Adherence to Radiation Protection Principles among Operating Room Students: Implications for Clinical Recommendations and Educational Interventions

doi:10.21203/rs.3.rs-4999824/v1

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Adherence to Radiation Protection Principles among Operating Room Students: Implications for Clinical Recommendations and Educational Interventions

https://doi.org/10.21203/rs.3.rs-4999824/v1

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Background

Due to the increasing use of ionizing radiation in the operating room environment, concerns about the potential risks of this type of radiation have increased. Therefore, this study aimed to investigate the level of knowledge, attitudes, and performance of last semester operating room nursing and anesthesia students toward radiation protection principles for their presence in the clinical educational environment.

Methods

This cross-sectional study was conducted at Hamadan University of Medical Sciences in 2024. In this study, students were selected via the census sampling method. The data related to the study were collected from valid questionnaires concerning the participants’ level of knowledge, attitudes, and performance toward ionizing radiation. Additionally, the data analysis was conducted at the descriptive and inferential statistics level via SPSS version 16 software.

Results

Students' knowledge, attitudes, and performance in both operating room nursing and anesthesia were moderate. Additionally, the mean attitude score toward protective principles was significantly greater among operating room nursing students than among anesthesia students (P value = 0.023). Furthermore, a positive and significant correlation was found between students' grade point average (GPA) and their scores on knowledge and attitudes toward protective principles (r = 0.449, P value = 0.000 and r = 0.648, P value = 0.000, respectively).

Conclusion

This study revealed an insufficient level of knowledge among the mentioned students regarding ionizing radiation. As a result, training courses should be conducted to increase students' knowledge and attitudes toward the risks of ionizing radiation, thereby improving their safety in the clinical educational environment.

Clinical Trial Number: Not applicable.

Operating room nursing

Anesthesia

Education

Radiation protection

Awareness

Perception

Currently, radiology is the cornerstone of clinical diagnosis and effective patient management in the medical sciences [1]. The ability of ionizing radiation to penetrate soft tissue to capture images that the human eye cannot see is essential in the branches of medical sciences [2]. The increase in the speed of modern imaging technologies is perceived as a double-edged sword because of the various radiation risks it poses [3]. On the other hand, universities must protect students' safety and security by educating them [4].

The operating room environment, which is considered a specialized clinical environment for operating room nursing and anesthesia students, is a high-risk environment due to various factors [5]. Individuals in the operating room are exposed to multiple risks, such as chemical and biological toxins, carcinogenic substances, and ionizing and nonionizing radiation [5]. The exposure of individuals to ionizing radiation is inevitable due to the use of radiology imaging technology, especially fluoroscopy with a C-Arm device, during orthopedic and spinal surgeries and implant placements in the operating room environment [6]. High-dose ionizing radiation (X-ray) has both deterministic and stochastic effects. These types of radiation can cause severe and irreversible damage, such as blood cancer and genetic injuries [7]. Ionizing rays can directly and indirectly damage DNA and living cells by creating free radicals, considered uncharged and unstable molecules [8]. These unstable radicals, to stabilize, can produce new toxic substances, such as hydrogen peroxide, in living tissues and other cellular alternations [9]. Therefore, the reasonable and optimal use of new medical imaging technologies, knowledge, and appropriate adherence to protection principles is crucial [8].

Generally, radiation protection principles refer to a set of measures aimed at minimizing the exposure of patients and healthcare personnel to ionizing radiation to reap the benefits of radiography while ensuring complete safety for the patient [3]. In performing all medical imaging techniques, three principles are applied: justification, optimization, and dose limitation, where the optimization principle serves to increase individuals' knowledge about the effects of radiation exposure [10]. To reduce the risk of radiation exposure, medical science students should have comprehensive knowledge of protective protocols against radiation exposure. This knowledge should be provided to students throughout their educational period in college [3]. In addition to providing proper education, the role of nursing managers in utilizing management skills and effective leadership styles in empowering staff, supporting them, and enhancing the quality of care can be impactful [11]. Holding training courses and upgrading employees by nursing managers, such as courses in radiation protection, organizational development, and increasing productivity, will follow [12].

