Key points

  • Clinical, research and industry professionals administering ionising radiation must prioritise training.

  • Employers and regulators must ensure radiation protection training is mandatory.

  • Expert radiation protection trainers are needed for the European training network.

  • Appropriate resourcing is required for radiation protection training development and implementation.

Background

The application of ionising radiation and nuclear technologies play a crucial role in healthcare through the three main medical specialties radiology, radiotherapy and nuclear medicine. These three specialties are among the most innovative of all medical disciplines and early adopters of new technologies. The technological advances in these specialties have enabled significant progress in early detection and diagnosis, treatment selection and monitoring, image-guided intervention. Precise and normal tissue sparing curative treatment of oncological and non-oncological diseases have contributed significantly to developments in personalised medicine. This significant technological progress brings however new challenges, that society must be aware of, in particular the increased exposure of patients and staff to ionising radiation.

To find solutions for these challenges, the European Commission (EU) funded a project [1] (EURAMED rocc-n-roll—EuRnR), to propose an integrated and coordinated European approach to research and innovation in medical applications of ionising radiation and related radiation protection (RP) based on stakeholder consensus and existing activities in the field. The overarching objective of EuRnR is to generate a European consensus on research needs and their priorities in medical radiation application and corresponding RP to optimise the use of ionising radiation in medicine and thereby improve its benefit to Europe’s patients. Under EuRnR, an Education and Training (E&T) framework for health professionals and researchers will be developed. The framework will be based on an analysis of the current E&T capabilities and what is required to support its successful integration into practice and to support further research following the EURAMED Strategic Research Agenda (SRA) and roadmap [2] implementation.

It is widely recognised that E&T in RP for health professionals is vital towards the development of a RP safety culture to protect patients and staff from the dangers arising from the exposure to ionising radiation. The International Commission on Radiological Protection (ICRP) supports that professionals involved directly in the use of ionising radiation should receive E&T in RP at the start of their career, and the education process should continue throughout their professional life as the collective knowledge of the subject develops [3]. However, due to the rapid development of medical techniques based on ionising radiation, there is a strong demand for new E&T models in medical RP. The major challenge is to address the variety of professions working on a daily basis with ionising radiation, but having different knowledge background and also different needs with respect to E&T. All of them, however, are working towards the same objective: patient and staff safety [2]. Also the Heads of the European Radiation Protection Authorities (HERCA) supports that E&T requirements for RP knowledge and skills should cover underpinning science, RP philosophy and principles, management, organisation and practical application techniques and knowledge and skills of applicable legislation and guidance [4]. It is therefore understandable that, considering all these important and relevant aspects, the European Commission has reinforced the importance of education, information and training in the field of medical exposure, in Article 18 of the Council Directive 2013/59 EURATOM. This lays down basic safety standards for protection against the dangers arising from exposure to ionising radiation, by requiring that European Member States “ensure that practitioners and the individuals involved in the practical aspects of medical radiological procedures have adequate education, information and theoretical and practical training for the purpose of medical radiological practices, as well as relevant competence in radiation protection” [5].

To understand the status quo of E&T in RP in Europe, the EuRnR project performed a SWOT (Strengths, Weaknesses, Opportunities and Threats) and TOWS analysis of the results/impact of E&T RP outputs developed under previous EU framework programmes [6,7,8].

Methods

To perform the SWOT analysis, the project team working on this task was split into four groups to analyse the “strengths” (group 1), “weaknesses” (group 2), “opportunities” (group 3) and the “threats” (group 4) of each document related to E&T in RP developed under previous EU programmes [9,10,11] and on the Guidelines on Radiation Protection Education and Training of Medical Professionals in the European Union [12].

Following the first analysis by the four groups, that resulted from a brainstorming amongst the group members, the draft SWOT matrix (planning tool) was sent out for review and comments to a dedicated cross disciplinary expert panel, composed of members of the project advisory board and external experts. This expert panel, composed of 14 members, integrated representatives from five European Professional Societies (CIRSE—Cardiovascular and Interventional Radiological Society of Europe; EANM—European Association of Nuclear Medicine; EFOMP—European Federation of Organisations for Medical Physics; EFRS—European Federation of Radiographer Societies; ESR—European Society of Radiology; ESTRO—European Society for Radiotherapy and Oncology), one European Voluntary Organisation (HERCA), two International Organisations (WHO—World Health Organisations; IAEA—International Atomic Energy Agency) and five clinical experts (Medical Physicist Expert; Nuclear Medicine Physician; Radiation Oncologist; Radiographer).

