Role of the Radiation Safety Officer: Final Evaluation Report

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Acknowledgements

The Canadian Nuclear Safety Commission (CNSC) would like to acknowledge and thank the following contributors:

The Ottawa Hospital for the valuable assistance that was provided in the planning of this evaluation:

We extend our appreciation to Michèle Légaré, Director and Corporate Radiation and Laser Safety Officer, for her participation as a radiation protection program expert on the Evaluation Advisory Committee. Her contribution was instrumental in helping the project evaluate potential factors that may lead to successful implementation of a radiation protection program for CNSC licensees.

Ms. Légaré organized a day of job shadowing to help CNSC evaluators better understand the role of radiation safety officers. She also hosted evaluators during a radiation safety committee meeting at The Ottawa Hospital. Participation in both of these activities provided valuable insight into the role of radiation safety officers in a health care facility.

Thank you to Ali Soushtarian, Nadia Zaid, Jon Aro, Alex Wolf and Praveen Ratra for sharing information on a variety of topics related to radiation safety such as internal permits, record-keeping practices, policies and overall program management.

Members of the radiation safety officer working group who provided expert advice and guidance to evaluators:

We extend our appreciation to the following individuals who provided valuable feedback on the evaluation planning documents, including the terms of reference, the theory of change, multiple interview guides and surveys:

• Kate Scheel, Program Manager, Ionizing Radiation, Simon Fraser University
• Stéphane Jean-François, Certified Health Physicist, Radioprotection Inc.
• Jeff Dovyak, Radiation Safety Coordinator, Winnipeg Regional Health Authority

External members who provided input and feedback on the evaluation methodology, scope, recommendation and report, and participated in the Evaluation Advisory Committee:

• John Mayne, Advisor on Public Sector Performance
• Steve Montague, Partner, Performance Management Network Inc.

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Executive summary

Context

The CNSC recognizes the critical importance of radiation safety officers (RSOs) who work for nuclear substances and radiation devices licensees. It also recognizes the significance of recent industry trends. For these reasons, the CNSC undertook this evaluation to analyze the contributing factors that lead to success for RSOs in the medical and academic/research sectors. While the CNSC’s REGDOC‑1.6.1, Licence Application Guide: Nuclear Substances and Radiation Devices, provides some guidance to RSOs, the evaluation sought to understand how infrastructure, institutional, interpersonal and individual ^{Footnote 1} factors can also have an impact.

Results of this evaluation will support the development of a new regulatory document that will provide additional guidance for licensees on the design and implementation of an effective radiation protection program.

This evaluation focuses on nuclear substances and radiation devices RSOs. Class II RSOs are out of scope of this evaluation.

Nuclear substances and radiation devices RSOs

With their expertise and knowledge of radiation protection, RSOs are critical to the implementation of the licensees’ radiation protection programs. RSOs’ contributions help to ensure that licensees are compliant with regulatory requirements, that doses to workers and the public are controlled and that licensees have an enhanced safety and security culture.

Licensees are responsible for putting in place safety and control measures through the implementation of a radiation protection program. The CNSC reviews these measures during its assessment of licence applications and verifies the measures through compliance activities. Through these oversight activities, the CNSC closely monitors trends in the licensees’ operational structures and performance.

During the evaluation, due consideration was given, through 11 case studies, to the different contexts in which RSOs operate. In the medical sector, operational contexts can be vastly different. This sector can include a wide variety of licensees – from large amalgamated hospitals, with complex operation and multiple sites, to small community hospitals with only one site. While RSOs working in the academic/research sector may also have complex operations, they do not face the same pressures as RSOs in the medical sector. In general, significant budget constraints and the important focus on patient care add an additional layer of complexity to the role of RSOs in the medical sector.

Methodology

The evaluation was conducted in 2017–18 and used standard evaluation and research methodology, Treasury Board Secretariat (TBS) standards and policies, and the good practices of the Canadian federal government.

To answer the evaluation questions, a mixed-methods approach was used, blending various data collection strategies. The rationale in using this approach is that the assessment of RSOs’ success factors and their influence on the radiation protection programs is mostly qualitative and relies, for the most part, on the judgment and experience of the stakeholders.

Evaluation results are based on information collected through:

• document and literature review
• key informant interviews
• online surveys
• case studies to examine the role of RSOs who work for specific licensees operating in different contexts and with different compliance records
• comparative analysis to explore the effectiveness of the role of the RSO when compared to the role of nuclear substances and radiation devices RSOs internationally (United States and United Kingdom) and other similar roles nationally such as:
  • biosafety officers
  • flight safety officers
  • occupational health and safety officers

The evaluation also relied on data analysis spanning a 10-year time frame (2007–17). CNSC staff provided over 40,000 rows of data to the evaluation team in support of this analysis, extracting the data from three sources:

• the Licence Operating Users Integrated System (LOUIS)
• administrative monetary penalty (AMP) notices of violation
• the Event Information Tracking System (EITS)

Recommendations

The following recommendations are proposed:

• 1.The CNSC’s Directorate of Nuclear Substance Regulation (DNSR) should provide regulatory guidance to RSOs with respect to:
  • the characteristics of a successful internal audit/inspection program (frequency, format, timing, templates)
  • adequate RSO resourcing levels based on the nature and magnitude of the licensed activity
  • the content of RSO work descriptions based on the nature and magnitude of the licensed activity
  • the appropriate composition and purpose of radiation safety committees given the different contexts in which RSOs operate
• 2. DNSR should enhance its existing compliance promotion strategy to support RSOs with their continuous improvement activities.

Observations

DNSR should consider, in collaboration with external partners:

• further promoting the nuclear substances and radiation devices mentorship opportunities for RSOs that are currently described on the CNSC’s external website
• exploring the possibility of supporting the development of an RSO training program

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Introduction

This report presents the findings, conclusions and recommendations from the evaluation of the role of nuclear substances and radiation devices radiation safety officers (RSOs) from the medical and academic/research sectors. Undertaken by the Canadian Nuclear Safety Commission (CNSC) between July 2017 and July 2018, it looks primarily at the contribution of the RSO to the effectiveness of the radiation protection program.

The work was conducted in accordance with the Treasury Board of Canada Secretariat’s Policy on Results and Standards on Evaluation and employed a mixed-methods approach to collect both qualitative and quantitative evidence.

Report structure

This evaluation report has been divided into chapters to allow the reader to select the level of information that meets their needs. While the report can be read as a comprehensive piece on the evaluation, each chapter offers different levels of information.

• Chapter 1 can be read as a standalone report. It provides an essential summary of the evaluation and offers the reader an overview of the evaluation purpose, consultation strategy and key findings. Where generalizations are made on effectiveness, these are based on triangulation of evidence (presented in chapter 2).
• Chapter 2 is written from an evaluator’s perspective. It presents the data behind the logic and offers the reader the supporting evidence from which the findings, conclusions and recommendations have been drawn. Chapter 2 summarizes the data from six technical reports that form the basis of the evidence collected.
• Chapter 3 outlines the detailed recommendations and observations.

