ‘select all that apply.’ Devices were listed as ‘frontal lead apron’, ‘wrap around lead apron (one piece)’, ‘wrap around lead apron (two piece)’, ‘thyroid shield’, ‘attenuating eyewear’, ‘machine mounted lead shield’, ‘mobile floor shield’, ‘attenuating gloves’, ‘other’, and ‘none of the above’. ‘Prefer not to answer’ was added as a response to the question to offer protection of those that may not choose to answer for any reason that would make them uncomfortable. Descriptive statistical analysis will show what devices are offered across the globe in IR and IC laboratories. 33 Correlations may be made with demographic information to study whether distinct roles, departments, ages, and location of residence show any statistical differences in responses. Utilization of Radiation Safety Devices / Dependent Variable 6 Measurements were taken to assess the utilization of radiation safety devices within the survey. The question was offered as a Likert Scale question with 0 as ‘never’, 1-2 as ‘sometimes’, 3-4 as ‘most of the time’, and 5 as ‘always’. An option was offered as ‘not applicable’ as IR and IC laboratories may have various devices that are not offered. This is assessed in Dependent Variable 5. The Likert Scale question was divided in responses to ‘frontal lead apron’, ‘wrap around lead apron (one piece)’, ‘wrap around lead apron (two piece)’, ‘thyroid shield’, ‘attenuating eyewear’, ‘machine mounted lead shield’, ‘mobile floor shield’, and ‘attenuating gloves’. Observing the utilization of radiation safety devices will assess how well the individual utilizes what is offered to mitigate their occupational dose. A descriptive statistical analysis will describe how often devices are utilized in IR and IC laboratories. Correlations may be made with demographic information to study whether distinct roles, departments, ages, and location of residence show any statistical differences in responses. Job Role or Title / Independent Variable 1 A multiple-choice question was offered to ask what job title or role best fit the individual taking the survey. Responses included ‘interventional radiologist,’ ‘interventional cardiologist,’ ‘radiology nurse,’ ‘cardiology nurse,’ ‘radiologic technologist, vascular interventional (VI),’ ‘radiologic technologist, cardiac interventional (CI),’ ‘radiologic technologist,’ ‘registered cardiovascular technologist (RCIS),’ and ‘other.’ ‘Prefer not to answer’ was included to protect those that may be 34 uncomfortable with providing this information. Statistical descriptive analysis will provide information on what the response rate of job roles among respondents. This information may be used in correlational analysis of dependent variables. Primary Working Department / Independent Variable 2 A multiple-choice question was offered to ask what primary working department best described the individual taking the survey. Responses included were ‘interventional radiology,’ ‘interventional cardiology,’ and ‘other.’ ‘Prefer not to answer’ was included to protect those that may be uncomfortable with providing this information. Statistical descriptive analysis will provide information on what the response rate of which department individuals are responding from. This information may be used in correlational analysis of dependent variables. Biological Capacity to Conceive and Carry a Pregnancy / Independent Variable 3 Because of radiation-related risks to fetal development during the childbearing years, a multiple-choice question was asked whether the individual is biologically capable of conceiving and carrying a pregnancy to term. Reponses to the question were offered as ‘yes, ‘no,’ and ‘prefer not to answer.’ This demographic question was included in observing descriptive analysis of what individuals can carry a child. This question may be utilized for correlational analysis to see if those that are biologically able have higher mitigation of occupational dose and more observance of radiation safety. Residence / Independent Variable 4 To gather the full reach of the research study and enrich the data. Two multiple choice questions were asked regarding the residence of the individual. Between the two 35 questions, individuals were asked whether they lived in or outside of the United States, and to print the full name of the state that they live in. ‘Prefer not to answer’ was listed as an option to protect those that are uncomfortable in providing this information. This question will be analyzed descriptively to observe where individuals reside and work in IR and IC laboratories. These questions may be utilized for correlational analysis to see radiation safety awareness, perceptions, and practices vary in various locations across the United States. Age / Independent Variable 5 Measurements were taken regarding the individuals age group. A multiple-choice question was offered with answers of age ranges as follows ’18-24’, 25-24’, ’25-44’, ’4554’, ’55-64’, and ’65-70’. ‘Prefer not to answer’ was listed as an option to protect those that are uncomfortable in providing this information. This question will provide descriptive statistical analyses of age groups that work in IR and IC laboratories. The question may be utilized for correlational analysis to see what radiation safety awareness, perceptions, and practices vary between age groups. Data Collection, Processing, and Analysis Data collection was offered in the Qualtrics Survey Tool. Initial responses were observed in the Qualtrics Survey tool and responses that either did not answer the informed consent or answered ‘No’ were deleted and removed from the dataset. Any data that did not meet inclusion criteria was also deleted and removed from the dataset. After the initial isolation of the dataset to include only responses that included ‘Yes’ to informed consent and met inclusion criteria, the data was exported to Microsoft Excel to 36 aid in cleaning data. IBM SPSS Statistics was utilized for analysis of data in descriptive statistics and correlational statistics as appropriate. Coding Question 1 asked for informed consent to the study. Since this data was cleaned prior to analysis the only coding available was 1 to represent ‘Yes’. Question 2 asked what the individual’s job title or role best described them. Coding for SPSS and Excel is as follows; 1 (Interventional Radiologist), 2 (Interventional Cardiologist), 3 (Radiology Nurse), 4 (Cardiology Nurse), 5 (Radiologic Technologist Vascular Interventional (VI)), 6 (Radiologic Technologist Cardiac Interventional (CI)), 7 (Radiologic Technologist), 8 (Registered Cardiovascular Invasive Specialist (RCIS)), 9 (Other), and 10 (Prefer not to Answer). Question 3 asked what primary department the individual worked in. Coding for SPSS and Excel is as follows 1 (Interventional Radiology), 2 (Interventional Cardiology), 3 (Other), 4 (Prefer not to Answer). Question 4 asked how important radiation safety was to them on a scale from 0 (not important) to 10 (very important). The dataset was coded in the same manner for statistical analysis in Excel and SPSS. Any responses that were not answered were given a value of 0, assuming that not answering the question related to not finding radiation safety important to them. Question 5 asked what radiation safety devices were offered in the facility that they worked in. The Qualtrics survey displayed this question as a ‘select all that apply.’ Extrapolating the data to SPSS made each selection its own category. Coding for each category is 0 (Device is not Offered) and 1 (Device is Offered). 