Previously published studies have shown that healthcare professionals and students in various medical science fields have limited knowledge about ionizing radiation and protective principles against it [13, 14]. In the past, training on the principles of working with radiation was not considered essential in the curriculum of medical science students. However, given its significant importance, currently, in some countries, such as Japan, the relevant educational council deems learning the principles of working with radiation and familiarizing oneself with the potential risks essential for better professional performance of nurses and healthcare personnel [15]. In this context, assessing the level of knowledge of medical science students and healthcare personnel and conducting radiation protection (RP) courses can help reduce the exposure of specialists and patients to ionizing radiation [10].

Determining people's knowledge, attitudes, and performance concerning radiation protection across different fields can help healthcare policymakers better manage and improve awareness, attitude modification, and performance. Most studies on ionizing radiation awareness and familiarity with protective principles have focused on specialists, physicians, and personnel. However, there have been no studies in Iran or other countries on the level of awareness among students of surgical technology and anesthesia due to their constant presence in the operating room environment and exposure to X-rays during orthopedic and spinal surgeries. Additionally, similar studies have focused primarily on assessing individuals' level of knowledge and attitudes. In contrast, in this study, students' performance was also examined alongside their knowledge and attitudes. Therefore, to investigate the necessary training for providing correct knowledge to students and healthcare personnel regarding radiation and its principles, the present study aimed to clarify the level of perception, attitudes, and performance of operating room nursing and anesthesia students toward protective principles against ionizing radiation.

Study Design and Participants

The present cross-sectional study was conducted in 2024 at Hamadan University of Medical Sciences. The statistical population included Hamadan University of Medical Sciences operating room nursing and anesthesia students, among whom 70 students were selected by the census sampling method and based on the inclusion criteria. Students were selected based on entrance criteria, including being in the last semester of operating room nursing and anesthesia and being willing to participate in the study. Additionally, students' participation in extra courses on learning the principles of working with radiation and C-Arm machines compared with others was considered an exit criterion for this study.

Collecting Data

In this research, two questionnaires were used for data collection as follows:

The demographic information questionnaire included questions about age, gender, field of study, student's grade point average (GPA), academic semester, and number of credits passed by the student.

The second part consisted of a questionnaire comprising 30 questions regarding attitudes, knowledge, and performance in the field of observing protective measures for patients and radiographers. The questions in this questionnaire included risks of ionizing radiation, the ALARA principle, permissible radiation dose limits, the role of film processing conditions, the role of different parts of the X-ray machine (collimator, filter, intensifying screen) in the patient and radiographer dose, the use of Bucky film, the use of protective equipment, and performing blood tests for health assessment of radiographers, as well as a survey about specific patient conditions. The reliability and validity of this questionnaire have been confirmed in previous studies. In the study by Karami and colleagues, the validity and reliability of the questionnaire were determined via the content validity method with several professors, and on the basis of the results of the Cronbach's alpha test, the reliability was determined to be 0.76 [16].

Implementation of the study

After obtaining permission from the Ethics Committee of Hamadan University of Medical Sciences, students who met the inclusion criteria were invited to participate in the study. After providing their consent and satisfaction, the researchers explained the study's objectives to them and distributed the questionnaires to them. Each student took approximately 20 minutes to complete the questionnaires. The confidentiality of the participants' information was assured.

Statistical analysis

Finally, data analysis was conducted via SPSS, version 16.0 (SPSS Inc., Chicago, Ill., USA) software, with a significance level of 0.05. First, the assumption of normality of the data was checked via the Kolmogorov‒Smirnov test. Descriptive statistics included the frequency, percentage, mean, and standard deviation. Fisher's exact test and independent t-tests were used to compare the frequency distributions of qualitative and quantitative demographic characteristics between the students. Additionally, the Pearson correlation coefficient was used to determine the relationships between the grades obtained from the questionnaire and their demographic characteristics.

This study examined 70 last-semester students in the operating room for nursing (n = 35) and anesthesia (n = 35). Additionally, 33 participants (47.14%) were male, and 37 participants (52.86%) were female. The mean ± standard deviation of the age of the students was 22.74 ± 1.25 years. Additionally, the mean GPA of the students based on the score was 17.49 ± 0.65. According to Fisher's exact test, there was no statistically significant difference in terms of sex between the two groups of operating room nursing and anesthesia students (P value = 0.811).

Furthermore, the independent t test results between the mean age and GPA of students in the operating room and anesthesia groups did not significantly differ. The significance levels were 0.186 and 0.776, respectively (Table 1).

