Radiography 24 (2018) 328e333

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Radiography
journal homepage: www.elsevier.com/locate/radi

A questionnaire study of radiography educator opinions about patient

lead shielding during digital projection radiography
C. Shanley*, K. Matthews
Radiography and Diagnostic Imaging, School of Medicine, University College Dublin, Ireland

a r t i c l e i n f o a b s t r a c t

Article history: Background: In projection radiography, lead rubber shielding has long been used to protect the gonads
Received 5 September 2017 both within and outside the collimated field. However, the relative radio-sensitivity of the gonads is
Received in revised form considered lower than previously, and doses from digital projection radiography are reported as being
26 March 2018
lower than in previous eras. These factors, along with technical difficulties encountered in placing lead
Accepted 5 April 2018
shielding effectively, lead to varied opinions on the efficacy of such shielding in peer reviewed literature.
Available online 30 April 2018
This current study has investigated what is currently being taught as good practice concerning the use of
lead shielding during projection radiography.
Keywords:
Patient protection
Method: An online questionnaire was distributed to a purposive sample of 44 radiography educators
Organ shielding across 15 countries, with the aim of establishing radiography educators' opinions about patient lead
Optimisation shielding and its teaching.
Radiation protection Results: From the 27 responding educators, 57% (n ¼ 15) teach students to apply gonadal shielding across
Good practice a range of radiographic examinations; only 22% (n ¼ 6) do the same for the breast, despite respondents
Survey being aware that the breast has higher relative radio-sensitivity than the gonads. Radiation protection
was the primary reason given for using shielding. Students are generally expected to apply patient lead
shielding during assessments, although a small number of respondents report that students must justify
whether or not to apply lead shielding. Educators generally held the opinion that no matter what they
are taught, students are influenced by what they see radiographers do in clinical practice.
Conclusions: The current study has not found consensus in literature or in radiography educators'
opinions concerning the use of patient lead shielding. Findings suggest that a large scale empirical study
to establish a specific evidence base for the appropriate use of lead shielding across a range of projection
radiography examinations would be useful.
© 2018 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.

Introduction
In projection radiography, lead rubber aprons and shielding (all
termed lead shielding in this paper) may be used both within and
outside the collimated field for the purpose of patient radiation
protection, and traditionally have most commonly been applied to
protect the gonads.1 However, peer reviewed, English language
literature published between 1998 and 2017 reveals mixed opin-
ions on the use of such lead shielding.
During pelvic radiography, lead shielding of the female2 and
male3 gonads has been reported to both reduce radiation exposure
Now practising in Our Lady's Children's Hospital Crumlin, Dublin.
* Corresponding author.
E-mail address: caoimhe.shanley@ucdconnect.ie (C. Shanley).
of the gonads when used within the primary beam2e4 and to
provide patient reassurance.2 However, several authors advise
against shielding the ovaries during pelvis radiography because of
the risk of retake due to inaccurate positioning, anatomical variance
and the potential negative impact on AEC function.1,3,5e7
Shielding of both male and female gonads outside of the colli-
mated beam is reported by several authors to convey dose savings
during spine and chest radiography.8e12 Dose reductions to the
breast and ovaries are reported, particularly in scoliosis imaging of
the spine in female patients, with dose reductions of 80% to breast
tissue reported in some cases.8,11,12 However, an empirical study
suggests that the gonadal dose levels are so low anyway that lead
shielding is not warranted.13
Several papers have a paediatric focus.1,3,4,6,14 For example,
neonatal gonadal shielding is advocated during portable abdomen
examinations because these may be serial examinations.4 In direct