After incorporating the comments from the panel, the final version of the SWOT matrix was approved, and a TOWS (Threats, Opportunities, Weaknesses, and Strengths) analysis (an action tool) was performed as a strategy to address the results of the initial SWOT investigation and to define future strategies. The TOWS analysis was carried out by the aforementioned four groups to define how to minimise the threats and weaknesses by maximising the opportunities and strengths [13], thus overcoming a criticism of a standalone SWOT analysis by exploring the relationships between categories and specified factors. The findings for strengths—opportunities—activities sections were reviewed by all the working group members and consensus agreement reached on four main themes, namely: [1] Existing structures and training recommendations; [2] RP training needs assessment & E&T model(s) development; [3] E&T dissemination/harmonisation/accreditation; [4] Financial supports (Table 1 and 2). Similarly, weaknesses—threats—activities sections were evaluated for main themes and two were identified: [1] Awareness and prioritisation at a nation/global level and [2] Awareness and prioritisation by healthcare professional groups and researchers (Table 3 & 4).

Table 1 Summary of the weaknesses identified by SWOT analysis
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Results

SWOT analysis of the results/impact of E&T in RP aspects developed under previous EU framework programmes and EU-funded projects

Strengths

Ten principal strengths were identified the following SWOT analysis, and the agreed text summarising the findings is as follows:

  1. 1.

    Ten-year history of collaboration across Europe via various radiation protection research platforms (MELODI—Multidisciplinary European Low Dose Initiative; EURADOS—European Radiation Dosimetry Group; and more recently EURAMED—European Alliance for Medical Radiation Protection Research) and research projects and partnerships (DoReMi—Low Dose Research towards Multidisciplinary Integration; OPERA—Open Project for the European Radiation Research Area; CONCERT—European Joint Programme for the Integration of Radiation Protection Research).

  2. 2.

    Recognised importance of E&T within EU project calls, with specific financial support to organise and manage E&T as part of EU-funded research projects.

  3. 3.

    Assessment of training needs already completed (ENETRAP; European Network on Education and Training in Radiological Protection; MEDRAPET—Medical Radiation Protection Education and Training).

  4. 4.

    Strategic research agendas of radiation protection platforms have been produced and disseminated and include E&T elements.

  5. 5.

    Existing guidelines for E&T in RP for health professionals (MEDRAPET).

  6. 6.

    Euratom regulation and National Competent Authorities in existence for many years.

  7. 7.

    Some continued financial support for E&T, even in initiatives not specifically targeting the medical field (e.g. ENEN +—European Nuclear Education Network).

  8. 8.

    Established Network and experience of organising European common training and initiatives on Education and Training in Radiological Protection in Europe (e.g. ENETRAP).

  9. 9.

    E&T initiatives support/encourage European mobility among students/trainees in the field of RP.

Weaknesses

A series of perceived deficiencies were identified and are summarised in Table 1. Two thirds of the weaknesses were in relation to training availability, training content and the training of trainers in radiation protection education.

Opportunities

Nine principal opportunities were derived from the text comments and responses received during the SWOT analysis, the agreed opportunities are namely:

  1. 1.

    Many recommendations have been made in the course of previous programmes, however, much of this work is between 10 and 15 years old. Opportunity to systematically review all recommendations and to propose up-to-date recommendations based on the findings of the review.

  2. 2.

    To focus E&T in RP on the needs of the current, and future, clinical workforce (including consideration of different areas of practice and different professions and the need to build knowledge, skills, and competences, directly related to benefit-risk communication with patients and the public).

  3. 3.

    To focus E&T in RP on the needs of the current, and future, medical radiation protection researchers (outside the clinical departments and including pre-clinical research).

  4. 4.

    To propose a sustainable and harmonised model for E&T in RP (many past programmes have not succeeded in producing sustainable outcomes).

  5. 5.

    European-level accreditation or endorsement of a recommended, gold standard model of E&T in RP by EURAMED and/or the professional societies EANM, EFOMP, EFRS, ESR, ESTRO.

  6. 6.

    To identify differences in contents and regulations of E&T in RP in EU member states and to propose a European standard for mandatory E&T course contents and certification based on consensus.

  7. 7.

    To stress the importance of well-trained future generations of RP experts with sufficient knowledge, skills, and competences, to cover future needs of E&T.

  8. 8.