37 Question 6 asks what the limit is for whole body effective dose. This question was coded in two ways for different descriptive analysis. The first method of coding was to assign a numerical identification to each answer; 1 (25mSv/y), 2 (50mSv/y), 3 (75mSv/y), 4 (100mSv/y), and 5 (I am unsure). Any response that was missing or not answered was given a 5 (I am unsure), assuming that if they did not answer the question that they did not know the answer. The second coding method was to assign a 0 (Incorrect) and 1 (Correct), the correct answer being 50mSv/y. Question 7 asks what the limit is for whole body effective dose. This question was coded in two ways for different descriptive analysis. The first method of coding was to assign a numerical identification to each answer; 1 (50mSv/y), 2 (100mSv/y), 3 (125mSv/y), 4 (150mSv/y), and 5 (I am unsure). Any response that was missing or not answered was given a 5 (I am unsure), assuming that if they did not answer the question that they did not know the answer. The second coding method was to assign a 0 (Incorrect) and 1 (Correct), the correct answer being 50mSv/y. Question 8 asks the individual about the frequency of observing their occupational dose reports. Coding for data in SPSS and Excel is as follows; 1 (Never), 2 (Weekly), 3 (Monthly), 4 (Quarterly), 5 (Semiannually), and 6 (Annually). Question 9 is posed in a way to assess the perceptions of oneself and their peers in how often they are wearing personal dose monitoring devices during fluoroscopically guided procedures. The Likert-scale question was ranked from 0 to 5. Coding is as follows; 0 (Never), 1 (Sometimes), 2 (Sometimes), 3 (Most of the time), 4 (Most of the time) and 5 (Always). another categorical grouping of 0 (Never), 1 (Sometimes), 2 (Most of the Time), and 3 (Always). 38 Question 10 assesses the personal use of radiation safety equipment during fluoroscopically guided procedures. The Likert-scale question was ranked from 0 to 5. Coding is as follows; 0 (Never), 1 (Sometimes), 2 (Sometimes), 3 (Most of the time), 4 (Most of the time) and 5 (Always). Question 12 assesses the capability of the individual to conceive and carry a pregnancy to term. Coding for the answers were 1 (Yes), 2 (No), and 3 (Prefer not to answer). Question 13 aimed to capture the reach of the study and asked if participants resided inside the United States or outside of the United States. Coding for this question was 1 (Please write the full state name), 2 (Prefer not to answer), and 3 (I reside outside of the United States). This question had a free text box to write the full state name for answer 1. Descriptive statistics for the question were performed with the frequencies option in SPSS. Question 14 asked the age group of the individual. Coding for SPSS and Excel is as follows; 1 (18-24), 2 (25-34), 3 (35-44), 4 (45-54), 5 (55-64), 6 (65-70), and 7 (Prefer not to answer). Assumptions It is assumed that the individuals taking the survey will be honest and truthful in their answers, take the survey only once, hold credentials valid for the study, and are between the ages of 18 and 70. An assumption is made that the collected sample will be representative of the broader population. Utilization of the Qualtrics program for creation and distribution of the survey is assumed to be dependable. It is assumed that statistical analysis programs that are used accurately process and analyze the data. 39 Limitations This study focuses on understanding of dose limits and utilization of personal dose monitoring devices and radiation safety devices; limitations to this study can include a lack of honest responses and can skew data analysis. The population of those that primarily work in IR and IC laboratories are few. Since the survey will be distributed in a convenience sampling method, there is a limitation regarding the reach of the study and generalizability. Delimitations A delimitating factor of this study was to purposefully exclude fluoroscopy operators in surgical specialties and general radiology departments. This exclusion is hoped to capture only IR and IC staff. The survey includes demographic questions regarding age group, current residence (state or country), and job role or title to aid in maintaining inclusion and exclusion criteria. Ethical Assurances Ethical considerations are taken deliberately for this study. An IRB, at Weber State University, approval will be sought prior to any data collection from participants. After IRB approval is obtained, individuals will read and acknowledge informed consent prior to starting the survey. Informed consent that will be disclosed to participants will include information on the purpose and voluntary nature of the study, who is conducting the study, who to contact with questions, the population and procedures, any risk or benefits, and confidentiality statements. Confidentiality of participants will be held in confidence in reports in which the study may be published. No personal identifiers will be included within the survey, and all data is kept in a password-protected system, 40 available solely to investigators for educational purposes. All data will be destroyed within 2 years. See Appendix B for a copy of the Informed Consent. Summary A quantitative design with a convenience sampling method was introduced in this chapter. Following other research literature on the topic, the quantitative design will complement the data that exists in one study, rather than many separate studies. Variables listed directly reflect the quantitative design and reasoning behind why the variable is observed. Convenience sampling is the chosen method for this research study because of the small population. The study was conducted with a Qualtrics survey distributed to IR and IC staff to target a sample of specific healthcare professionals. The survey results were collected from the survey and isolated from Microsoft Excel. The isolated data was transferred to IBM SPSS for statistical analysis. 41 Chapter 4: Findings The purpose of this quantitative study is to determine the awareness of occupational radiation exposure among staff of Interventional Radiology (IR) and Interventional Cardiology (IC) labs. A Likert-Scale questionnaire will be offered with informed consent to participants of IR and IC labs to assess their awareness with occupational dose limit regulations, how often staff wear personal radiation dose monitoring devices, what the utilization of radiation safety devices are, and the awareness of radiation workers dose reports. In addition, a question will ask what department they work in and their job title, their country/state of residence, age range, and a survey question that asks about what radiation safety devices are used in their lab. This chapter will explore the results of the survey with descriptive statistics outlined in Chapter 3. Data Elimination and Modification Data that was eliminated included 6 survey responses. One respondent did not meet inclusion criteria for listed credentials and primary working department (radiation therapist and radiation therapy). One respondent did not answer the informed consent question, and all subsequent data was eliminated. Three responses included individuals from outside of the United States and did not meet inclusion criteria (United Kingdom, Namibia, Trinidad and Tobago). Finally, one respondent did not answer any question other than the informed consent, this survey response was deleted because it did not provide any useful data. One modification of data was to protect the individual’s identity. In a free text box within the survey that asked what state the participant resided in, the participant 42 provided their full name. This information was deleted, and the response was changed to ‘prefer not to answer.’ Results Question 2 – Job Role or Title Table 8 shows the number of respondents to the Qualtrics Survey by Job Title. Of the respondents the highest response rates were collected from Radiology Nurses (N=11), Cardiology Nurses (N=13), and Radiologic Technologists (VI) (N=11). There were no responses from Interventional Cardiologists (N=0). Responses in the ‘Other’ category met inclusion criteria by holding one or more of the credentials but did not specify which one best suited their job role or title (N=5). 43 Table 8 Respondents by Job Title or Role Job Title or Role N % Interventional Radiologist 2 3.4% Radiology Nurse 11 18.6% Cardiology Nurse 13 22.0% Radiologic Technologist, Vascular Interventional (VI) 11 18.6% Radiologic Technologist, Cardiac Interventional (CI) 4 6.8% Radiologic Technologist 4 6.8% Registered Cardiovascular Invasive Specialist (RCIS) 9 15.3% Other, please specify 5 8.5% Note. Table 8 describes the results of Question 2 from the Qualtrics Survey in number of respondents and percent of respondents by job title or role. Question 3 – Primary Working Department Table 9, below, shows the number of respondents according to their chosen primary working department. Interventional cardiology (N=32) outnumbered responses from Interventional Radiology (N=22) by 10 responses. Responses listed as ‘Other’ still met inclusion criteria by free text of working in combination laboratories (N=3). There were missing responses from 2 participants and are not included in data analysis. 44 Table 9 Respondents by Primary Working Department Department N % Interventional Radiology 22 37.3% Interventional Cardiology 32 54.2% Other, please specify 3 5.1% Note. This table describes the results of Question 3 of the Qualtrics Survey in number of respondents and percent of respondents by primary working department. Question 4 – Importance of Radiation Safety The importance of radiation safety was assessed in question 4 of the Qualtrics survey. The mean importance of radiation safety to all participants (M = 7.80, SE = .475) was compared to individual job roles and titles, as well as primary working departments. See Table 10 for descriptive statistics of the importance of radiation safety by job title or role. Assessment of the importance of radiation safety by department showed Interventional Radiology (M = 8.55, SE = .616) and Interventional Cardiology (M = 7.06, SE = .746) ranked highly (see Table 11). Assumptions were made in the statistical analysis of this section in that if the participants did not answer the question, they do not report any importance of radiation safety. 45 Table 10 Importance of Radiation Safety by Job Role or Title Job Role or Title Mean Std. Error of Mean Interventional Radiologist 10.00 .000 Radiology Nurse 8.55 .888 Cardiology Nurse 7.00 1.14 Radiologic Technologist, Vascular Interventional (VI) 8.36 .887 Radiologic Technologist, Cardiac Interventional (CI) 7.50 2.50 Radiologic Technologist 5.00 2.89 Registered Cardiovascular Invasive Specialist (RCIS) 8.44 1.08 Other, please specify 7.40 1.89 Total 7.80 .475 Note. Table 10 describes the results of Question 4 from the Qualtrics Survey by importance of radiation safety by job title or role. The mean values listed are derived from a 0 (not important) to 10 (very important) scale. 46 Table 11 Importance of Radiation Safety by Primary Working Department Primary Department Mean Std. Error of Mean Interventional Radiology 8.55 .616 Interventional Cardiology 7.06 .746 Other, please specify 9.33 .667 Total 7.75 .490 Note. Table 11 describes the results of Question 4 from the Qualtrics Survey based on importance of radiation safety by primary working department. The mean values listed are derived from a 0 (not important) to 10 (very important) scale. Question 5 and 10 – Radiation Safety Devices The survey asked in Question 5 what radiation safety devices are offered in the facility that the individual works in. The descriptive statistics shown in Table 12 show that facilities are offering devices for radiation protection in different frequencies. The percentage of facilities that offer devices from highest to lowest percentage are thyroid shields (93.2%), wrap around 2 piece apron (88.1%), machine mounted lead (64.4%), ceiling suspended lead shield (64.4%), attenuating eyewear (57.6%), frontal apron (50.8%), mobile floor shields (45.8%), wrap around 1 piece apron (40.7%), and attenuating gloves (5.1%). 47 Table 12 Devices Offered by Facility Device Type N % Frontal Apron 30 50.8% Wrap Around 1 Piece 24 40.7% Wrap Around 2 Piece 52 88.1% Thyroid Shield 55 93.2% Attenuating Eyewear 34 57.6% Machine Mounted Lead 38 64.4% Suspended Lead Shield 38 64.4% Mobile Floor Shield 27 45.8% Attenuating Gloves 3 5.1% Note. Table 12 describes the offerings of personal radiation safety devices offered by facilities, Question 5 from the Qualtrics Survey. The number of responses and percent of responses are listed. Survey Question 10 related to the utilization of radiation safety devices. Datapoints that were missing were filled in two ways. The first way included observation of what radiation safety devices were offered in each facility. Datapoints that were missing were filled in with a 0 if the device was not offered. All other missing datapoints were filled using the means collected from SPSS descriptive statistics. This was determined to provide percentage of use as ‘never,’ ‘sometimes,’ ‘most of the time,’ and 48 ‘always.’ Mean utilization of each radiation safety device are as follows; frontal apron (M = 1.87, SE = .327), wrap around 1 piece (M = 1.27, SE = .307), wrap around 2 piece (M = 4.02, SE = .240), thyroid shield (M = 4.87, SE = 0.74), attenuating eyewear (M = 1.98, SE = .295), machine mounted lead (M = 3.02, SE = .316), ceiling suspended lead shield (M = 2.21, SE = .304), mobile floor shield (M = 1.13, SE = .220), attenuating gloves (M = 0.05, SE = 0.040). Accounting for all participants of the study, Table 13 illustrates how often the participants are using radiation protection devices. Statistical analysis of how often individuals are wearing protective aprons is difficult because individuals may prefer or only have access to one type of apron or the other. The statistics provided are informational in relation to the type of apron. Appropriate statistical analysis of other radiation safety devices is feasible because there are no alternatives or substitutions for these items. Observing those that ‘always’ wear radiation safety devices; thyroid shield (72.9%), machine mounted lead (33.9%), suspended lead shield (20.3%), mobile floor shield (3.4%), and attenuating gloves (0.0%). A notable descriptive statistic is that attenuating eyewear is ranked as ‘never’ worn during fluoroscopically guided procedures at 35.6%. 