Purpose of the evaluation

The need for this evaluation was identified by the Director General of the Directorate of Nuclear Substance Regulation (DNSR) in response to performance trends in the industry, and in DNSR’s presentation of the Annual Regulatory Oversight Report on the Use of Nuclear Substances in Canada: 2015 to the Commission.

The Commission asked CNSC staff to evaluate and recommend a regulatory approach for nuclear substances and radiation devices RSOs in the medical and academic/research sectors, because regulatory oversight identified weaknesses in implementation of radiation protection programs with some licensees undergoing transitions.

The evaluation results are intended to support the development of regulatory guidance for licensees on the design and implementation of effective radiation protection programs.

Program description

Radiation protection programs are required for every licensee to ensure that contamination levels and radiation doses received by workers are monitored, controlled and maintained below regulatory dose limits, and kept as low as reasonably achievable (ALARA). In general, these programs ensure that licensees are in compliance with regulatory requirements. All licensees are required to designate a minimum of one person who is responsible for implementing the radiation protection program. This person is named the radiation safety officer (RSO). The purpose of having a person dedicated to radiation protection within the licensee’s organization is to ensure effective implementation of the radiation protection program and the overall safety performance of the licensee.

REGDOC-1.6.1,Licence Application Guide: Nuclear Substances and Radiation Devices,provides guidance on qualifications and duties of RSOs. Some of these responsibilities, as listed in appendix C of REGDOC-1.6.1, indicate that RSOs may need to:

• assess the qualifications and competence of workers who will use nuclear substances and radiation devices to determine whether they can do so safely and in compliance with regulations and the licence
• ensure that workers who are required to use nuclear substances and radiation devices are adequately trained in radiation safety and radiation protection procedures
• authorize qualified workers to use nuclear substances or operate radiation devices
• ensure that workers whose duties may occasionally expose them to nuclear substances and radiation devices, such as cleaners, administration or other support staff, receive appropriate training in radiation safety
• communicate with all workers and management
• monitor, advise and consult on issues related to the handling of nuclear substances and radiation devices in accordance with regulations and licence conditions
• review requests for authorization to purchase or use nuclear substances and radiation devices in order to ensure that the radioactive material and the proposed handling and location of storage are acceptable and comply with the regulations and licence requirements

Designating RSOs

The designation of RSOs for nuclear substances and radiation devices licences is the responsibility of the person accountable for the management and control of the licensed activity. Known as the applicant authority, this person is generally a member of senior management within the organization with sufficient delegated authority to direct human and financial resources to address any issue of non-compliance identified by the CNSC.

Certification

Nuclear substances and radiation devices RSOs are not required to be certified by an independent body or by the regulator. They are required to maintain sufficient knowledge related to the proposed licensed activities and the applicable regulatory requirements to enable the licensee to effectively manage activities with nuclear substances and radiation devices in accordance with the terms of the CNSC licence. The RSOs’ qualifications are included in the licence applications. A CNSC licensing officer will assess, as part of the regulator’s review of the application, if the RSO listed in it has sufficient knowledge and expertise with regard to the applicant’s proposed activities. This assessment will form part of the CNSC’s recommendation on the application.

Corporate and site RSOs

Depending on the complexity of the licensee’s radiation protection program, a licensee may designate a corporate RSO to oversee the management of the program at the corporate level. Site RSOs report to the corporate RSO and are responsible for overseeing the program at the site to ensure that the corporate program is effectively implemented at the local level.

Depending on the structure and size of the organization, it may be necessary to designate several site RSOs for the same location. The authority, role, responsibility and qualifications of each site RSO must be clearly defined and communicated throughout the organization.

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Chapter 1 – Results of the evaluation

Setting the stage

Through collaboration with DNSR and RSOs across Canada, the CNSC’s program evaluation team launched the evaluation of the role of RSOs in 2017.

The goal of this project was to gather evidence for DNSR and the Commission on the key factors that impact RSOs’ success in their roles. The work took into consideration the variety of licensee operations such as level of complexity of operations, differences in organization size and the geographic disparity of sites. The findings will support the development of a new regulatory document that will provide additional guidance for licensees on the design and implementation of an effective radiation protection program.

Sectors

Nuclear substances and radiation devices are used in a broad range of applications in Canada. As a result, the CNSC has grouped them by five sectors, according to their primary uses, which are: medical, academic/research, industrial, waste nuclear substance and commercial.

In the past decade, a number of licensees in these sectors have implemented significant changes in the way they organize and conduct business. In the public sector, several provinces, including Alberta, Quebec and Nova Scotia, have transitioned to provincial or regional governance structures for health facilities. The objective of these transitions is to improve coordination of the delivery of health services, reduce administrative overhead and leverage cost efficiencies.

This project focused on two sectors – medical and academic/research. DNSR selected these sectors because they have more complex radiation protection programs and share similarities in RSO functioning. They are also representative of a changing landscape, with a number of amalgamations having taken place in recent years. Approximately 380 RSOs work in these two sectors. Through early engagement, several RSOs have demonstrated an interest in supporting the CNSC in better understanding the impact of the RSOs’ role on licensees’ radiation protection program performance.

The project included two licensees from the commercial sector. This provided some idea of how the results of the project could be applied to this sector.

It is important to mention that CNSC licensing and compliance activities have not identified a systemic problem that would indicate an issue with the qualifications or suitability of RSOs as a whole. However, given the critical importance of RSOs to radiation safety, this evaluation is an opportunity to review the CNSC’s oversight strategy, in order to identify opportunities to more proactively influence licensees’ radiation safety performance.

Engagement strategy

From January to March 2018, the evaluation team reached out to a wide range of people directly involved in radiation protection programs in both hospitals and universities. The evaluators gathered qualitative data through interviews and online surveys. They conducted over 90 in-person interviews and visited 11 licensees. They supplemented these sources of information with licensee compliance data, a document and literature review, and comparative analysis research. They analyzed data by triangulating information gathered from these different methods.

While the primary stakeholders were RSOs, the team also consulted other stakeholders, including:

• nuclear medicine technologists
• chiefs of nuclear medicine
• cardiologist technologists
• graduate students
• housekeeping and security personnel
• physicians
• professors and associate professors
• veterinarians and veterinary technologists
• senior managers

The ultimate goal of the engagement phase was to collect as much information as possible on the factors that help RSOs succeed in their role, given the different contexts in which they operate. Throughout this phase, the CNSC evaluation team was impressed by the high level of stakeholder participation and contribution to the project.

RSOs’ four areas of activity

RSOs have a wide range of responsibilities. Working with the RSO community, the evaluation team developed a straightforward approach that grouped their work into four main areas. These four areas reflect the core activities that form the daily work of RSOs. This structure allowed for the identification of factors that impact the success of RSOs for each activity area, which are described below.

Area 1 – Training activities

RSOs deliver training to ensure that workers adopt safe work practices. Included in the training activities are the design and delivery of the course content, as well as the evaluation, update and maintenance of the training content to ensure that it is up to date and relevant. RSOs offer training in many different ways – classroom-style, one-on-one or through an online platform.

Area 2 – Communication and advice activities

A large part of the RSOs’ work involves sharing performance information with management and providing timely information and feedback to workers. RSOs also act as the main point of contact with the CNSC and have exchanges on regulatory issues with their licensing officers.