https://doi.org/10.1016/j.radi.2018.04.001
1078-8174/© 2018 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.
 C. Shanley, K. Matthews / Radiography 24 (2018) 328e333
response to this paper, other author's question whether the very
low doses justify using such lead shielding.14,15 Similarly in pelvis
radiography, shielding is not advocated to be used due to risk of
retake of projections.1,6
An Australian paper3 combines the findings of a literature re-
view with empirical consideration of dose levels, and proposes that
for a range of single examinations, gonad shielding both within and
outside collimation is ineffective at reducing the risk of genetic
effects because the doses in question are so small anyway.
This low consensus on the efficacy of gonad shielding exists in
an era when the relative radio-sensitivity of the gonads is consid-
ered lower than previously. Relative radio-sensitivity is a concept
implicit in tissue weighting factor (Wt): any factor greater than
0 indicates higher than average radio-sensitivity, and the weighting
factors of all the body tissues add up to 1.16 In 2007, the Interna-
tional Commission on Radiological Protection (ICRP) reduced the
gonadal Wt from 0.2 to 0.08,17 implying that the relative radio-
sensitivity of the gonads is considered less than it was previously.
The main reason for decrease in gonadal Wt is the “reduced sig-
nificance” attached to genetic effects.17 In the same guidelines, the
ICRP state that the radio-sensitivity of the breast is higher than
previously specified, with a Wt increasing from 0.05 to 0.12. The
main reason for the increase in Wt for the breast is the “focus on
cancer incidence in detriment calculations”.17
The Wt of different tissues permits consideration of their
contribution to effective dose, which is a single value figure
determined by the risks of cancer, hereditary diseases or genetic
mutations due to ionising radiation.17 It is relevant to these changed
ICRP weighting factors that two recent papers advocate application
of lead shielding over the female breast during lumbar spine ex-
amination11 and during spine imaging for scoliosis.12
This context of mixed opinion and changed advice on tissue
radio-sensitivity engendered consideration of what actually is good
practice in the application of lead shielding during projection
radiography. Consideration of the ALARA principle may persuade
some radiographers that lead shielding should be applied no
matter how small the dose saving, because any dose reduction
enhances optimisation. Conversely, other radiographers may have
the opinion that the various reported risks of misplacement along
with the low doses in projection radiography are sufficiently
compelling to dispense with gonad shielding. Also, current tissue
weighting factors may be a stimulus for radiographers to recon-
sider which organs should be shielded. The initial basis for good
practice and application of the ALARA principle has to be what
radiographers learn in their pre-registration education.18 The cur-
rent research therefore set out to establish what is being taught as
good practice in the placement of patient lead shielding.
Methods
The proposed research was approved by the institutional Ethics
Committee. This research did not receive any specific grant from
funding agencies in the public, commercial or not-for-profit sectors.
Questionnaire design
The authors conducted a literature review to establish published
evidence concerning the use of lead shielding. This evidence, along
with knowledge of local clinical practice, was considered in
developing an online questionnaire using commercial software
(Survey Monkey ®) to investigate opinions about lead shielding,
what is taught about lead shielding, and what influences curricu-
lum content. The questions required either categorical or Likert
type responses, with open text options to permit further
329
explanation or additional opinions to be given. The questionnaire
was reviewed by an academic radiography colleague before being
tested in a small pilot study.
A pilot study was conducted to gather feedback on any ambi-
guity or lack of clarity which could be addressed before the main
study.19 The pilot study also established how long the questionnaire
took to complete, the potential response rate, and approximately
how long it took for the questionnaire to be returned. The ques-
tionnaire was sent to two academic teaching centres with one ac-
ademic and one clinical lecturer invited to participate from each:
this constituted approximately 10% of the proposed sample.20 Pilot
study participants were requested to complete the questionnaire
within two weeks. A response rate of 25% (one participant) was
received. Reasons for the remaining three participants who did not
respond were not given. The same approach for selection of par-
ticipants for the pilot study questionnaire was adopted for the main
study. Minor grammatical amendments were made, and a decision
was taken to follow up with reminders in the main study to
enhance the response rate.
Survey sample
The research was directed at establishing opinions from radi-
ography educators in centres with a reasonably comparable stan-
dard of radiography education. An overall population was not
established. Purposive sampling was followed to draw a sample of
educators from third level institutions that have at least a three year
programme encompassing some clinical placement, and where the
educators speak sufficient English to be able to complete the
questionnaire: these were the inclusion criteria. The indicative
sample was found through a combination of internet browsing and
institutional associations, and the research supervisor reviewed
that the level of practice of radiography was similar though not
identical across all. Arising from the search and supervisor guid-
ance, 23 third level institutions in 11 different countries were
identified: nine in the United Kingdom and Ireland; seven in other
European countries; three in Australia/New Zealand and four in the
United States/Canada. A lecturer in each institution with an
accessible e-mail address was contacted and asked to forward the
participant invitation to one academic lecturer and one lecturer
teaching in clinical practice. The potential sample of 44 educators is
presented as indicative only, and power sampling was not applied.
Clearly there are limitations to the sampling process, however the
findings represent an initial attempt to establish opinions on this
topic across an international cohort of educators.
Survey distribution
For the main study an active link to the online questionnaire was
e-mailed to participants in early December 2016. In order to pro-
mote response rate, a polite reminder was e-mailed two weeks
later. The questionnaire did not deactivate for a further two weeks
after this to allow for as many respondents to respond as possible.
Analysis
Descriptive statistics were applied to establish the frequency of
specific opinions about the use of lead shielding. Likert scale re-
sponses were evaluated by establishing median Likert scores. Open
text responses were subject to simple thematic analysis to establish
more common opinions or practices, although these must be
appreciated in the context of the relatively small number of
responses.
330 C. Shanley, K. Matthews / Radiography 24 (2018) 328e333