49 Table 13 Percent Personal Utilization of Radiation Safety Devices Device Type Never Sometimes Most of the Time Always Frontal Apron 39.0% 33.9% 5.1% 22.0% Wrap Around 1 Piece 52.5% 28.8% 3.4% 15.3% Wrap Around 2 Piece 5.1% 10.2% 33.9% 50.8% - - 27.1% 72.9% Attenuating Eyewear 35.6% 32.2% 15.3% 16.9% Machine Mounted Lead 23.7% 6.8% 35.6% 33.9% Suspended Lead Shield 32.2% 32.2% 15.3% 20.3% Mobile Floor Shield 47.5% 32.2% 17.0% 3.4% Attenuating Gloves 89.8% 10.2% - - Thyroid Shield Note. Table 13 reports the results from Question 10 of the Qualtrics Survey. Percentages are derived from mean values from the survey 0 (Never), 1 and 2 (Sometimes), 3 and 4 (Most of the Time), 5 (Always). Cells that contain (-) did not have any data. Question 6 and 7 – Understanding of Dose Limit Regulations Two questions were asked regarding dose limit regulations provided by the ICRP. They were presented as multiple-choice questions to evaluate how often answers were correct. Data was collected and then cleaned to either 0 (not correct) or 1 (correct). Some datapoints were filled in place of missing answers. Missing answers were assumed to be ‘I am unsure,’ granting an incorrect answer of 0 (Not Correct). Of all participants the 50 percentage of correct answers for Whole Body Effective Dose Limit was 40.7%, and for Lens of the Eye Equivalent Dose Limit was 25.6%. (See Table 14) Table 14 Understanding of Dose Limit Regulations N % Correct 24 40.7% Incorrect 35 59.3% Correct 15 25.4% Incorrect 44 74.6% Whole Body Effective Dose Limit Lens of the Eye Equivalent Dose Limit Note. Table 14 reports the results from Question 6 and 7 of the Qualtrics Survey. Results were marked as correct or incorrect based on the multiple-choice nature of the questions. The number and percent of responses as correct and incorrect are listed. Due to the broad range of participant values in each job role or title, Table 15 compares the mean values of correct answers by job role or title of Whole-Body Effective Dose Limit Regulations. Inclusive of all job roles and titles the mean correct score was 0.41 with a standard error of .065. Interventional Radiologists scored the highest (M = 1.0, SE = 0.0), the second highest group of scores were between Radiologic Technologists (M = 0.75, SE = .250) and Radiologic Technologists, Cardiac 51 Interventional (CI) (M = 0.75, SE = .250), followed by Radiologic Technologist, Vascular Interventional (M = 0.64, SE = .152) and Registered Cardiovascular Invasive Specialists (M = 0.33, SE = .167). The nursing groups scored the lowest, Cardiology Nurse (M = 0.31, SE = .133) and Radiology Nurse (M = 0.0, SE = 0.0). Table 15 Whole Body Effective Dose Mean Value of Correct Answers by Job Role or Title Job Role or Title Mean Std. Error of Mean Interventional Radiologist 1.00 .000 Radiology Nurse .00 .000 Cardiology Nurse .31 .133 Radiologic Technologist, Vascular Interventional (VI) .64 .152 Radiologic Technologist, Cardiac Interventional (CI) .75 .250 Radiologic Technologist .75 .250 Registered Cardiovascular Invasive Specialist (RCIS) .33 .167 Other, please specify .40 .245 Total .41 .065 Note. Table 15 illustrates the mean value of correct answers to the whole-body effective dose limit, Question 6 in the Qualtrics Survey, by job role. Mean values are derived from a 0 (Incorrect) and 1 (Correct) scale. 52 Comparing the means of Equivalent Dose for the Lens of the Eye is outlined in Table 16. Inclusive of all job roles and titles the mean correct score was 0.25 with a standard error of .057. Interventional Radiologists (M = 1.0, SE = 0.0) scored the highest, followed by Radiologic Technologists, Cardiac Interventional (CI) (M = .50, SE = .289), Radiologic Technologists, Vascular Interventional (M = .36, SE = .152) and Registered Cardiovascular Invasive Specialists (RCIS) (M = .33, SE = .167). The lowest scoring groups were Cardiology Nurses (M = .15, SE = .104), Radiology Nurses (M = 0.0, SE = 0.0), and Radiologic Technologists (M = 0.0, SE = 0.0). 53 Table 16 Lens of the Eye Equivalent Dose Mean Value of Correct Answers by Job Role or Title Std. Error of Job Role or Title Mean Mean Interventional Radiologist 1.00 .000 Radiology Nurse .00 .000 Cardiology Nurse .15 .104 Radiologic Technologist, Vascular Interventional (VI) .36 .152 Radiologic Technologist, Cardiac Interventional (CI) .50 .289 Radiologic Technologist .00 .000 Registered Cardiovascular Invasive Specialist (RCIS) .33 .167 Other, please specify .40 .245 Total .25 .057 Note. Table 16 illustrates the mean value of correct answers to the lens of the eye equivalent dose limit, Question 7 in the Qualtrics Survey, by job role. Mean values are derived from a 0 (Incorrect) and 1 (Correct) scale. Observing the results of answers by primary working department is outlined in Tables 17 and 18. Interventional Radiology Departments (M = .36, SE = .105) scored lower than that of Interventional Cardiology Departments (M = .41, SE = .088) regarding Whole Body Effective Dose Limit. In contrast, Interventional Cardiology Departments 54 (M = .19, SE = .070) scored lower than Interventional Radiology Departments (M = .23, SE = .091) for Equivalent Dose Limits for the Lens of the Eye. Table 17 Whole Body Effective Dose Mean Value of Correct Answers by Primary Working Department Primary Department Mean Std. Error of Mean Interventional Radiology .36 .105 Interventional Cardiology .41 .088 Other, please specify .67 .333 Total .40 .066 Note. Table 17 illustrates the mean value of correct answers to the whole-body effective dose limit, Question 6 in the Qualtrics Survey, by primary working department. Mean values are derived from a 0 (Incorrect) and 1 (Correct) scale. 55 Table 18 Lens of the Eye Equivalent Dose Mean Value of Correct Answers by Primary Working Department Primary Department Mean Std. Error of Mean Interventional Radiology .23 .091 Interventional Cardiology .19 .070 Other, please specify 1.00 .000 Total .25 .058 Note. Table 18 illustrates the mean value of correct answers to the lens of the eye equivalent dose limit, Question 7 in the Qualtrics Survey, by primary working department. Mean values are derived from a 0 (Incorrect) and 1 (Correct) scale. Question 8 and 9 – Occupational Dose Monitoring Question 8 asks how often the participant observes their occupational dose record. Some datapoints were filled in as they were missing answers, any missing answer was filled in with a 1, indicating an assumption that they never observe their occupational dose record. 45.8% of all participants never observe their occupational dose report, 15.3% monthly, 23.7% quarterly, 5.1% semiannually, and 10.2% annually (See Table 19). 56 Table 19 Frequencies of Observing Occupational Dose Reports Frequency N % Never 27 45.8% Monthly 9 15.3% Quarterly 14 23.7% Semiannually 3 5.1% Annually 6 10.2% Note. Table 19 provides the frequencies that participants observed their personal occupational dose reports. Numerical and percent response data are provided. Question 9 asked the participants to rate how often they personally wear personal dose monitoring devices and to rate how often their peers are wearing them as well. There are many missing data points that were expected due to working departments hosting different job titles. The missing data points were filled with the mean observances of all participants. The mean utilization of dose monitoring devices are as follows: Self (M = 4.54), Interventional Radiologist (M = 4.28), Interventional Cardiologist (M = 4.13), Radiology Nurse (M = 3.88), Cardiology Nurse (M = 4.40), Radiologic Technologist, Vascular Interventional (VI) (M = 4.47), Radiologic Technologist, Cardiac Interventional (CI) (4.48), Radiologic Technologist (M = 4.65), Registered Cardiac Invasive Specialist (RCIS) (M = 4.50). Observing the rates of ‘always’ wearing dose monitoring devices, participants ranked themselves (57.6%) highest, followed by 57 Radiologic Technologists (47.5%), Interventional Radiologists (40.7%), Cardiology Nurse (33.9%), Radiologic Technologist, Vascular Interventional (VI) (33.9%), Radiology Nurse (32.2%), Interventional Cardiologists (30.5%), Radiologic Technologist, Cardiac Interventional (28.8%), and Registered Cardiovascular Invasive Specialists (27.1%) (See Table 20). 