Area 3 – Monitoring, controlling and reporting activities

These activities consist of ensuring that nuclear substances and radiation devices are handled in accordance with regulations and licence requirements. They can encompass designating nuclear energy workers (NEWs), developing a security plan, designing monitoring programs, monitoring occupational radiation doses received by workers, conducting inspection activities, and much more.

Area 4 – Continuous improvement activities

RSOs undertake these activities to ensure that they are aware of industry good practices that can be applied to their own radiation protection program. This may include reviewing changes in regulatory requirements, monitoring reportable events in Canada and internationally, or attending conferences and training.

Other influencing elements

Limiting the scope of this project to these four areas of activity would not provide a comprehensive picture of the RSOs’ contribution to radiation protection programs. For a more complete appreciation of the other elements that directly impact the RSO, the team explored other themes. These included the following.

• Governance – Are the right governance models in place?
• Certification – Are there advantages to considering certification for nuclear substances and radiation devices RSOs?
• Alignment across regulatory bodies – Is there an impact to alignment or lack of alignment across regulatory bodies?
• Relationship with the CNSC – Does the relationship with the regulator allow for open communication and effective resolution of non-compliance?

The RSOs’ influence on stakeholder behaviour

This evaluation focused on understanding how the RSOs’ efforts in each of the four areas of activity contribute to the effectiveness of radiation protection programs. That meant making a distinction between the RSOs’ core activities and radiation protection programs as a whole.

To help with this, the evaluation team adopted the COM-B model ^{Footnote 2}, a recognized tool in evaluation, to guide the team’s understanding of behaviour. This model allowed the team to look more closely at the conditions that should exist for people to change their behaviour. In simple terms, the COM-B model looks at the following three elements necessary for behaviour change to occur.

• Capabilities – Do people have the right knowledge and skills?
• Opportunity – What outside factors help or hinder the desired behaviour changes to occur?
• Motivation – How engaged, motivated and committed are people?

For example, it’s possible to think that worker participation in a radiation protection training session will lead to a greater understanding of the topic. But for the training to be understood, a number of different factors or conditions need to be present, such as timeliness of its delivery and suitability of the content for the specific audience.

In addition to considering COM-B elements that contribute to behaviour change, the team also considered conditions and factors that can either help or hinder realization of the desired change. Based on the work of Pawson and Tilley (2004), these factors are grouped under four categories called the 4Is: infrastructure, institutional, interpersonal and individual (appendix D). The evaluation looked at the presence or absence of these factors and how they impact the RSOs’ ability to positively influence the performance of the radiation protection programs.

What the evaluation team found

Overall, RSOs in both sectors had the capabilities, opportunity and motivation to deliver effective radiation protection training, disseminate essential information and conduct thorough monitoring and oversight activities. When it came to continuous improvement activities, the degree of access RSOs have to radiation protection good practices and lessons learned is varied. This is due to barriers such as lack of time to attend learning events, lack of funding to attend learning events, lack of management support and lack of adequate access to online resources.

Keeping in mind the wide variety of licensee operations and differences in organizational size, structure and complexity, not all RSOs are equally successful in all four core areas of activity. When the team compared the medical and academic/research sectors, RSOs in the medical sector appeared to face more obstacles than their counterparts in the academic/research sector. This is primarily due to factors such as budget constraints, complexity of operations, and the nature of the RSOs’ work in the medical sector – that is, the need to manage the additional variable of patient care.

RSOs in large institutions in the medical sector face unique challenges. These can be compounded if they lack sufficient time to fulfill their RSO-related duties. They may lack time because they are part-time RSOs managing complex radiation protection programs, the operations are spread across different sites, or direct patient care takes precedence over their RSO duties.

The evaluation team heard from both new and experienced RSOs, in both small and large organizations, that additional regulatory guidance from the CNSC would be beneficial. Several RSOs are looking for additional guidance to support their internal inspection activities. Specifically, they feel that it would be valuable to have templates to help them conduct effective internal inspections, as well as guidance on the frequency and format.

Many RSOs put forward ideas such as how to leverage social media to provide just-in-time regulatory information. Others suggested ways the CNSC could enhance its online resources to provide more detailed and practical regulatory information and guidance.

The team noticed that in large hospitals, budget constraints and travel freezes can limit the RSOs’ ability to participate in learning activities. Many RSOs shared their thoughts on how the CNSC could increase its use of technology to facilitate virtual participation in some learning activities.

The need for further regulatory guidance stood out as a recurring theme throughout the engagement with RSOs; therefore, the evaluation recommendations focus on this area.

Training activities

In most cases, the training activities delivered by RSOs are effective in helping workers adopt safe practices. There was no evidence of a wide-ranging problem in the RSOs’ ability to deliver radiation protection training to those who need it.

However, case study evidence identified situations where some RSOs face challenges. For instance, it can be more difficult for part-time RSOs in large hospitals with multiple locations to have enough time to handle all the administrative duties of the training program (identifying the workers who need to be trained, maintaining the content, tracking attendance and delivering the training in a timely manner). A challenge that RSOs working in the commercial sector can face is finding the right time to train shift workers. This is because the workers face operational production pressures and are not able to take time during their shift to attend training. As a result, workers may need to either come in early before a shift or stay late after a shift to attend training.

The evaluation team found that training offers participants a solid understanding of effective radiation protection practices and procedures, particularly if it is timely and tailored to the audience. RSOs value online learning management systems to help alleviate the time required to deliver in-class or refresher training. Those currently without an online learning platform are seeking to adopt one, as they recognize it would be a valuable time saver. Workers were of the opinion that more opportunities to learn through hands-on exercises, such as practising to clean up a mock spill, were needed.

83% of the RSOs feel that nuclear energy workers demonstrate strong motivation and engagement in the learning. They tend to ask questions and show active engagement during the training. Likewise, auxiliary staff also demonstrate good engagement levels in learning, even though their level of involvement in the radiation protection program is indirect.

Most workers feel a sense of responsibility, are motivated and adopt safe radiation protection practices, but it is not always as a direct result of the training. It can result from the organization’s safety culture or from the sense of the possibility of regulatory consequences.

The overall health of an organization’s safety culture also plays a key role in ensuring that safe practices are adopted. For instance, the team often heard that workers keep each other accountable by speaking up when they witness a potentially unsafe work practice.

In terms of the impact of regulatory consequences, RSOs often told the evaluation team that the threat of a potential negative impact to a licence is the primary factor that motivates workers to adopt safe work practices.

COM-B findings

From the COM-B perspective, workers understand radiation protection practices as a result of the training they receive. This understanding is generally attributed to the fact that the majority of RSOs tailor the radiation protection training to the audience. For example, RSOs might offer a more simplified level of training to auxiliary workers using pictograms, particularly if there is a language barrier because English is the workers’ second or third language. More in-depth training accompanied by a comprehensive training manual would be offered to nuclear energy workers and non-nuclear energy workers.

94% of the workers are provided with sufficient time away from their work to attend training. The evaluation team heard that it can be challenging to find the right time to provide training to shift workers in the commercial sector.