    To develop and deliver European-level online training programmes targeting all relevant professional groups to increase accessibility.

  9. 9.

    To develop E&T in RP during the undergraduate course programmes

Threats

Threats evidenced from responses during SWOT analysis are summarised in Table 2.

Table 2 Summary of the threats evidenced during SWOT analysis
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Tows analysis to propose actions to maximise strengths and opportunities to minimise weakness and threats

From the TOWS analysis a list of actions to be developed have been defined and are summarised in Tables 3 and Tables 4 and 5.

Table 3 Summary of actions to use strengths to maximise opportunities and minimise threats
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Table 4 Themed opportunities and actions to minimise weaknesses and to minimise weaknesses to avoid threats
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Table 5 Use opportunities to minimise weaknesses and actions to minimise weaknesses to avoid threats
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Discussion

To our knowledge this is the first TOWS analysis on the SWOT results/impact of E&T in RP aspects developed under previous EU framework programmes and EU-funded projects. Despite the success of the EuroSafe Imaging initiative, which is now in its sixth year of active engagement of its’ call for action to achieve international radiation protection goals this study has identified that there is a significant path ahead to achieve delivery, harmonisation and accreditation of radiation protection training across all stakeholders [14,15,16]. Extensive literature has been published in recent years which evidences the efforts of European collaborations and the critical work of medical physics and in the achievement of optimal radiation protection practices [17]. Despite this extensive evidence literature base, our SWOT analysis and TOWS findings have identified that there is a need to prioritise resources and efforts to address the weaknesses and threats which have been identified through this study. To facilitate discussion of our findings four areas of consideration are presented.

Developing training material and trainers

The development of training material and trainers in a manner which is sustainable and facilitates continual refreshing to match technology advances is identified as core consideration for strategic framework planning [18]. Whilst a significant portion of curriculum planning has already been prepared through the work of the MEDRAPET project the sustainable development of training materials is now required. This process needs to align to the continual advances in medical imaging technology and their subsequent radiation protection considerations. Currently, no single training network exists, therefore, it is timely for the stakeholders to consider how a truly holistic approach to radiation protection training could be launched for the benefit all professional disciplines and meet specific professional needs, as identified in this work (Table 2). The Framework to facilitate a truly pan European training network needs to consider how such a process could function at a European, national and local clinical level.

In recent years our access to digital education technologies, has substantially increased, particularly so during the COVID-19 pandemic [19,20,21]. Educators across multiple professional disciplines have managed this change in teaching practice and have thrived within the online learning environment [22, 23]. The SWOT findings highlight the importance of short online learning objects (Table 4b), this form of learning is promoted across teaching and learning research and the facility for efficient updating is of extreme importance in medical imaging [24]. The willingness of learners to participate in online learning in recent literature is also extremely encouraging and an important consideration when developing material [25,26,27]. The potential for teaching delivery by a multidisciplinary group of experts at a European level, complimented by nationally supported local teaching, could in some part address the lack of suitably qualified trainers across Europe as identified in TOWS analysis as well as ensuring quality of content [28] The software and technologies used in education now incorporate greater intractability and the use of 2D, 3D and augmented reality software options, which can engage learners more effectivity than some traditional teaching pedagogies and should be incorporated in proposed training frameworks [29].

Developing “buy-in”

To achieve successful radiation protection training goals, it is essential that those administering ionising radiation in the clinical, research or industry environments see the benefit of training and possess a desire to train. Our findings highlight the importance of meeting profession-specific needs and a current lack of priority placed upon the importance of radiation protection training across professional disciplines, researchers, education institutions, national and European bodies (Table 2). In the most recent European investigation of radiographer radiation protection education in the IAEA, substantial differences in duration and quality of training were highlighted [30, 31]. The literature also highlights similar concerns related to radiation therapy training and the need to improve radiation safety awareness [32]. Similarly, Walsh et.al (2019) identified a low baseline radiation safety knowledge for participating orthopaedic surgeons and trainees. These professionals are frontline workers administering ionising radiation daily and exemplify the need to consider tailored training in addition to core principles. The study highlighted that until now all EU projects have been focussed upon the training of E&T of Radiation Protection Officer (RPO), Radiation Protection Expert (RPE) and Medical Physics Expert (MPE) therefore it is understandable how the health professionals’ community may perceive a lack of professional relevance, and this must be addressed. However there remains a lack of suitably qualified staff to assist in training, predominantly those with a medical physics background, but also from across the stakeholder professions who would be required to assist with training a truly holistic training programme [33, 34].