58 Table 20 Percent Utilization of Occupational Radiation Dose Monitoring Devices Observed Individual Yourself Never Sometimes Most of the Time Always - 3.4% 39.0% 57.6% Interventional Radiologist 1.7% 6.8% 50.9% 40.7% Interventional Cardiologist 1.7% 3.4% 64.5% 30.5% Radiology Nurse 1.7% 11.9% 54.3% 32.2% Cardiology Nurse - 5.1% 61.1% 33.9% - 3.4% 62.8% 33.9% Interventional (CI) - 1.7% 69.5% 28..8% Radiologic Technologist - - 52.5% 47.5% - - 72.9% 27.1% Radiologic Technologist, Vascular Interventional (VI) Radiologic Technologist, Cardiac Registered Cardiovascular Invasive Specialist (RCIS) Note. Table 20 describes the respondents’ observations of various staff members utilization of personal dose monitoring devices during interventional fluoroscopic procedures. Percentages were derived from mean values from the survey question 0 (Never), 1 to 2 (Sometimes), 3 to 4 (Most of the Time), and 5 (Always). The ‘-‘ indicates that no data was available. 59 Question 12, 13, and 15 – Demographics Demographics of the ability to conceive and carry a pregnancy were evaluated in the survey (Table 21). Of all participants of the survey, 35.6% were able to conceive and carry a pregnancy to term while 37.3% could not. 1.7% chose that they preferred not to answer the question and 25.4% did not answer the question. Table 21 Capability of Conceiving and Carrying a Pregnancy to Term Capability for Pregnancy N % Yes 21 35.6% No 22 37.3% Prefer not to answer 1 1.7% Did not Answer 15 25.4% Note. Table 21 describes the responses and percent response of respondents to their ability to conceive and carry a pregnancy to term. Based on the individual responses of capabilities to conceive and carry a pregnancy to term those that were able to conceive and carry rated the importance of radiation safety at a mean of 6.71 with a standard error of .966. Those that were not able to conceive and carry rated the importance of radiation safety at a mean of 9.45 with a standard error of .171 (See Table 22). 60 Table 22 Importance of Radiation Safety by Ability to Conceive and Carry a Pregnancy to Term Capability for Pregnancy Mean Std. Error of Mean N Yes 6.71 .966 21 No 9.45 .171 22 Prefer not to answer 10.00 Total 8.16 1 .509 44 Note. Table 22 reports mean values of importance of radiation safety by the respondent’s ability to conceive and carry a pregnancy to term. The mean values listed are derived from a 0 (not important) to 10 (very important) scale. Question 13 gathered demographic information of the reach of the study throughout the United States. Table 23 shows how many states the participants responded from. Utah had the most responses at 36.6% of all respondents that chose to answer the question. 61 Table 23 Response Rates per State in the United States N % California 1 2.4% Connecticut 2 4.9% Florida 1 2.4% Georgia 1 2.4% Idaho 1 2.4% Illinois 1 2.4% Indiana 3 7.3% Maryland 1 2.4% Massachusetts 1 2.4% Minnesota 1 2.4% New York 1 2.4% North Dakota 1 2.4% Oklahoma 1 2.4% Pennsylvania 1 2.4% South Carolina 1 2.4% Tennessee 1 2.4% Texas 3 7.3% Utah 15 36.6% Virginia 1 2.4% West Virginia 1 2.4% 62 Wisconsin 2 4.9% Note. Table 23 shows the response number and rates of respondents by state of residence in the United States. Additional demographics were collected on the age range that the participant fit in. There were missing data points that were filled in one way. The data that was missing was assumed to be that the participant did not feel comfortable answering the question, so the missing response was labeled as 7 (Prefer not to Answer). The majority of participants reported themselves to be in the 25-34 years of age range (33.9%) (See Table 24). 63 Table 24 Age at Time of Taking the Survey Age Range N % 18-24 2 3.4% 25-34 20 33.9% 35-44 11 18.6% 45-54 10 16.9% 55-64 1 1.7% Prefer not to answer 15 25.4% Total 59 100.0% Note. Table 24 shows the number of and percent of respondents by age range at the time of taking the survey. Evaluation of Findings Q1. What is the awareness of interventional radiology and interventional cardiology staff of dose limits and regulations? Based on the research questions outlined in Chapter 1 the results of the Qualtrics Survey indicate that both Interventional Radiology (M = .36, SE = .105) and Interventional Cardiology (M = .41, SE = .088) staff as a whole are not aware of whole body effective occupational radiation dose limit regulations provided by the ICRP. Participants of IR (M = .23, SE = .091) and IC (M = .19, SE = .070) staff are even less aware of the lens of the eye equivalent occupational radiation dose limit regulations. 64 These questions were not observed in previous literature and will be expanded in Chapter 5. Q2. How often are staff of interventional labs wearing personal radiation dose monitoring devices? The results of the survey indicate that staff members are not always wearing their personal radiation dose monitoring devices. Observing the rates of ‘always’ wearing dose monitoring devices, participants ranked themselves (57.6%) highest, followed by Radiologic Technologists (47.5%), Interventional Radiologists (40.7%), Cardiology Nurse (33.9%), Radiologic Technologist, Vascular Interventional (VI) (33.9%), Radiology Nurse (32.2%), Interventional Cardiologists (30.5%), Radiologic Technologist, Cardiac Interventional (28.8%), and Registered Cardiovascular Invasive Specialists (27.1%). The three lowest groups of staff members all represent those from Interventional Cardiology Departments and may indicate a lack of training in personal dose monitoring of occupational radiation exposure. Comparing this data to that observed in the literature review shows conflicting findings. Findings in the literature review were gathered from individuals that scored themselves, whereas this study asks for the observations of various staff members in distinct roles. Findings in this study showed that individuals are not wearing their personal dose monitoring devices as often as previous literature shows. This will be further explained in Chapter 5. Q3. What is the utilization of various radiation safety devices in IR and IC laboratories? This survey covered 21 states in the United States and gathered a broad range of what radiation safety devices are offered by various facilities. The most common device 65 that was offered was the thyroid shield (93.2%) followed by the wrap around two-piece lead apron (88.1%). Only 57.6% of facilities in this survey offered attenuating eyewear for staff involved in fluoroscopically guided procedures. Since occupational radiation exposure should always be mitigated, observance of how often staff are ‘always’ wearing these devices is important. It is difficult to assume the total percentage of how often participants were wearing lead aprons because the survey asked for three different apron types. The only conclusion that can be seen is that participants ‘always’ wear wrap around two-piece lead aprons more than other styles. The thyroid shield (72.9%) was the highest ranked radiation safety device to be utilized during fluoroscopic procedures. Alarmingly, attenuating eyewear (16.9%) was one of the least common radiation safety devices ‘always’ worn. Q4. What is the awareness of medical radiation workers regarding their dose reports? 