The team found that workers were engaged in learning about radiation protection and that the RSOs’ views mostly align with this opinion. Even though auxiliary workers may only be peripherally impacted, they understand the training and are engaged in it.

Key factors

The factors that impact the success of RSO training activities and should be considered in the development of regulatory guidance are outlined below.

Factors that support success	Factors that limit success
timely training delivery (individual/interpersonal) hands-on, practical training components (individual/interpersonal) audience-specific training content (individual/interpersonal) strong safety culture, specifically pressure from peers to work safely (interpersonal) the potential of negative regulatory consequences (infrastructure)	lack of time allocated to the RSO function to ensure that training content is up to date and approach is meaningful to learners (institutional) competing operational priorities such as number of patients to see in a day (institutional)

Communication and advice activities

RSOs in the medical and academic/research sectors are effective in their communication and advice activities. The majority of RSOs in both sectors appear to have the necessary skills, time and ability to communicate and engage with program stakeholders, and these efforts contribute to workers adopting safe radiation protection practices.

The evaluation team identified some situations in the medical sector where workers did not value the RSOs’ communications. In each case, the reason was because the workers did not view the RSO as a credible authority on radiation protection, due to the perception that the RSO lacked experience either in the licensed activity or as an RSO.

The evaluation team found no evidence of systemic problems in the RSOs’ ability to transmit program information to workers, their management or the CNSC. In a few cases, RSOs working in large organizations with multiple sites told the team that they would like to have more time to proactively disseminate information. As it stands, given their workload, their communications tend to be reactive, rather than proactive.

One of the keys to successful communication is the physical proximity of the RSO to the workers. More frequent interactions naturally take place when RSOs are located in the same department, on the same floor or in the same unit as the workers. As a result, workers are more inclined to ask the RSO questions because they see each other on a daily basis. The team observed that corporate RSOs in large organizations in the medical sector rely on the site RSOs at the other locations to act as the main point of contact for workers.

Communication between RSOs and the applicant authority is generally effective, even though it may be very infrequent. 89% of the applicant authorities report receiving advice from the RSO on their organization’s radiation protection program. In small hospitals, RSOs appear to interact with management more frequently than do RSOs in larger organizations. In large or amalgamated organizations, RSOs may speak to the applicant authority monthly, once a year or less often.

The evaluation team found no evidence that either frequent or infrequent communication had a direct impact on the overall success of a radiation protection program. The team heard from the vast majority of RSOs that, as long as no compliance issues arise, the applicant authority is generally not concerned with the details of the radiation protection program. 67% of the applicant authorities read the radiation safety committee meeting minutes they receive from the RSO, and this appears to be sufficient to meet their information needs.

COM-B findings

From the COM-B perspective, the evaluation team found that the information the RSOs disseminate helps workers and management better understand the radiation protection program objectives. The team found no evidence of information gaps or any overall lack of knowledge either from workers or management on the radiation protection program.

In the vast majority of cases, workers are able to receive information and advice from RSOs and feel comfortable reaching out in person, via email or by phone.

Workers and management value information disseminated by RSOs. There are exceptions in the medical sector, where some RSOs are not seen as credible authorities on radiation protection. As a result, workers rely on colleagues, rather than the RSO, for advice. The team also found that management can become more heavily involved in the day-to-day management of the program if they lack confidence in the credibility or authority of the RSO.

Key factors

The factors that impact the success of RSO communication activities and should be considered in the development of regulatory guidance are outlined below.

Factors that support success	Factors that limit success
the ease of access of the RSO to workers to provide just-in-time advice and information (individual and interpersonal)	lack of time allocated to the RSO function to proactively share information with stakeholders (institutional) competing operational priorities such as number of patients to see in a day (institutional) RSO not perceived as a credible authority of radiation protection (individual/interpersonal)

Monitoring, controlling and reporting activities

RSOs in both sectors are generally able to conduct effective monitoring, controlling and reporting activities. As a result, workers make adjustments to their work when needed and licensee management obtains useful performance information.

There are some differences within the medical sector. Full-time RSOs have sufficient time for these activities because they do not juggle as many other tasks such as patient care. They have sufficient time to conduct internal audits, disseminate the audit findings, prepare reports for the CNSC and maintain internal records. Part-time RSOs working in large and small hospitals mostly have enough time for these activities, but it is at the expense of other work. In other words, it’s always a balancing act for them to fulfill their administrative duties while also tending to patient care activities.

One of the keys to a successful internal audit program is timely follow-ups on audit findings. These follow-ups are essential because they ensure that changes are implemented. Part-time RSOs in large hospitals with multiple sites have time to conduct internal audit activities, but they lack sufficient time to verify that the audit findings and recommended changes are implemented. As a result, they may see issues recur over time.

90% of the workers in both sectors, regardless of organization size, receive clear feedback from RSOs on their work performance. This feedback is usually shared in person, via email or through the employee’s line manager.

When RSOs identify areas of non-compliance through internal audit activities, they feel that they are successful in enforcing radiation protection practices. RSOs who are less successful feel that barriers such as worker complacency and the perceived lack of RSO credibility prevent them from achieving success.

RSOs resolve worker non-compliance (such as lack of contamination control) through open dialogue with the worker. If required, the issue is escalated to the employee’s manager. RSOs consistently viewed that this informal enforcement strategy was effective.

COM-B findings

From the COM-B perspective, the evaluation team found that the monitoring, controlling and reporting activities provide stakeholders with increased knowledge of program performance. 89% of the applicant authorities receive the information they need to assess the effectiveness of their radiation protection program. The CNSC receives the required reports such as the annual compliance reports on time, and data analysis indicates that the level of compliance with this requirement has been trending upward and reached a level above 80% in 2017.

Workers receive information that helps them improve their work performance and lower their doses. Not all RSOs feel that they have enough time to complete these activities to the extent they deserve, particularly part-time RSOs in large hospitals.

The evaluation team did not identify any issues with stakeholders lacking sufficient time to review the information they receive from RSOs. Management has time to review the radiation safety committee meeting minutes they receive. Workers told the team that they receive and incorporate the feedback they receive following internal inspections.

From a motivation standpoint, in most cases workers demonstrate openness to adopting effective practices that lead to overall program improvement. Applicant authorities, while not generally involved in the daily oversight of the program, believe that they have sufficient information on the program and its performance.

Key factors

The factors that impact the success of RSO monitoring, controlling and reporting activities and should be considered in the development of regulatory guidance are outlined below.

Factors that support success	Factors that limit success
the RSOs’ ability to communicate effectively with various stakeholders (individual) timely follow-ups on internal audit findings (individual and institutional)	lack of time allocated to the RSO function to conduct adequate follow-ups after internal inspections (institutional) RSO not perceived as a credible authority of radiation protection (individual/interpersonal) worker complacency (individual)

Continuous improvement activities

Most RSOs in the academic/research sector have greater access than their counterparts in the medical sector to radiation protection good practices and lessons learned. In general, the RSOs in the academic/research sector told the evaluation team that they participate in continuous learning activities and/or are members of groups, such as the Canadian Radiation Protection Association (CRPA) or the Canadian University RSO listserv (CURSO-l), which share information.