Table (1): Mean and standard deviation of age and GPA of students by field of study

	Field of Study	Mean	Standard deviation	P-value
Age	Operating room nursing	22.94	1.23	0.186
Age	Anesthesia	22.54	1.26	0.186
Grade Point Average	Operating room nursing	17.51	0.66	0.776
Grade Point Average	Anesthesia	17.47	0.64	0.776

Based on our findings, the means ± standard deviations of the total scores of students' knowledge levels regarding radiation protection methods among operating room nursing and anesthesia students were 5.40 ± 2.64 and 4.71 ± 2.46, respectively. Additionally, the means ± standard deviations of the total scores of students' attitudes toward radiation protection methods among operating room nursing and anesthesia students were 5.82 ± 2.68 and 4.42 ± 2.35, respectively. Moreover, the means ± standard deviations of the total score of their performance level in the two groups were 5.82 ± 1.09 and 5.71 ± 1.07, respectively (Table 2).

Table (2): The mean scores of students' level of knowledge, attitude, and performance regarding the principles of radiation protection by field of study and gender

Variable	Mean (Standard deviation)
	Field of Study		P-value	Gender		P-value
	Operating room nursing	Anesthesia	P-value	Male	Female	P-value
Knowledge	5.40 (2.64)	4.71 (2.46)	0.266	3.87 (2.59)	6.10 (2.05)	0.000
Attitude	5.82 (2.68)	4.42 (2.35)	0.023	3.48 (2.12)	6.59 (2.07)	0.000
Performance	5.82 (1.09)	5.71 (1.07)	0.661	5.54 (1.06)	5.97 (1.06)	0.098

The independent t-test results revealed a statistically significant relationship between the scores of students' attitudes toward radiation protection principles among operating room nursing and anesthesia students (P value = 0.023). There was no statistically significant relationship between the mean scores of knowledge level and performance of students between the operating room nursing and anesthesia groups. However, the average score among operating room nursing students was greater than that among anesthesia students.

Furthermore, Table 2 shows the mean scores and standard deviations of students' knowledge level, attitudes, and performance regarding radiation protection principles based on gender. According to the results of this table, the mean scores of knowledge level and attitudes toward radiation protection principles among female students were significantly higher than those among male students (P value < 0.001). However, no statistically significant difference was observed in the performance level scores of the students in terms of these principles between the male and female students (P value = 0.098).

The results indicate a statistically significant relationship between the overall GPA of all the students and the mean scores of their knowledge level and attitudes toward radiation protection principles, such that there is a positive and significant correlation between the students’ GPA and the mean scores of their knowledge level and attitudes toward radiation protection principles (P value = 0.000). However, statistical analyses revealed no relationship between the GPA and the grade obtained from students' performance concerning radiation protection principles (P value = 0.059). Furthermore, among operating room nursing students, there was a significant positive correlation between their GPA and their level of knowledge and attitudes toward radiation protection principles (r = 0.575 and r = 0.677, respectively) (p value = 0.000). However, among anesthesia students, only a significant and positive correlation was found between their attitude level and GPA (r = 650) (p-value = 0.000) (Table 3).

Table (3): Correlation coefficients of the scores of knowledge level, attitude, and performance towards the principles of radiation protection with grade point average and age of students

Variable	Field of Study	Knowledge		Attitude		Performance
Variable	Field of Study	r	P-value	r	P-value	r	P-value
Grade Point Average	Operating room nursing	0.575^*	0.000	0.575^*	0.000	0.142	0.416
	Anesthesia	0.309	0.070	0.650	0.000	0.314	0.066
	Total	0.449^*	0.000	0.648	0.000	0.227	0.098
Age	Operating room nursing	0.205	0.237	0.272	0.114	0.361^*	0.033
	Anesthesia	-0.250	0.148	-0.208	0.230	-0.120	0.491
	Total	0.005	0.970	0.085	0.482	0.127	0.296

Concerning the variable of the students' age, no significant correlation was found between the ages of all the students and their levels of knowledge, attitudes, and performance. However, among operating room nursing students, only a significant and positive correlation was found between their performance level with respect to radiation protection principles and their age (r = 0.361) (P = 0.033). No significant correlation was found among anesthesia students regarding age, knowledge level, attitudes or performance.

