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Introduction: The SAFE EUROPE project, a European-funded project, addressed educational gaps of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) by offering a series of free webinars. This study aimed to assess the quality of these webinars and their impact on professional practice., Methods: Data collection involved two methods: an automated feedback form administered after each webinar, supplemented by a survey disseminated through social media. The collected data encompassed attendance statistics, participants' professions and geographic locations, webinar quality assessment, the acquisition of new knowledge and skills, the application of this newfound knowledge in practice, and the likelihood of recommending these webinars. Descriptive statistics and thematic analysis were used to analyse the quantitative and qualitative data, respectively. Ethical approval for the study was obtained., Results: 11,286 individuals from 107 countries participated in 18 webinars. Despite 72.7% being radiographers, a diverse array of professionals attended the webinars, including medical physicists, oncologists, radiologists, and academics. Remarkably, 98.7% of respondents rated the webinar quality as either good or excellent. The average rating for the likelihood of recommending these webinars to colleagues was 8.96/10. A substantial proportion of respondents expressed agreement or strong agreement that the webinars enhanced their knowledge (85%) and skills (73%). Furthermore, 79% of participants indicated that the webinars motivated them to change practice, with 65% having already implemented these changes. The insights from open-ended questions corroborated these findings., Conclusion: The webinars effectively achieved the aim of the SAFE EUROPE project to enhance practice by increasing knowledge and skills. Participants overwhelmingly endorsed the quality of these webinars., Implications for Practice: Webinars represent a cost-efficient training tool that reaches a global audience and various radiography/radiotherapy professions. The development of additional webinars is strongly recommended., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus+ Sector Skill Alliances programme [grant agreement 2018–2993/001-001]. The European Commission support for the production of this publication does not constitute endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Adapting radiotherapy services with workforce innovation using skills-mix or task-shifting optimises resources, supporting current and future demands. Advanced practitioners (APs) work at a different level of practice (beyond initial registration) across four pillars: clinical practice, leadership and management, education, and research. There is limited cross-country research on the advanced therapeutic radiographers/radiation therapists (TR/RTTs), particularly in Europe. This study aimed to investigate European radiotherapy stakeholders' perceptions regarding current and future advanced practice (AP)., Methods: From June to September 2022, one-to-one online semi-structured interviews were conducted in English, and audio and video were recorded. Full verbatim audio files were independently transcribed and checked by interviewer and interviewees. Braun and Clarke's seven steps guided the thematic analysis (using NVivo)., Results: Thirty-three interviewees working or studying in 16 European countries represented practitioners (n=14), managers (n=6), educators (n=4), professional bodies (n=4), students (n=3), and regulators (n=2). Four overarching themes emerged: "AP drivers and outcomes", "AP challenges vs enablers", "Current vs future AP", "Becoming and being advanced practitioner". Participants identified research as the neglected AP pillar due to a lack of protected time, limited staff skills, no research culture, no funding, workload, and clinical priorities. Interviewees highlighted the importance of consistency in job titles, harmonisation of education models and curricula, definition of AP requirements, and support for all AP pillars through job plans and workforce planning., Conclusion: Neither the profession nor education of TR/RTTs are harmonised across Europe, which is highly reflected in advanced-level practice. Advanced TR/RTTs should work across all pillars, including research, and these should be embedded in master's programmes, including leadership., Implications for Practice: This study highlights a policy gap in the education and practice of APs in radiotherapy., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus Sector Skill Alliances programme [grant agreement 2018-2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. Helen Anne McNair is funded by a National Institute for Health Research and Health Education England (HEE/NIHR), Senior Clinical Lectureship and supported by the NIHR Biomedical Research Centre at The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

The radiation therapy (RT) landscape is continuously evolving, necessitating adaptation in roles and responsibilities of radiation therapists (RTTs). Advanced Practice Radiation Therapists (APRTs) have taken on a proactive role in expanding services and assuming responsibilities within multi-professional teams. A European Society for Radiotherapy and Oncology (ESTRO) brought geographically diverse and experienced RTTs together, to discuss how advanced practice (AP) in the RTT profession should be future-proofed and create a global platform for collaboration. Challenges in achieving consensus and standardisation of APRT was identified across jurisdictions, emphasising the importance of international collaboration. Whilst highlighting the pivotal role of APRTs in driving innovation, improving patient care, and navigating the complexities of modern RT practice, this position paper presents outcomes and recommendations from the workshop. Discussions highlighted the need for standardised role definitions, education frameworks, regulatory support, and career development pathways to enable the advancement of APRT effectively. Increasing networks and collaboration is recommended to ensure APRTs can shape the future of RT., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 The Author(s).)