In the medical sector, a number of RSOs have access to continuous improvement activities. There are, however, a number who still struggle to keep abreast of industry best practices and lessons learned.

Some part-time RSOs in large hospitals have little time to dedicate to continuous improvement activities. Others told the evaluation team that there is no funding to attend learning events such as conferences or CNSC outreach events. And others said that they lack management support to participate in these activities.

Overall, information sharing within the RSO community can be limited, mostly in the medical sector. Some RSOs told team members that they had never heard of national organizations such as the CRPA. And even though the CNSC provides a list of CRPA members offering to share knowledge and experience in their specialty areas to licensees, the team met only two RSOs during the evaluation who knew about these potential mentorship opportunities. When it came to finding information online, both CNSC staff and RSOs told the team that it can be difficult to navigate the CNSC website rapidly to find relevant information.

The majority of RSOs who come across radiation protection good practices integrate them into their programs, share them with workers and other site or delegated RSOs. Sharing of good practices with management, including the applicant authority, happens infrequently, unless the applicant authority is a member of the radiation safety committee. Many members of radiation safety committee told the team that the committee was a forum where good practices were shared.

COM-B findings

From a COM-B perspective, the evaluation team noticed that RSOs in both sectors are aware of good practices in radiation protection if they are members of professional associations and are able to attend continuous learning events.

Management is not necessarily aware of good practices. The day-to-day radiation protection program activities are managed by RSOs, and management trusts that good practices and lessons learned are integrated into the radiation protection program as applicable.

Key factors

The factors that impact the success of RSO continuous improvement activities and should be considered in the development of regulatory guidance are outlined below.

Factors that support success	Factors that limit success
having support from management to undertake continuous learning activities (institutional)	lack of funding to attend learning events (e.g., travel freeze in the medical sector in some provinces) ( institutional) lack of adequate CNSC online resources (e.g., difficulty to navigate the CNSC website rapidly to find relevant information) (infrastructure) lack of opportunities to connect and exchange with other RSOs (infrastructure and interpersonal)

Success factors at a glance

Area of activity	Factors that support success	Factors that limit success
Training	timely training delivery (individual/interpersonal) hands-on, practical training components (individual/interpersonal) audience-specific training content (individual/interpersonal) strong safety culture, specifically pressure from peers to work safely (interpersonal) the potential of negative regulatory consequences (infrastructure)	lack of time allocated to the RSO function to ensure that training content is up to date and approach is meaningful to learners (institutional) competing operational priorities such as number of patients to see in a day (institutional)
Communication and advice	the ease of access of the RSO to workers to provide just-in-time advice and information (individual/interpersonal)	lack of time allocated to the RSO function to proactively share information with stakeholders (institutional) competing operational priorities such as number of patients to see in a day (institutional) RSO not perceived as a credible authority of radiation protection (individual/interpersonal)
Monitoring, controlling and reporting	the RSOs’ ability to communicate effectively with stakeholders at all levels (individual) timely follow-ups on internal audit findings (individual/institutional)	lack of time allocated to the RSO function to conduct adequate follow-ups after internal inspections (institutional) RSO not perceived as a credible authority of radiation protection (individual/interpersonal) worker complacency (individual)
Continuous improvement	having support from management for continuous learning activities (institutional)	lack of funding to attend learning events (e.g., travel freeze in the medical sector in certain provinces) (institutional) lack of adequate CNSC online resources (infrastructure) lack of opportunities to connect and exchange with other RSOs (infrastructure/interpersonal)

Other influencing elements

1.Are the right governance models in place?

A few RSOs working in the medical sector in organizations that have undergone amalgamation told the evaluation team that the governance structure of their organization can create challenges to their effectiveness. They feel far removed from the applicant authority and perceive that their role is not valued within the organization. Other RSOs feel that they are still able to manage their radiation protection program effectively even though there are several layers of management.

For the most part, RSOs in both sectors told the evaluation team that they feel well supported by their applicant authority and generally communicate with them on an as-needed basis. The team heard from RSOs who rarely or never communicate directly with their applicant authority, and from others who communicate with their applicant authority weekly.

2. Does the CNSC provide sufficient guidance?

Many RSOs feel that the current communication channels used by the CNSC, such as the website and email distribution list, can be improved. For example, a number of RSOs feel that the website is difficult to navigate, and that information is moved and reorganized frequently.

As for the emails that are distributed through the CNSC mailing list, including the DNSR Newsletter, RSOs told the evaluation team that they appreciate the information but that the newsletters are published too infrequently and are not audience specific. RSOs want to receive information from the CNSC that is timely and applicable to their area of work.

In terms of the nature of the guidance that is available, many RSOs would like to have additional regulatory guidance to support them in the day-to-day management of the radiation protection programs. The areas of guidance most frequently mentioned are:

• how to determine adequate RSO resourcing levels based on the nature of the work and the magnitude of licensee operations
• what to include in an RSO work description to ensure that the role of the RSO is accurately captured and defined, not tacked on to a job description as an afterthought
• support for internal audits including guidance on the audit frequency, format and templates
• guidance on radiation safety committee composition and purpose

3. Would there be advantages to certification?

Results are mixed among RSOs regarding the advantages of requiring certification. 49% of the RSOs surveyed told the evaluation team that certification could be beneficial as it would:

• provide an opportunity for RSOs to take part in continuous learning
• ensure a standardized base level of technical and regulatory knowledge
• help to ensure that the RSOs are competent and qualified
• increase the RSOs’ credibility or weight/influence within their organization

Almost half of the RSOs interviewed who were in favour of certification do not see it as a way to directly improve radiation protection program performance, but as a means to support access to continuous learning opportunities. In other words, if there is a regulatory requirement to maintain a certification, it would likely necessitate regular training or continuous learning. As such, this would be a way for RSOs with limited learning and development opportunities to access continuous learning.

The following quote illustrates the majority view in support of certification: “I think that there should be RSO certification. Credentials to maintain a certain level of education should be required and mandatory attendance for continuing education and refresher courses. I think the consequences of not having these things [lead to] a very poor understanding of radiation safety, which then gets passed through the organization. This perpetuates the lack of safety in these areas, lack of understanding turns into complacency […].”

Almost half of the RSOs in the medical sector feel that the CNSC could work with the CRPA or another professional body to develop a standardized and recognized RSO training program.

4. Is there an issue with the alignment across regulatory bodies?

The majority of RSOs see no issues in terms of the need for greater alignment across regulatory bodies. Those who did told the evaluation team that greater alignment across regulatory bodies could help to avoid overlap and duplication of work. For example, in the medical sector, some RSOs feel that the CNSC should work with the provincial ministries of labour to align the timing of their inspection efforts so as to avoid back-to-back inspections within a short period of time.

Another example came from an RSO working in the commercial sector. The RSO cited a potential misalignment between the Health Canada requirements concerning the addition of saline solution to a vial after the radioactive substance has already been added as opposed to adding the saline solution first. In the RSO’s view, the first method can contribute to extremity dose, but if the saline could be introduced first in the vial, there would be no exposure. 