The use of modern medical imaging technology plays a vital role in the diagnosis and management of diseases. The ability of these methods to provide necessary information in the shortest possible time is widely increasing in various surgical procedures, especially orthopedic and spinal surgeries. However, facing the risks of using ionizing radiation via various imaging methods and adhering to protective protocols by personnel and students, in addition to their level of knowledge, can depend on multiple factors, such as their education level, current training policies for individuals, and the tools available for their training and practice [10]. Considering the limited studies on the level of knowledge, attitudes, and performance of students in these fields toward ionizing radiation, we resorted to research conducted on students in other medical science disciplines to investigate and compare our results with those of other studies in this area.

On the basis of our findings, considering the score range between zero and ten, the levels of knowledge, attitudes, and performance of operating room nursing and anesthesia students were average. In line with this result, in research conducted by Cheki et al., the level of knowledge of radiology students about radiation protection principles was also average [17], which may be due to

They are more familiar given that they receive more education due to the nature of their profession. However, a study conducted in Norway on final-year medical students indicated a low level of knowledge among students regarding the risks associated with ionizing radiation [18]. These results can be justified, considering that radiology students have more information about the principles of protection against ionizing radiation than do students in other disciplines. Additionally, in research conducted by Faggioni et al., the students' level of knowledge regarding the principles of radiation protection in several fields of medical sciences was fragile [19]. In line with these findings, Salih et al. reported that final-year nursing students' level of awareness and knowledge

was poor [20]. In addition, a study in Iran revealed that the level of knowledge among operating room staff regarding principles of protection against radiation was low, and their performance was average [21].

The abovementioned issues indicate a fundamental concern at different levels of education in various medical science disciplines regarding the ineffectiveness of teaching radiation protection principles. This lack of knowledge can lead to misconceptions and behaviors that may affect the health services provided. Additionally, the lack of knowledge among students can potentially lead to unnecessary prescription of ionizing radiation imaging tests in the future [18]. This can also result in inadequate patient education for various procedures, resulting in diverse challenges. Furthermore, these issues can impact legal matters such as obtaining informed consent from patients for surgical procedures. This approach can expose patients to various risks and challenges because patients, without receiving accurate information from healthcare professionals, may be unable to make informed decisions regarding alternative treatments based on the advantages and disadvantages of each method.

Our study revealed that operating room nursing students have significantly greater attitudes than anesthesia students do. In this context, in the study by Alavi et al., the field of study of individuals was also considered one of the predictors of individuals' knowledge level regarding radiation protection principles [22]. This difference can be explained by the educational curriculum and the direction of training in working with C-Arm machines by operating room nursing students, who have taken courses such as medical physics and familiarized themselves with the basics of radiology, which are not included in the radiography curriculum, may have higher scores as a result. Therefore, on the basis of our study findings and other research, it is recommended that educational units or specific courses, such as RP courses, be considered for students in various fields, especially those present in the operating room environment. Guidelines for using these types of radiation to utilize these technologies confidently for patient treatment should be established. Previous studies have shown that clinical training courses in the field of radiation protection principles significantly impact students' knowledge and performance regarding these principles [23].

In our study, a significant difference was found in the level of knowledge and attitudes between male and female students, with women reporting higher levels. However, no significant difference was found in performance regarding safety principles based on gender. In line with the results of our study, Aspasia Goula et al. reported a significant relationship between individuals' gender and their attitudes toward radiation protection principles. They observed that women had more misconceptions than male employees did. In this study, fear and stress among women regarding pregnancy in the future and the continuous risks of fluoroscopy and its effects on the fetus were considered reasons for the misconceptions and attitudes of female personnel [24]. In contrast, in the research of Kahkhaei and Sarani, among operating room staff, men had a higher level of awareness and lower performance than women did [21]. In this regard,

Asadian and Zarghani concluded no significant relationship exists between gender, knowledge, attitudes, and performance and radiation protection principles [25]. In their study of radiology students, Felayani et al. reported no significant relationship between students' level of knowledge and awareness and their gender [26]. These findings were consistent with the results of the studies by Cheki et al. [17] and Shabani et al. [10]. The reason for this discrepancy could be attributed to differences in the study population, the academic disciplines of the students, and the countries where the research was conducted, which affect how people are educated.

The findings of our study demonstrated a significant and positive relationship between GPA and the level of knowledge and attitudes toward radiation protection principles among operating room nursing students. Additionally, this relationship was also present among anesthesia students regarding their GPA and attitudes. However, in this study, the Pearson correlation test results did not reveal a significant relationship between the age of operating room nursing or anesthesia students and their attitudes toward or knowledge of radiation protection principles. In line with the results of our study, in the study by Jabari, no correlation was observed between the knowledge and performance of operating room personnel and their age and educational level [27]. Furthermore, Amjadi et al. reported no correlation between individuals' demographic variables and their knowledge and awareness of radiation protection principles [28]. In line with this result, in the study by Sundaran Kada, no relationship was found between the age of medical students and their knowledge and knowledge [18], suggesting that age cannot be considered a predictive factor for students' level of knowledge, attitudes, or performance.