Introduction: Patients suffering from head and neck (HN) cancer undergoing Radiotherapy (RT) suffer from various debilitating side effects that greatly hinder their eating ability. This leads to patients having a poor nutritional status causing weight loss. This study aimed to assess if an e-Delphi method variation allowed efficiently developing dietary advice leaflets addressing these side effects and achieving a consensus among healthcare professionals., Methods: An e-Delphi style approach was used. Six participants representing the professions working with HN patients were asked to give feedback on four symptom-specific dietary leaflets. These leaflets were designed based on a previous extensive literature review. After each round, the participants' suggested changes were applied. Before applying major changes to the leaflet, the participants were asked to vote if they agreed with each major change., Results: Overall consensus was reached after three rounds since all participants voted "highly likely" to use it in their clinical practice. Most suggestions by the participants agreed with the existing literature. The only change (accepted as a result of voting) that contradicted the literature was concerning sugar intake., Conclusion: The participants reached consensus and developed leaflets that were based on literature recommendations for use for patients that, in their opinion, were acceptable for clinical use. This e-Delphi variation proved to be efficient to achieve consensus among healthcare professionals regarding patient information tools., Implications for Practice: This eDelphi method is an efficient and effective way to revise and achieve consensus regarding the development of patient information material., Competing Interests: Conflict of interest statement None., (Copyright © 2023 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: The ratio of breast glandular tissue to fatty tissue is known as breast density. This study assessed the knowledge and awareness of breast density of Maltese women undergoing mammography screening at the National Screening Unit. Increased breast density knowledge may lead to an increase in supplementary imaging attendance. In Europe, there are very limited studies assessing the knowledge and awareness of breast density, providing a solid rationale for this study to be done locally., Methods: Women aged 50 to 69 who were eligible for breast cancer screening at the National Screening Unit were given a validated closed-ended questionnaire as part of a quantitative, prospective, cross-sectional, and descriptive study. The questionnaire was designed to achieve the aims of the study. Using IBM-SPSS (v28) software, the data was analysed using the Friedman and Kruskal Wallis tests., Results: A total of 127 surveys were gathered, with a maximum margin of error of 8.66% based on a 95% confidence range. Breast density and the risks associated with it were not well known or understood (average scores ranging from 2.80 to 3.34 out of 5), but supplemental screening was more widely known (3.65). Participants' knowledge and awareness were correlated with their age, profession, and degree of education. Leaflets (40%) and medical experts (40%) were respondents' favourite sources of information., Conclusion: The population under study lacks knowledge and awareness of breast density and the risks it entails. It's important to provide women more details about breast density. With this information, women will be empowered to seek the finest care., Implications for Practice: Although some socio-demographic parameters were linked to women's knowledge and awareness, it is advised that more research be done using a bigger sample size through interviews and other studies. Moreover, more information regarding breast density must be provided to women undergoing breast cancer screening in Malta to increase their knowledge and awareness., Competing Interests: Conflict of interest statement None., (Copyright © 2023 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: This study aims to assess the proficiency level of digital skills, the factors influencing that level and the training needs of Therapeutic Radiographers/Radiation Therapists (TR/RTTs), due to the differences in technology availability and accessibility, variations in the regulation and education of TR/RTTs in European countries, and the lack of a digital skills framework., Methods: An online survey was distributed to TR/RTTs working in Europe to capture their self-assessment of proficiency levels of digital skills when performing their clinical role. Information was also gathered regarding training, work experience and level of information and communication technology (ICT) skills. Quantitative measures were analysed using descriptive statistics and correlation between variables, and qualitative responses using thematic analysis., Results: 101 respondents from 13 European countries completed the survey. Digital skills in treatment planning followed by management and research were the least developed skills, while the most developed were transversal digital skills followed by digital skills in treatment delivery. The Radiotherapy areas of practice where TR/RTT has experience (e.g. Planning Image, Treatment Planning, Treatment), as well as the level of generic ICT skills (communication, content creation and problem-solving), was related to the level of proficiency of TR/RTT digital skills. Greater scope of practice and level of generic ICT were associated with a higher level of TR/RTT digital skills. Thematic analysis allowed the identification of new sub-themes to be included in the training of TR/RTTs., Conclusion: Education and training of TR/RTTs should be improved and adapted to the current needs of digitalisation to avoid differences in digital proficiency levels., Implications for Practice: Aligning TR/RTTs' digital skill sets with emerging digitalisation will improve current practice and ensure the best care to all RT patients., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus+ Sector Skill Alliances programme [grant agreement 2018-2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. Jéssica Rodrigues is supported by a PhD fellowship from Fundação para a Ciência e a Tecnologia, Portugal (UI/BD/152282/2021)., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Global warming and the increase in greenhouse gases are a current concern worldwide. The healthcare sector constitutes about 4.4% of all emissions. This study aims to evaluate the knowledge, awareness and attitudes of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) regarding environment-related concepts to inform the development of educational curriculum., Methods: A validated self-designed survey was distributed to TR/RTTs across Europe by the SAFE EUROPE partners and via social media between October 2021 and February 2022. The survey was divided into six sections: (i) demographics, (ii) knowledge of Circular Economy (CE) and Green Skills (GS), (iii) personal attitudes, (iv) TR/RTTs attitudes, (v) the importance of CE, and (vi) education. Questions consisted of mostly Likert scales complemented with other closed- and open-ended questions., Results: 31%-42% of participants are aware of national and departmental policies in CE and GS concepts. Even though half of the participants considered that they advocate and practice CE, the open questions indicated that participants only focus on waste management, ignoring all the other dimensions of CE in healthcare. Personal attitudes and lifestyles also did not reflect CE. TR/RTTs considered CE practices and GS development essential. However, the suggested academic level at which these skills should be developed was split between High School (44%) and Bachelor's degree (32%)., Conclusion: It is essential to raise awareness among TR/RTTs about the various dimensions of CE applied to healthcare: "green transportation", "environment-friendly procurement", "hospital building design", "food process optimisation", "water reduction", "energy efficiency", and "waste management"., Implications for Practice: These GS must be developed by TR/RTTs to decrease their impact on the environment. Their training may need to be lifelong, starting during basic high school education and continuing as healthcare professionals after graduation., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus+ Sector Skill Alliances programme [grant agreement 2018-2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. Jéssica Rodrigues is supported by a PhD fellowship from Fundação para a Ciência e a Tecnologia, Portugal (UI/BD/152282/2021)., (Crown Copyright © 2023. Published by Elsevier Ltd. All rights reserved.)