5. Does the relationship with the regulator allow for open communication and effective resolution of non-compliance?

91% of the RSOs in both sectors feel that their relationship with the CNSC allows for open communication and resolution of non-compliance. The evaluation team heard from some RSOs who feel that communication with the CNSC is ineffective because they were asked by their licensing officer to limit their communications to email. This might result in numerous exchanges to resolve an issue that could have been resolved efficiently over the phone.

4% of the RSOs felt that their relationship with the CNSC allowed for very little open communication. Barriers that hinder the relationship with the CNSC include:

• lack of clarity on who to contact within the CNSC
• inability to reach someone when calling the CNSC
• lack of clarity in CNSC expectations (i.e., RSOs feel that the CNSC seems hesitant to offer a clear interpretation of its regulation or be forthcoming with its expectations; this is viewed as counterproductive)
• delays in obtaining inspection reports
• nature of the relationship between regulator and licensee (at times seen as adversarial); a small minority of RSOs feel that the CNSC penalizes based on the “tiniest of infractions”, based on interpretation, not the regulations

Most applicant authorities believe that they have a collaborative relationship with the CNSC that allows for efficient resolution of non-compliance. Only one applicant authority stressed that the CNSC was not collaborative and that the regulator has adopted a policing approach which is seen as counterproductive in the pursuit of safety.

Stakeholder views

An alternate approach to presenting the information collected during the evaluation is to summarize the viewpoints of each group. This section presents the views of the different stakeholder groups with the aim of showcasing the different perspectives.

RSOs

• Most believe that the biggest obstacle they face is the lack of time to fulfill their RSO duties.
• RSOs feel that the CNSC could offer more guidance on RSO work descriptions, RSO resourcing levels based on magnitude of operations and internal audit format and frequency.
• Most offer training to workers different ways: some leverage e-learning solutions, others rely on a third party because they do not have time, and others use a combination of online, in-class and training manual/materials.
• RSOs recognize the importance of internal audit follow-ups, but not all RSOs have time to complete this task.
• They recognize that workers are generally receptive to their advice, but sometimes feel that workers can be too overwhelmed with their daily work to incorporate the feedback.
• Some feel that they have effective radiation safety committees, while others feel that their committee is ineffective and identified challenges in determining appropriate committee composition and purpose.
• Some feel that they do not have access to continuous learning opportunities.
• RSOs believe that taking a collaborative approach to problem solving supports worker engagement.
• They believe that there is an opportunity to clarify the roles and responsibilities of the RSO.
• Some face challenges when dealing with the CNSC licensing officer – ineffective communication, multiple back and forth, unclear expectations, and frequent staff turnover.

Workers (including nuclear energy workers, non-nuclear energy workers, auxiliary staff, physicians, graduate students, professors)

• Workers believe that the RSO offers comprehensive training that helps them understand how to protect themselves and would like more hands-on practical exercises.
• They are almost always able to reach the RSO when they have questions.
• They recognize that having an RSO that is in close proximity to them is helpful and facilitates communication and daily interactions.
• Most workers consider the RSO to be the expert when it comes to regulatory requirements.
• Workers receive clear and specific feedback from the RSO after internal inspections and believe that the feedback leads to improvements, such as lower dosimeter readings.

Applicant authorities

• Applicant authorities feel that existing governance models are effective.
• They believe that radiation safety committees support the integration of good practices into the radiation protection program.
• They recognize that open communication between the RSO and the workers helps to promote engagement.
• Some value more frequent interactions with RSOs; others are satisfied with infrequent interactions (i.e., no news is good news).
• Some feel that the CNSC should take a more collaborative approach with licensees.

Radiation safety committee members

• Committee members see the committee as serving multiple purposes: ensuring compliance with regulatory requirements, ensuring that staff follow protocols, acting as a platform for information sharing across disciplines, ensuring that best practices are implemented, and reviewing incidents and recommending solutions.
• They value the contribution of RSOs to the committee, except where the RSO is not viewed as being a credible authority on radiation protection.
• They feel that the CNSC needs to be clear on expectations and provide guidance on the time requirement for RSO roles/activities based on the magnitude of operations.
• They recognize that there is room to improve worker training (more tailoring, more hands-on, releasing workers to attend training).
• They believe that their organization adjusts their practices as a result of internal audit findings or as a result of implementing best practices.

DNSR staff

• DNSR staff recognize that not all RSOs have the resources (financial, time or human) they need to effectively run their radiation protection programs.
• They believe that the lack of time allocated to the RSO function is the most frequent resourcing issue facing radiation protection programs.
• They feel that, while it is a regulatory expectation that RSOs have authority to stop work or restrict operations, in practice not all RSOs feel comfortable doing so or receive support from management to do so.
• They hear directly from RSOs that they want clear direction and requirements from the CNSC, particularly on the time requirement for RSO roles/activities based on the magnitude of operations.
• They believe that to support effective communication between the applicant authority and the RSO there needs to be a clearer understanding of roles and responsibilities.

Case study takeaways

The evaluation team completed 11 case studies during the evaluation. The studies were designed to look at the role of RSOs in different contexts. The team also provided an in-depth understanding of how the role of the RSO and associated “success factors” influences the radiation protection program performance ^{Footnote 3} in these varied situations.

To better understand success factors and barriers in different contexts, in other words, “what works for whom, in which context”, the case studies have been grouped into five categories:

1. Medical, large complex with geographic disparity
2. Medical, large complex with location proximity
3. Medical, small, one site
4. University/academic research
5. Commercial sector

Key takeaways

RSOs in the medical sector, working in large hospitals with complex programs and geographic disparity of sites, faced challenges if the following circumstances were present:

• a lack of management support for radiation protection
• inadequate time allocated to the RSO function and lack of clear RSO roles and responsibilities
• competing priorities between expeditious patient care and worker radiation protection

RSOs in the medical sector working in large, complex hospitals without geographic disparity, faced challenges if the following circumstances were present:

• inadequate time allocated to the RSO function
• perceptions that the RSO was not a credible and trusted authority on radiation protection

The small hospital had consistently good regulatory compliance. Management demonstrated a high level of involvement in the radiation protection program. There was open communication between the RSO, the workers and management.  

Organizations in the academic/research sectors had consistently good regulatory compliance. Support from management was strong and RSOs had significant access to learning and development opportunities. One barrier to effective communication between the RSO and workers was observed in a situation where the RSO was not physically located with the workers.

Among commercial sector organizations, RSOs faced challenges if the following circumstances were present:

• inadequate time allocated to the RSO function
• a lack of time for shift workers to attend radiation protection training and/or refreshers

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Chapter 2 – Detailed findings and supporting evidence

This chapter is written from an evaluator’s perspective. It presents the data behind the logic and the supporting evidence from which the findings, conclusions and recommendations have been drawn.

This chapter summarizes the technical reports of the following data sources.

Case study

Eleven case studies were completed to examine the role of RSOs who work for specific licensees operating in different contexts and with different compliance records. The objective of the case studies was to provide an in-depth understanding of how the role of the RSO and associated “success factors” influences the radiation protection program performance ^{Footnote 4} in these varied situations.