The challenges ahead should not be underestimated, the impact of the COVID-19 pandemic has further impacted staff resources in both clinical and academic environments, in addition to the increased volume of articles related to professional burnout and the lack of funding for strategic staff contingency planning across healthcare disciplines published pre-COVID-19 [35,36,37]. In our analysis of how to maximise opportunities and minimise threats, the matter of financial support was identified with the suggestion of using finances to promote training developments to professionals’ communities; however, literature would indicate the need for increased staff resources to facilitate training time and training material development which incorporates realistic budgeting as core to the success of the proposed framework documentation [38, 39].

In addition to the development of training material, we must also consider training the trainers. Higher education institutions are well placed to assist with, considering their experience in teaching and learning pedagogies and access to a broad array of teaching technologies, experienced teachers and education technologists and their incorporation in the EuRnR Framework documentation is essential. To ensure trainers themselves are effective in the clinical, research, industry, and academic environments, it is essential that they themselves are “trained” to a high standard. This is reiterated across several sections of this study aligned to appropriate financial and staff resourcing.

Our findings also identify the need to improve the importance upon which professionals, managers and national agencies place on radiation protection training. The critical role that regulators have in ensuring training programmes are completed is clearly identified in the TOWS analysis (Table 3). EuRnR framework development must specify how regulators and national governments should engage and clarity is required in relation to EuRnR expectations of regulator collaboration. To achieve success the national regulators in turn need to consider how they can influence greater cohesion between the health and research and the EURATOM communities nationally under the single umbrella of radiation protection training in their efforts to protect the public [40].

Embedding RP training and accreditation

Once training materials and networks are developed our study has identified the importance of determining how a radiation protection network on a European scale, which has national and local on-site activity, could be embedded as mandatory practice by employers and regulators and potentially also have employment incentives potentially attached (Table 2). Furthermore, the issue of accreditation, quality control and training oversight was a recurring item of the SWOT investigation and TOWS analysis. The EuRnR strategic framework documentation will need to consider how accreditation processes are recognised by national regulators and professional groups as national legislation may demand national accreditation of training and not be legally permitted to recognise a pan European accreditation process. How this matter is managed is critical, as mandatory compliance with regulation agencies linked to government bodies is important in the achievement of sufficient funding for the development of a successful radiation protection training network and one which is mandated as a continued professional development requirement.

Strategic resource planning of RP training

As stated within the discussion at different junctures as with any training programme, the cost of development and implementation requires consideration: from the funding of time and expertise to develop teaching material, hosting virtual/online learning environments, teaching material delivery, trainer costs, academic and clinical site costs, accreditation costs and resourcing of quality review processes. All these items are significant and will differ across nations and locally across clinical, academic and industrial sites and how this can be managed requires intensive discussion and must be clearly and realistically addressed in the proposed EuRnR strategic framework documentation to be completed by this project.

Limitations

In the past, most EU-funded programmes and projects were profession specific or not directly related to medical procedures. Nevertheless, considering the composition of the EuRnR consortium, the group brings together experts in RP from the most relevant health professions and researchers involved in the clinical use of ionising radiation (e.g. Radiologists, Nuclear Medicine Physicians, Radiographers, Medical Physicists, Radiation Oncologists), it was possible to minimise the described limitation, through several multi-professional group meetings, as a strategy to obtain consensus regarding the SWOT analysis and the respective TOWS actions. Future consideration does need to incorporate the expertise of E&T scientists as the EuRnR framework documentation is progressed.

Conclusion

E&T in RP is of paramount importance for health professionals and researchers to acquire and develop knowledge, skills and competences in the field of RP to protect patients and staff from the dangers arising from the exposure to ionising radiation. Although several projects have been developed in the past years related to E&T in RP, the SWOT analysis showed a clear lack of real and effective implementation of RP principles in daily practice and therefore there is a critical opportunity under EuRnR to define and set a new momentum, through an objective and dedicated action plan for E&T in RP in Europe. EuRnR Strategic planning documentation needs to consider processes at European, national and local levels and incorporate the multiple factors identified in this SWOT investigation and TOWS analysis. To achieve success, governance structures and strong leadership are key as is the full exploitation of existing resources however equally, appropriate financial support is essential to permit our professions to work collaboratively to achieve a pan European radiation protection training network which is sustainable and accredited across multiple national domains.