Results Reasons for lead shielding

The response rate was 61% (27 of 44 invited participants), with
24 participants providing geographic information as presented in
Table 1.
All respondents had worked as a clinical radiographer during
their career, most (74%, n ¼ 20) had been in a teaching position for
more than five years. Most respondents (65%, n ¼ 18) were
teaching as an academic lecturer, with 35% (n ¼ 9) holding a
clinical teaching position. As can be anticipated not all questions
were answered by all respondents and therefore reported per-
centages are calculated from the number of responses to each
question.
Opinions about lead shielding
Radiography educators reported their agreement with a series
of opinion statements on a balanced five point Likert scale from
strongly agree (scoring 5) through neutral (scoring 3) to strongly
disagree (scoring 1). Median Likert Scores (MLS) across all re-
spondents are presented in Fig. 1.
In open text responses, 12 educators reported their opinion on
the use of lead shielding had changed over the course of their
career. The questionnaire design was flawed in that educators were
not required to specify are they more or less likely to advise use of
lead shielding currently. However, four respondents specifically
proposed that improvements in collimation and digital detectors
reduce the validity of using lead shielding.
Radiation protection was the reason most frequently reported
for teaching the use of lead shielding, as shown in Fig. 2.
Assessment of student use of lead shielding
Educators reported that student use of lead shielding is assessed
by a variety of assessments and coursework including written,
practical and clinical tests. Respondents explained in open text how
an assessment grade would be affected if what was taught about
lead shielding was not applied. Only four educators reported that
grades would not be affected at all. In 28 of 38 comments (re-
spondents offered multiple comments), the implication of not us-
ing gonadal lead shielding would be at least a grade reduction, and
eight of these comments indicated the possibility of an automatic
fail of clinical assessment. Six further comments suggested a case
by case consideration, with students being judged on their ability to
justify whether to apply lead shielding or not.
Opinions compared with what is taught
What educators teach about the use of lead shielding (Table 2)
was compared with the opinions they reported about lead shield-
ing (Fig. 1) and also with their length of experience using Pearson's
Chi-square analysis. No statistically significant associations were
found, with p values for the various analyses ranging from 0.22 to
0.81.

Placement of lead shielding Discussion

For five broad categories of examination, educators reported Arising from mixed opinions in peer-reviewed literature con-
whether they would teach students to shield the gonads or breast cerning the application of lead shielding during projection radi-
for reasons of any of protection, image quality or patient reassur- ography, this small survey was undertaken to establish what is
ance. Not all respondents answered all questions, the responses being taught in this regard in undergraduate programmes. Results
given are summarised in Table 2. are reported from 27 staff in 23 institutions across 11 countries. The
Generally the educators that did report teaching the place- mixed opinions on the efficacy of lead shielding that are reported in
ment of lead shielding did so across all patient types. However, literature are apparent in similar mixed opinions and approaches
for each group of examinations a small number of respondents among educators. Similarly as seen in other literature, organs
(always three or fewer) reported they would teach the use of radiographers state need to be protected might not be performed in
gonadal lead shielding mainly for female, paediatric and/or practice.21 The authors make no claim that the current findings are
pregnant patients. Depending on the examination type, between necessarily representative of all opinions and approaches, rather
12 and 35% of respondents would not protect the gonads at all. that they may be sufficiently indicative to raise questions for
When considering the breast, the proportion not teaching lead investigation in a larger scale study.
shielding at all rose to between 59 and 71% depending on ex- Reference to Fig. 1 indicates educators strongly agree (MLS ¼ 5)
amination type. However, 40% of respondents would teach breast that lead shielding should be used over organs with higher radio-
shielding for female patients during examinations of the sensitivity. However, educators opinions are neutral (MLS ¼ 3) on
abdomen, spine and pelvis. whether lead shielding is more important for the gonads
(Wt ¼ 0.08) than the female breast (Wt ¼ 0.12), and in disagree-
ment that lead shielding is more important for the colon
Table 1 (Wt ¼ 0.12) than the ovaries (Wt ¼ 0.08).
Geographical data concerning participants. These comparisons are relevant if the aim of using lead shielding
Country Number of educators Number of educators is to offer protection, which in the current study is indeed the
currently working here who trained here primary reason that use of shielding is taught (Fig. 2). This being the
United Kingdom 8 10
case, it is logical that such shielding should be applied to organs
Canada 3 3 that are more radio-sensitive. However in the current study, edu-
Finland 2 2 cators reported teaching the use of gonadal shielding over and
Netherlands 2 2 above shielding of other tissues with higher tissue weighting factor.
Slovenia 2 2
For example, during upper extremity examinations, 63% (n ¼ 17) of
Australia 1 1
Belgium 1 1 educators advocate for gonadal shielding whereas 56% (n ¼ 15) of
Denmark 1 1 educators teach that breast shielding is unnecessary. The authors
Ireland 1 0 acknowledge that in all examinations, elements such as the direc-
Italy 1 1 tion of the beam and position of the patient must be considered.
New Zealand 1 0
However, all other elements optimised, the point is simplistically
 C. Shanley, K. Matthews / Radiography 24 (2018) 328e333 331

Figure 1. Median Likert Scores as indicators of educator opinions on lead shielding during projection radiography.