In consultation with the CNSC’s regional site coordinators, criteria were established for the selection of case studies. These focus on licensees in the medical and/or academic/research sectors who have experienced situations of change such as:

• a change in RSO
• a change in radiation protection program performance over time, either improvement or decline
• a change in work environment/organization; e.g., complex environments, multiple sites across provinces, amalgamation

The case studies were also selected to examine different regulatory situations such as:

• licensees with both nuclear substances / radiation devices and Class II licences
• licensees with a radiation safety committee
• licensees with significant reported events

Comparative analysis

The comparative analysis explored the effectiveness of the role of the RSO when compared to:

• the role of nuclear substances and radiation devices RSOs internationally (United States and United Kingdom)
• other similar roles nationally such as:
  • biosafety officers (Public Health Agency of Canada)
  • flight safety officers (Transport Canada)
  • occupational health and safety officers
  • Class II RSOs (CNSC)

The intent is to provide a comprehensive picture of the RSO role, its regulatory expectations, guidance, success factors and influence in relation to other similar roles. The evaluators conducted comparative analysis by sharing information via email and phone interviews with the United States Nuclear Regulatory Commission (U.S. NRC), the United Kingdom’s Health and Safety Executive (HSE) and other regulator program officials, as well as by reviewing regulatory documents. In seeking to understand what contributes to the effectiveness of the RSO’s role, the following areas were compared:

• legislation
• regulatory guidance
• certification
• governance models and reporting relationship
• oversight committee structure
• reporting requirements
• level of RSO authority

Interviews

Interviews were central to this evaluation in bringing both a breadth and depth of data. The interviews covered all 22 evaluation questions. 97 interviews were completed with 102 CNSC and licensee stakeholders. Interviewparticipants by stakeholder group consisted of:

CNSC internal interview stakeholders (n=12):

• DNSR and DERPA ^{Footnote 5} management: n=4
• DNSR staff (both from compliance and licensing): n=9

External interview participants were selected from two groups (n=89):

• Group 1 – Representative sample participants (n=3)
  • RSOs: n=3
• Group 2 – Specific to case study participants (n=86)
  • RSOs (either corporate or site): n=28
  • Radiation safety committee members: n=16
  • Applicant authorities: n=9
  • Workers (nuclear energy workers (NEWs) and non-NEWs, including physicians): n=33

Literature review

The purpose of the literature reviewwas to gather open source information on similar roles that are used by other federal and/or provincial/territorial regulatory organizations, as well as on good practices related to regulation and associated guidance. The review strengthened the theory of change behind the role and interventions of the RSO. The scope of the literature review was adjusted based on evaluation schedule and interview findings.

Survey

The RSO survey was designed as a census of the RSOs in the medical and academic/research sectors across Canada. The evaluators administered the survey to licensees with high/medium- and low-risk use types. This report summarizes the results of the high/medium-risk respondents only. Low-risk respondent results were excluded because the level of complexity of their operations is very different from those in the high/medium-risk group. Combining the results of both groups would have misrepresented the survey data. Licensees with low-risk use types operate in very different environments than licensees with high/medium-risk use types. They are generally from much smaller organizations, typically with only one CNSC licence. Although they possess nuclear substances, it is possible that these substances are accessed only once per year, and they are always handled by the same individual.

RSO survey features:

• 55 questions (multiple choice and open ended)
• Total respondents: 255/342 (high/medium risk)
• Response rate: 75% (high/medium risk)
• Average completion time: 42 minutes
• Data collection time frame: February 6, 2018 to March 31, 2018
• Data gathered on all 22 evaluation questions

The survey of applicant authorities was designed as a randomized sample of the population (approximately 191), which represents a confidence level of 95% and confidence interval (or margin of error) of +/-5.

Applicant authority survey features:

• 10 questions (multiple choice and open ended)
• Total respondents: 49/185
• Response rate: 26%
• Average completion time: 9 minutes
• Data collection time frame: February 6, 2018 to March 1, 2018
• Data gathered on evaluation questions (3, 7, 8, 10, 13, 18, 20, 21 and 22) related to issues of communication, authority, governance and regulatory guidance.

As the CNSC does not maintain contact information on workers in the radiation protection programs, the workers were identified by 20 RSOs who were selected at random. Each RSO was asked to provide the email addresses of two to four workers from their organization who would be willing to complete the survey.

Worker survey features:

• 10 questions (multiple choice and open ended)
• Total respondents: 19/29
• Response rate: 66%
• Average completion time: 6 minutes
• Data collection time frame: February 6, 2018 to March 1, 2018
• Data gathered on evaluation questions (2, 5, 6, 9, 11, 12) related to issues of training, communication and feedback, and barriers/enablers to adoption of safe practices

All surveys were developed internally and administered by a third party. Respondents were able to complete the survey in either official language. During the survey period, two reminders were sent to participants who had not completed the survey. In an effort to further increase survey participation, CNSC staff made follow-up phone calls to RSOs who had not completed the survey.

The survey results are anonymous and the data collected is protected and handled per the TBS Policy on Results and supporting guidance.

Training activities

A key activity as part of the RSO’s role in overseeing radiation protection programs is to ensure adequate training for workers who are required to use or handle nuclear substances and radiation devices ^{Footnote 6}. Training activities delivered by the RSO include the design, delivery and evaluation of training (formal such as in-class and informal such as workshops and online training).

The CNSC’s series of regulatory documents provides licensees with detailed guidance on the elements of an effective training system ^{Footnote 7}.

Findings

Across both sectors, RSOs are generally successful in undertaking radiation protection training. The vast majority of RSOs believe that through training, they are able to convey radiation protection program objectives to workers. As a result, workers feel that they have a good understanding of the role they play in radiation protection and adopt safe radiation protection practices.

Mostly in the medical sector, competing operational requirements, the lack of time (i.e., pressure to do more with less time) and worker complacency are some issues that can arise and can impede workers from adopting safe work practices.

Important factors that motivate workers across both sectors to adopt effective radiation protection practices include the quality of training (including a hands-on component), timeliness of the training, pressure from peers to be safe and the fear of potential regulatory consequences (i.e., the loss of a licence or the issuance of an administrative monetary penalty).

Supporting evidence

Reach – Is the RSO able to reach the workers who require training?

To be effective in delivering training, RSOs should be able to identify and contact workers. In turn, workers ^{Footnote 8} should be able to attend the required training. For any of this to be possible, the radiation protection program needs to be properly resourced in terms of financial, human or physical resources.

95% of the RSOs surveyed (n=259 ^{Footnote 9}) believe that they are successful at identifying and contacting the workers who require radiation protection training, even when their program is not properly resourced.

Corporate RSOs rely on site RSOs or other managers (i.e., the line managers of housekeeping or security personnel) to identify who needs to be trained and to reach out to workers who require training.

94% of the RSOs surveyed (243/255) believe that workers who require radiation protection training are able to attend the training. It can occasionally be a challenge to have workers released from their duties to attend training.

77% RSOs surveyed in the medical and academic/research sectors (193/251 ^{Footnote 10}) believe that they are equipped with the necessary resources (i.e., financial resources, human resources, training facilities and time) to develop and maintain an effective radiation protection program in their organization.

23% of the RSOs surveyed (58/251) expressed concern over a lack of resources. This view was more prevalent among part-time RSOs in the medical sector managing complex radiation protection programs with multiple locations. This group reports that they lack time because they must balance operational work, such as direct patient care, with their other RSO-related duties.