45.8% of all participants never observe their occupational dose report, 15.3% monthly, 23.7% quarterly, 5.1% semiannually, and 10.2% annually (See Table 19). Summary Interventional Radiology (M = .36, SE = .105) and Interventional Cardiology (M = .41, SE = .088) staff as a whole are not aware of the effective whole body occupational radiation dose limit regulations provided by the ICRP. Participants of IR (M = .23, SE = .091) and IC (M = .19, SE = .070) staff are even less aware of the lens of the eye equivalent occupational radiation dose limit regulations. The results of the survey indicate that staff members are not always wearing their personal radiation dose monitoring devices. Findings in this study showed that individuals are not wearing their 66 personal dose monitoring devices as often as previous literature reports. The thyroid shield (72.9%) was the highest ranked radiation safety device to be utilized during fluoroscopic procedures. Alarmingly, attenuating eyewear (16.9%) was one of the least common radiation safety devices ‘always’ worn. Observing the mean values between groups, it appears that interventional cardiology staff do not review their occupational dose records as often as interventional radiology staff. 67 Chapter 5: Implications, Recommendations, and Conclusions Medical radiation workers in IR and IC have higher occupational exposure to radiation compared to medical radiation workers that do not utilize fluoroscopic units (Akram & Chowdhury, 2022). There is concern in the IRCP Publications that radiation monitoring may be skewed due to radiation workers not wearing personal dose monitoring devices regularly (ICRP, 2018). There is little information that is presented in how often medical radiation workers wear personal radiation dose monitoring devices, posing the question of whether dose limits and reporting are accurate. Performing a quantitative study will help delineate whether dose reporting is accurate and estimate the confidence of IR and IC staff in their dose limits and reports. The purpose of this quantitative study is to assess the awareness of dose limits and regulations, adherence to radiation monitoring devices, and utilization of personal radiation safety equipment. This study focuses on understanding of dose limits and utilization of personal dose monitoring devices and radiation safety devices; limitations to this study can include a lack of honest responses and can skew data analysis. The population of those that primarily work in IR and IC laboratories are few. Since the survey will be distributed in a convenience sampling method, there is a limitation regarding the reach of the study and generalizability. Ethical considerations are taken deliberately for this study. An IRB, at Weber State University, approval will be sought prior to any data collection from participants. After IRB approval is obtained, individuals will read and acknowledge informed consent prior to starting the survey. Informed consent that will be disclosed to participants will include information on the purpose and voluntary nature of the study, who is conducting the study, who to contact with questions, the population and 68 procedures, any risk or benefits, and confidentiality statements. Confidentiality of participants will be held in confidence in reports in which the study may be published. No personal identifiers will be included within the survey, and all data is kept in a passwordprotected system, available solely to investigators for educational purposes. All data will be destroyed within 2 years. This Chapter will explore the implications, recommendations, and conclusions of this study. Implications Q1. What is the awareness of interventional radiology and interventional cardiology staff of dose limits and regulations? Based on the research questions outlined in Chapter 1 the results of the Qualtrics Survey indicate that both Interventional Radiology (M = .36, SE = .105) and Interventional Cardiology (M = .41, SE = .088) staff as a whole are not aware of whole body effective occupational radiation dose limit regulations provided by the ICRP. Participants of IR (M = .23, SE = .091) and IC (M = .19, SE = .070) staff are even less aware of the lens of the eye equivalent occupational radiation dose limit regulations. These questions were not observed in previous literature and provide a framework for future continuing education of staff that work in interventional fluoroscopy laboratories. Educational institutions should provide more education of occupational dose limits to better prepare each individual to enter the profession. Q2. How often are staff of interventional labs wearing personal radiation dose monitoring devices? The results of the survey indicate that staff members are not always wearing their personal radiation dose monitoring devices. Observing the rates of ‘always’ wearing dose 69 monitoring devices, participants ranked themselves (57.6%) highest, followed by Radiologic Technologists (47.5%), Interventional Radiologists (40.7%), Cardiology Nurse (33.9%), Radiologic Technologist, Vascular Interventional (VI) (33.9%), Radiology Nurse (32.2%), Interventional Cardiologists (30.5%), Radiologic Technologist, Cardiac Interventional (28.8%), and Registered Cardiovascular Invasive Specialists (27.1%). The three lowest groups of staff members all represent those from Interventional Cardiology Departments and may indicate a lack of training in personal dose monitoring of occupational radiation exposure. Comparing this data to that observed in the literature review shows conflicting findings. Findings in the literature review were gathered from individuals that scored themselves, whereas this study asks for the observations of various staff members in distinct roles. Findings in this study showed that some individual professions are not wearing their personal dose monitoring devices as often as previous literature shows. 70.7% of interventional radiology and interventional cardiology nurses were historically ‘never’ wearing their personal occupational dose monitoring device (Table 5). This study shows that 1.7% of radiology nurses and 0% of cardiology nurses ‘never’ wear their personal occupational dose monitoring device. This is a vast improvement from what is seen in previous literature. This study showed that both IR nurses and IC nurses are wearing the devices ‘most of the time’ or ‘always.’ Observing radiologic technologists as a whole, the number of technologists that are ‘always’ wearing dose monitoring devices has decreased. Previous literature showed that ~80% and 57.8% of radiologic technologists are ‘always’ wearing dose monitoring devices. This study showed decreased values of VI (33.9%), CI (28.8%), and radiologic technologists (47.5%) in wearing these devices. The 70 data collected in prior studies have asked the individual to report their rates, whereas this study asks various professionals to assess their peers. The current study could imply that individuals are not answering honestly, or they have reduced their use of personal dose monitoring devices since prior studies. There is concern in the IRCP Publications that radiation monitoring may be skewed due to radiation workers not wearing personal dose monitoring devices regularly (ICRP, 2018). This study in addition to previous studies could provide insight to the ICRPs concerns and could bring change to the professions that work in interventional fluoroscopy labs to improve compliance. Q3. What is the utilization of various radiation safety devices in IR and IC laboratories? This survey covered 21 states in the United States and gathered a broad range of what radiation safety devices are offered by various facilities. The most common device that was offered was the thyroid shield (93.2%) followed by the wrap around two-piece lead apron (88.1%). Only 57.6% of facilities in this survey offered attenuating eyewear for staff involved in fluoroscopically guided procedures. Since occupational radiation exposure should always be mitigated, observance of how often staff are ‘always’ wearing these devices is important. It is difficult to assume the total percentage of how often participants were wearing lead aprons because the survey asked for three different apron types. The only conclusion that can be seen is that participants ‘always’ wear wrap around two-piece lead aprons more than other styles. The thyroid shield (72.9%) was the highest ranked radiation safety device to be utilized during fluoroscopic procedures. Alarmingly, attenuating eyewear (16.9%) was one of the least common radiation safety devices ‘always’ worn. 71 As mentioned above, it is difficult to assume the total percentage of how often participants were wearing lead aprons because the survey asked for three different apron types. Conclusions of this data cannot be described. Previous literature reported that 43%, 94%, and 70% of radiologic technologists, interventional radiologists, and nurses respectively ‘always’ wore a thyroid shield. Attenuating eyewear was ‘always’ worn, reported at 5.0% and 54% for radiologic technologists and interventional radiologists. This study showed that 75% of nursing staff wear thyroid shields during fluoroscopic procedures, a 5% increase from previous literature. Radiologic technologists (73.7%) wore thyroid shields in this study, a marked increase from previous literature (43%). Regarding ‘always’ wearing attenuating eyewear, this data showed 4.2% and 31.6% of nurses and radiologic technologists, respectively. Previous studies did not have data on nursing staff wearing attenuating eyewear. This provides a ground for further research. Observing previous literature for radiologic technologists, a marked increase from 5.0% in previous literature to 31.6% in this study is a substantial improvement to protect technologists from cataractogenesis. Interventional radiologists in this study were reported with two respondents and generalizability cannot be ascertained. Other devices are not routinely reported in literature, and no conclusive evidence can be used for comparison. Utilization of this data can be used for further analysis in future studies. Q4. What is the awareness of medical radiation workers regarding their dose reports? 45.8% of all participants never observe their occupational dose report, 15.3% monthly, 23.7% quarterly, 5.1% semiannually, and 10.2% annually (See Table 19).This data is not represented in previous literature and can be used as a basis for further 72 research on the topic. Increasing how often staff members observe their occupational dose records could increase awareness of their occupational dose. Recommendations Practical applications of this study can be used in further research assuming the mentioned limitations are understood. Sampling for some subjects was too small to create generalizability (interventional radiologists (2), interventional cardiologists (0)). A longer study length with the help of other societies and institutional review boards for facilities would greatly increase participation of the study to broaden the reach. Within the choice of the researcher, the survey should be constructed in a way that makes each question mandatory to answer, to include a selection of ‘prefer not to answer.’ This was a barrier in this study where several questions were not answered, and it decreased the overall data that could be utilized for generalizability. Future research should be collected in occupational dose records, if able to gain approvals. Occupational dose records of participants will give further insight into how their perceptions of importance, radiation safety, and occupational dose monitoring practices influence their occupational dose measurements. Conclusions Interventional Radiology (M = .36, SE = .105) and Interventional Cardiology (M = .41, SE = .088) staff as a whole are not aware of the effective whole body occupational radiation dose limit regulations provided by the ICRP. Participants of IR (M = .23, SE = .091) and IC (M = .19, SE = .070) staff are even less aware of the lens of the eye equivalent occupational radiation dose limit regulations. These questions were not observed in previous literature and provide a framework for future continuing education 73 of staff that work in interventional fluoroscopy laboratories. 70.7% of interventional radiology and interventional cardiology nurses were historically ‘never’ wearing their personal occupational dose monitoring device (Table 5). This study shows that 1.7% of radiology nurses and 0% of cardiology nurses ‘never’ wear their personal occupational dose monitoring device. This is a vast improvement from what is seen in previous literature. Previous literature showed that ~80% and 57.8% of radiologic technologists are ‘always’ wearing dose monitoring devices. This study showed decreased values of VI (33.9%), CI (28.8%), and radiologic technologists (47.5%) in wearing these devices. The data collected in prior studies have asked the individual to report their rates, whereas this study asks various professionals to assess their peers. The current study could imply that individuals are not answering honestly, or they have reduced their use of personal dose monitoring devices since prior studies. . This study showed that 75% of nursing staff wear thyroid shields during fluoroscopic procedures, a 5% increase from previous literature. Radiologic technologists (73.7%) wore thyroid shields in this study, a marked increase from previous literature (43%). Observing previous literature for radiologic technologists, a marked increase from 5.0% in previous literature to 31.6% in this study is a substantial improvement to protect technologists from cataractogenesis. The two groups that observed their occupational dose records most infrequently were Cardiology Nurses (M = 2.15, SE = .456) and Radiology Nurses (M = 2.0, SE = .426). Reviewing the data, the results were expected that nursing staff would not observe their dose records as often as machine operators (physicians and technologists). Observing the mean values between groups, it appears that interventional cardiology (M = 2.44, SE = .304) staff do not review their occupational dose records as often as interventional radiology (M = 2.95, 74 SE = .392) staff. This data is not represented in previous literature and can be used as a basis for further research on the topic. 75 References Abdelrahman, M.A., Alfwares, A.A., Alewaidat, H., Alhasan, M., Rawashdeh, M.A., Al Mousa, D.S. (2018). Compliance with radiation protection practices among radiologists. Health Physics. 115(3), 338-343. https://doi.org/10.1097/hp.0000000000000886 Abuzaid, M., Elshami, W., Hasan, H. (2019). Knowledge and adherence to radiation protection among healthcare workers at operation theater. Asian Journal of Scientific Research. 12(1), 54-59. 