On the basis of the findings of the present study, organizing training courses and incorporating coursework familiarizing students with the principles of working with ionizing radiation into the operating room nursing and anesthesia curriculum could be considered essential. Additionally, studies have shown that increasing students' knowledge can significantly reduce their stress and anxiety while working with ionizing radiation [15]. Therefore, specific training courses that include the necessary knowledge of the biological effects of radiation, the justification of exposure, the optimization of implementation methods, and the advantages and disadvantages of each technique are recommended. These courses can play a significant role in reducing students' stress and mitigating the risks associated with exposure to ionizing radiation.

Limitations and recommendations

Some of the limitations and shortcomings of this study include its cross-sectional nature. Another limitation of this study was the use of self-report measures, and incorrect answers could influence the responses. Therefore, the participants were assured of the confidentiality of the questionnaires. Additionally, the limited research population compared with the previous semester's operating room nursing and anesthesia students at Hamadan University of Medical Sciences was another limitation of this study that could impact the generalizability of its results. Owing to the level of knowledge and awareness of operating room nursing and anesthesia students, various training courses on the principles of radiation protection should be held at universities, and their effectiveness should be evaluated in future studies. Additionally, owing to the low number of students in these fields in each faculty, further studies should be conducted in this area, and their results should be compared with those of the present study.

Based on the results of the current study, the level of knowledge, attitudes, and performance of operating room nursing and anesthesia students toward protective principles is insufficient. Therefore, to minimize unnecessary exposure and ensure that operating room personnel understand the correct principles of working with radiation, nursing managers, department officials, and educational policymakers need to prioritize training on radiation safety principles. A fundamental effort is required to provide a more robust education and acquire greater RP in universities. Proper KAP and continuous training can easily prevent many types of radiation-related harm for both interventionalists and patients. Taking part in in-service training programs is crucial for cultivating positive RP attitudes. Creating a culture that emphasizes self-care is essential for improving performance.

Ethical Considerations

The study was approved by the Ethics Committee of Hamadan University of Medical Sciences with the code (IR.UMSHA.REC.1402.677). All participants were informed about the purpose of the study and informed consent to conduct the research was obtained. Also, the research units were assured of the confidentiality of the information.

Consent for publication

Not applicable.

Conflict of interest

There are no conflicts of interest.

Author details

¹ Sina Ghasemi. Student Operating Room (MSc), Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran. ² Hossein Khosravi. Assistant Professor of Medical Physics, Department of Radiology, School of Allied Medical Sciences, Hamadan University of Medical Sciences, Hamadan, Iran. ³ Behzad Imani. Associate Professor, Department of Operating Room, School of Paramedicine, Hamadan University of Medical Sciences, Hamadan, Iran. ⁴ Naeeme Shabani. MSc Student in Critical Care Nursing, Department of Medical Surgical Nursing, Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran. Orcid: 0009-0002-2652-4841

Funding

The study was funded by Vice-chancellor for Research and Technology, Hamadan University of Medical Sciences .

Author Contribution

S.Gh. and H.kH. conceptualized the study and developed the study protocol. B.I. oversaw the investigations and conducted analyses. S.Gh. wrote the main manuscript text. N.Sh. provided resources for data collection and performed data collection.

Acknowledgments

This study results from a research plan approved by Hamadan University of Medical Sciences. We would like to express our gratitude to the Research and Technology Vice-Chancellor of Hamadan University of Medical Sciences for the financial support of this study in the form of project number 140211109876.

Availability of data and materials

The datasets used during the current study are available from the corresponding author on reasonable request.

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Adherence to Radiation Protection Principles among Operating Room Students: Implications for Clinical Recommendations and Educational Interventions

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Abstract

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Introduction

Materials and Methods

Study Design and Participants

Collecting Data

Implementation of the study

Statistical analysis

Results

Discussion

Limitations and recommendations

Conclusion

Declarations

Author details

Funding

Author Contribution

Acknowledgments

Availability of data and materials

References

Additional Declarations

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