They feel that it is insufficient to have a part-time RSO manage a complex program spread across multiple sites. The following quote illustrates this view: “Takes years to design training. Not enough to have a part-time RSO who also has significant other duties to fulfill.”

89% of the CNSC staff from the Directorate of Nuclear Substance Regulation (DNSR) (8/9) do not believe that all RSOs have adequate resources to develop and maintain an effective radiation protection program in their organization. They believe that this varies significantly from one organization to the next, depending on the size of the organization and complexity of the operations.

A challenge facing RSOs working in the commercial sector is finding the right time to train shift workers. Offering training to workers after an overnight shift does not lend itself to optimal learning conditions. Some indicated that having an online learning management system would be very beneficial, but that their management does not support an investment in a learning platform. The following quote illustrates this view: “I try to find times that work but with shift work it can be difficult; online training would be useful as people could all do [training] at a convenient time.”

The comparative analysis with other federal regulators reveals that, as part of their compliance promotion activities, some organizations provide licensees with additional resources to support licensees in the conduct of their training activities. The Public Health Agency of Canada (PHAC) has developed an online laboratory biosafety and biosecurity learning portal accessible to all its licensees. This portal includes learning material and e-learning courses on the principles and practices of biosafety and biosecurity to support regulated parties.

Through this portal, the biological safety officers (BSOs) are able to track worker course completion and test results, thus reducing the administrative burden on them to create and maintain such tracking mechanisms. The courses are reported to be popular with BSOs and many of them have decided to make the courses mandatory training for their laboratory personnel.

Knowledge – Do workers understand radiation protection practices and procedures?

As a result of their participation in training activities, workers should have increased their skills and gained an understanding of effective radiation protection practices. By gaining these skills and increasing their knowledge, workers should know what is expected of them in the conduct of their daily activities. The evaluation sought to understand if, through the training activities, RSOs are able to influence the workers’ understanding of radiation protection program objectives. Conditions that promote this increased understanding include the workers’ capabilities and motivation, the tailoring of the training to its audience, and the timeliness of the training.

100% of the RSOs interviewed across both sectors (28/28) indicate that they tailor the radiation protection training content to meet the needs of different audiences. This was also reported to be the case when RSOs rely on a third party to deliver the radiation protection training.

Tailoring a training program generally means offering different levels of information. A simplified level of training may be offered to auxiliary workers using pictograms, particularly if there is a language barrier because English is not the workers’ first language. More in-depth training accompanied by a comprehensive training manual would be offered to nuclear energy workers and non-nuclear energy workers.

A minority of RSOs feel that training could be further tailored to include more specific examples and practical applications, but that lack of time prevents them from working on this.

89% of the RSOs interviewed (16/18 ^{Footnote 11}) feel that they offer training in a timely manner. They generally offer training either in a group setting or one-on-one. The down side of offering one-on-one training is that it can be time consuming for RSOs. Some RSOs believe that having a learning management system allows them to deliver timely training to workers.

100% of the workers (29/29) feel that the training is offered to them in a timely manner. Many explained that they received timely training as it is a prerequisite for obtaining their thermoluminescent dosimeter (TLD) ^{Footnote 12} and their site access card.

91% of the RSOs interviewed (21/23) believe that workers recognize the importance of radiation protection. They feel that, for the most part, workers want the radiation protection program to succeed. This is demonstrated when they ask questions and are actively engaged during the training.

16% of the RSOs interviewed (3/19) do not feel that workers are engaged and believe that they attend training simply because “they have to”. Other RSOs believe that the level of worker engagement in learning depends on the trainee’s role in the organization. For example, nuclear energy workers demonstrate high engagement levels because they have completed their education in a field that already provides a good base of knowledge of radiation protection. They also demonstrate high levels of interest in radiation safety due to the nature of their work with patients.

94% of the RSOs (n=251 ^{Footnote 13}) believe that workers understand the objectives of the radiation protection program as a result of the training they receive. Some RSOs use the training test results as an indicator of the workers’ level of understanding. 100% of the workers surveyed (20/20) believe that the training received helps them understand the role they play in radiation protection.

Behaviour – As a result of the training they receive, do workers adopt safe practices?

As a result of having increased their knowledge of effective work practices through training, radiation protection program workers should adopt safe radiation protection practices in their workplace. Conditions that promote this behavior include having: management support; motivated workers who want to positively influence the radiation protection program; and RSOs who are perceived to be credible, trusted and recognized as the authority on radiation protection. The evaluation sought to understand if workers were adopting effective practices, and if not, what barriers or challenges prevented this from happening.

100% of the RSOs interviewed across both sectors (28/28) feel that workers adopt effective radiation protection practices and procedures as a result of their participation in radiation protection training. The following quote illustrated this view: “Without training, workers would not be aware of the regulations (and the workplace policies and procedures that support the regulations).”

RSOs also mentioned that, to their knowledge, workers were not intentionally being non-compliant with radiation protection practices and procedures. The view was that most situations of worker non-compliance were related to lack of knowledge and awareness. This is why, they said, periodic radiation protection refresher training is valuable.

A strong radiation protection program and peer pressure to adopt safe practices are among the factors that support workers in adopting effective radiation protection practices and procedures.

94% of the workers (n=46 ^{Footnote 14}) feel that they adopt effective radiation protection practices as a result of attending training. The following quote illustrates this view: “The training certainly did help; [it] taught me how to protect myself and how to handle substances to ensure I was comfortable handling the substances.”

4% of the workers interviewed and surveyed (2/49), all of whom were physicians, feel that as a result of their profession, they do not need additional training in order to adopt effective radiation protection practices. They do not see a need to take part in the training because radioactive substances are handled by workers (i.e., technologists) and not by them directly.

When prompted, both RSOs and workers identified a number of challenges that can prevent workers from adopting safe radiation protection practices:

• competing operational requirements and limited time
• views that safe practices are an unnecessary burden
• complacency and/or lack of motivation to adopt safe practices

Compliance data analysis validates that for the most part workers adopt safe radiation protection practices. Between 2007 and 2017, the percentage of compliance in the proper use of equipment, clothing and procedures at the work site has been at 95% or higher (figure 1). This shows that workers do adopt safe radiation protection practices.

Figure 1: High compliance in use of appropriate equipment, clothing and procedures

Description

The data from 2007 to 2017 shows a high level of compliance.

	2007	2008	2009	2010	2011	2012	2013	2014	2015	2016	2017
% of compliance	97%	95%	98%	97%	94%	98%	99%	98%	99%	97%	95%

Case study findings relating to training

In the medical sector, particularly in large hospitals with complex radiation protection programs and a geographic disparity of sites, the RSO function and overall radiation protection program may be inadequately resourced.

This impacts the ability of RSOs to deliver training activities. This was apparent in a case study where the RSO from a large complex hospital with multiple sites was part-time. The RSO had identified areas to improve the radiation protection training program, making the training more hands-on, but struggled to find time to deliver the training across all sites and to have workers from all sites removed from their operational duties for training purposes.

Reviewing the theory of change