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Physical and Engineering Sciences in Medicine, 46(1), 353-365. https://doi.org/10.1007/s13246-023-01226-7 81 Appendices Appendix A: Qualtrics Survey Occupational Radiation Dose Perceptions and Practices in Interventional Radiology and Interventional Cardiology Which of the following best describes your job title or role. o Interventional Radiologist o Interventional Cardiologist o Radiology Nurse o Cardiology Nurse o Radiologic Technologist, Vascular Interventional (VI) o Radiologic Technologist, Cardiac Interventional (CI) o Radiologic Technologist o Registered Cardiovascular Invasive Specialist (RCIS) o Other, please specify ________________________________________ o Prefer not to answer 82 In which department do you primarily work? o Interventional Radiology o Interventional Cardiology o Other, please specify _________________________________________________ o Prefer not to answer How would you rate the importance of radiation safety from 'not important' to 'very important'? Not Important 1 2 3 4 5 Very Important 6 6 7 8 9 10 83 What radiation safety devices are provided in your procedure room? Select all that apply. o Frontal Lead Apron o Wrap Around Lead Apron (One Piece) o Wrap Around Lead Apron (Two Piece) o Thyroid Shield o Attenuating Eyewear o Machine Mounted Lead Skirt o Ceiling Suspended Lead Shield o Mobile Floor Shield o Attenuating Gloves o Other, please specify ________________________________________ o None of the Above o Prefer not to answer Based on your knowledge and education, what is the annual individual whole-body effective dose limit in millisieverts? o 25mSv/y o 50mSv/y o 75mSv/y o 100mSv/y o I am unsure. 84 Based on your knowledge and education, what is the annual individual equivalent dose limit for the lens of the eye? o 50mSv/y o 100mSv/y o 125mSv/y o 150mSv/y o I am unsure How often do you review your occupational dose record? o Never o Weekly o Monthly o Quarterly o Semiannually o Annually 85 How often do the following individuals use personal dose monitoring devices during fluoroscopically guided procedures, based on your observations? Never Sometimes Most of Always the time 0 Yourself Interventional Radiologist Interventional Cardiologist Radiology Nurse Cardiology Nurse Radiologic Technologist, Vascular Interventional (VI) Radiologic Technologist, Cardiac Interventional (CI) Radiologic Technologist Registered Cardiovascular Technologist (RCIS) 1 2 3 Not Applicable 4 5 86 To what extent do you personally utilize the following radiation safety devices during fluoroscopically guided procedures? Never Sometimes Most of Always the time 0 Frontal Lead Apron Wrap Around Lead Apron (One Piece) Wrap Around Lead Apron (Two Piece) Thyroid Shield Attenuating Eyewear Machine Mounted Lead Skirt Ceiling Suspended Lead Shield Mobile Floor Shield Attenuating Gloves 1 2 Not Available 3 4 5 87 The following questions are additional demographic questions to enrich the study data. If you do not wish to answer these questions, you may select 'Prefer not to answer. Because of radiation-related risks to fetal development during the childbearing years, do you currently have the biological capacity to conceive and carry a pregnancy to term? o Yes o No o Prefer not to answer If living in the United States, please specify what state you reside in. o Please write the full state name ______________________________________ o Prefer not to answer o I reside outside of the United States If living outside of the United States, please specify what country you reside in. o Please write the full country name ____________________________________ o Prefer not to answer o I reside in the United States 88 What is your current age? o 18-24 o 25-34 o 35-44 o 45-54 o 55-64 o 65-70 o Prefer not to answer 89 Appendix B: Informed Consent IRB STUDY # IRB-AY24-25-412 WEBER STATE UNIVERSITY INFORMED CONSENT Occupational Radiation Dose Perceptions and Practices in Interventional Radiology and Interventional Cardiology You are invited to participate in a research study exploring the understanding of occupational radiation dose and radiation safety among interventional radiology (IR) and interventional cardiology (IC) laboratory staff. You were selected as a possible subject; you are currently employed within a profession associated with interventional fluoroscopic procedures. You are between the age of 18 and 70. We ask that you read this form and ask any questions you may have before agreeing to be in the study. The study is being conducted by Tanya Nolan and Brayden Crismon as part of an MSRS research project at Weber State University. STUDY PURPOSE: The purpose of this study is to research the understanding of occupational dose limit regulations, observe the utilization of personal dose measurement devices, and utilization of radiation safety equipment in IR and IC laboratories. As there is limited research regarding occupational radiation dose and mitigation of occupational radiation dose, research questions highlight the current opportunities, resources, challenges, and benefits of professionals within IR and IC laboratories. NUMBER OF PEOPLE TAKING PART IN THE STUDY: If you agree to participate, you will be one of a maximum of 50 subjects who will be participating in this research. 90 PROCEDURES FOR THE STUDY: If you agree to be in the study, you will be asked to complete a 10 minute electronic survey including questions on occupational dose limits, utilization of personal dose monitoring devices, and utilization of radiation safety devices in IR and IC laboratories and some demographics. RISKS OF TAKING PART IN THE STUDY: The risk of completing the survey may include discomfort in answering questions regarding personal practices and understandings of occupational radiation dose. BENEFITS OF TAKING PART IN THE STUDY: You will not receive payment for taking part in this study. ALTERNATIVES TO TAKING PART IN THE STUDY: There are no alternatives to taking part in the study. CONFIDENTIALITY: Efforts will be made to keep your personal information confidential. We cannot guarantee absolute confidentiality. Your personal information may be disclosed if required by law. Your identity will be held in confidence in reports in which the study may be published. No personal identifiers will be included within the survey, and all data is kept in a password-protected system, available solely to investigators for educational purposes. All data will be destroyed within 2 years. Organizations that may inspect and/or copy your research records for quality assurance and data analysis include groups such as the study investigator and his/her research associates, the Weber State University Institutional Review Board or its designees, the study sponsor, and (as allowed by law) state or federal agencies, specifically the Office for Human Research Protections (OHRP) and the Food and Drug Administration (FDA) [for FDA-regulated research and research involving positron-emission scanning], the 91 National Cancer Institute (NCI) [for research funded or supported by NCI], the National Institutes of Health (NIH) [for research funded or supported by NIH, etc., who may need to access your medical and/or research records. CONTACTS FOR QUESTIONS OR PROBLEMS: For questions about the study, contact the researcher Tanya Nolan at 801-626-8172. For questions about your rights as a research participant or to discuss problems, complaints, or concerns about a research study, or to obtain information, or offer input, contact the Chair of the IRB Committee IRB@weber.edu. VOLUNTARY NATURE OF STUDY: Taking part in this study is voluntary. You may choose not to take part or may leave the study at any time. Leaving the study will not result in any penalty or loss of benefits to which you are entitled. Your decision whether or not to participate in this study will not affect your current or future relations with your clinical affiliate or the University. SUBJECT’S CONSENT: By selecting “yes” below, you have consented to participate in the study. Yes No