Table 2
Sites and reasons for applying lead shielding in different examination categories.

Examination Response frequency Reason

Over the gonads Over the breast

Upper Extremity 15 8 Radiation Protection

Lower Extremity 17 8
Skull/Cervical spine/Shoulder 13 9
Chest/Thoracic spine 17 5
Abdomen/Pelvis/Lumbar spine 19 11
Upper Extremity 0 0 Image Quality
Lower Extremity 0 0
Skull/Cervical spine/Shoulder 0 0
Chest/Thoracic spine 0 0
Abdomen/Pelvis/Lumbar spine 1 0
Upper Extremity 5 1 Patient reassurance
Lower Extremity 4 0
Skull/Cervical spine/Shoulder 2 0
Chest/Thoracic spine 1 0
Abdomen/Pelvis/Lumbar spine 2 0
Upper Extremity 4 10 Not necessary
Lower Extremity 3 9
Skull/Cervical spine/Shoulder 7 8
Chest/Thoracic spine 5 10
Abdomen/Pelvis/Lumbar spine 1 6
332 C. Shanley, K. Matthews / Radiography 24 (2018) 328e333
Figure 2. Reasons for placing lead shielding across all examination types.
made that if lead shielding is going to be used, it should be used
over organs that have higher than average radio-sensitivity.
This brings the consideration to whether lead shielding outside
of the beam offers any meaningful dose reduction to the shielded
organ, an issue which has been questioned by some authors.13e15
Educators had mixed opinions on the dose saving when lead
shielding is outside of the primary beam, with the wide spread of
response resulting in a neutral MLS ¼ 3. This ambivalence reflects
the mixed opinions that are apparent in literature, and in
conjunction with the reported teaching about shielding, suggests
that educators are advising students to protect the gonads when
sometimes no substantial dose reductions are perceived. No-one
could dispute that to err on the side of caution is probably good
practice in the context of optimisation, yet not one of the re-
spondents disagreed that their teaching about lead shielding is
based on literature evidence. Given the uncertainty in literature
about the protective efficacy of lead shielding, a large scale
empirical study to establish unequivocal evidence for the use or
otherwise of lead shielding seems to be needed.
The authors were interested to understand how educator's
opinions on lead shielding related to student assessment. In open
text responses, 28 of 38 separate statements suggested that lead
shielding should always be applied during assessment: several of
these comments were received from educators who agreed that
minimal dose reduction would accrue. Contradictions between
taught theory and applied assessment criteria are not conducive to
either deep learning or eventual good clinical practice. Again in
light of the low literature consensus, it seems a better approach to
assessment would be to assess whether students can justify the use
or non-use of lead shielding on an individual patient basis. This
approach was reported in only six of 38 comments received.
The current study focussed on what is being taught about lead
shielding because what is being taught will inevitably promulgate
into practice.22 It is noteworthy then, that educators strongly
agreed (MLS ¼ 5) that students will be influenced by what radi-
ographers do in practice irrespective of what they are taught. This
opinion highlights the importance of all staff, academic and clinical,
taking on the promulgation of good practice, and adds weight to the
need for a study on lead shielding identifying what good practice
should be.
Conclusions
The current study is not definitive, but has raised several points
for consideration.
There is mixed literature evidence on whether to adopt the use
of patient lead shielding both within and outside the primary beam
during projection radiography.
There are some apparent contradictions between radiography
educators' opinions regarding organ radio-sensitivity and their
teaching, and gonadal lead shielding for all patients across a range
of examinations seems to be the predominant practice. The breast
is acknowledged as a radiosensitive organ, but is not so widely
protected with lead shielding as are the gonads. Students are
generally expected to apply gonadal shielding in clinical and writ-
ten assessments, although a small number of educators expected
their students to carefully justify whether or not to use lead
shielding.
Findings suggest the need for a large scale empirical study to
establish a well-founded and specific evidence base for the
appropriate use of lead shielding across a range of projection
radiography examinations. Such evidence would greatly assist both
academic and clinical radiographers in establishing and promul-
gating good practice in the use of patient lead shielding.
Conflict of interest
There is no conflict of interest.
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