Introduction: Advanced Practice (AP) roles in Radiotherapy (RT) over time are variable, often locally developed and not underpinned by professional standards which leads to conceptual and practical gaps. This study aimed to assess AP roles amongst Therapeutic Radiographers/Radiation Therapists (TR/RTTs) and identify educational gaps for this level across Europe., Methods: An anonymous online survey was designed, validated, and distributed across Europe. Convenience sampling was used to recruit advanced TR/RTTs practitioners or TR/RTTs working in AP roles. Descriptive analysis from closed questions and thematic analyses from open questions are reported., Results: A total of 272 responses were obtained, of which 189 eligible participations were from 21 European countries. 42% of respondents acknowledged additional education required to perform AP, and 25% reported a minimum of five years of RT practice to perform AP roles/tasks. There is a trend to work more on the clinical practice domain with a low percentage of working time allocated to research. Inconsistency was found in job titles, scopes of practice, and educational backgrounds across and even within countries. Education needs regarding knowledge about image-guided and adaptive RT, multimodal imaging and technologies, and advanced treatment planning were found. Training needs on leadership and management skills and clinical site-specific expertise were identified., Conclusion: This study clearly shows a gap in education support, a need for standardisation in job titles and scopes of practice across Europe., Implications for Practice: As the first large-scale assessment of current AP roles and educational support amongst TR/RTTs across Europe, this study recommends the establishment of governance structure and role regulation. It also informs the curricula for master programmes to align the education with current and future practice., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus Sector Skill Alliances programme [grant agreement 2018–2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. Helen McNair is funded by a National Institute for Health Research and Health Education England (HEE/NIHR), Senior Clinical Lectureship and supported by the NIHR Biomedical Research Centre at The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: It is estimated that around 50% of cancer patients require Radiotherapy (RT) at some point during their treatment, hence Therapeutic Radiographers/Radiation Therapists (TR/RTTs) have a key role to play in patient management. It is essential for TR/RTTs to keep abreast with new technologies and continuously develop the digital skills necessary for safe RT practice. The RT profession and education is not regulated at European Union level, which leads to heterogeneity in the skills developed and practised among countries. This study aimed to explore the white and grey literature to collate data on the relevant digital skills required for TR/RTTs practice., Methods: An exhaustive systematic search was conducted to identify literature discussing digital skills of TR/RTTs; relevant grey literature was also identified. A thematic analysis was performed to identify and organise these skills into themes and sub-themes., Results: 195 digital skills were identified, organised in 35 sub-themes and grouped into six main themes: (i) Transversal Digital Skills, (ii) RT Planning Image, (iii) RT Treatment Planning, (iv) RT Treatment Administration, (v) Quality, Safety and Risk Management, and (vi) Management, Education and Research., Conclusion: This list can be used as a reference to close current gaps in knowledge or skills of TR/RTTs while anticipating future needs regarding the rapid development of new technologies (such as Artificial Intelligence or Big Data)., Implications for Practice: It is imperative to align education with current and future RT practice to ensure that all RT patients receive the best care. Filling the gaps in TR/RTTs skill sets will improve current practice and provide TR/RTTs with the support needed to develop more advanced skills., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus+ Sector Skill Alliances programme [grant agreement 2018-2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: To identify the potential of beam hardening techniques, specifically the use of higher kilo voltage (kV) and copper (Cu) filtration, to optimise digital planar radiographic projections. The study assessed the suitability of such techniques in radiation dose reductions while maintaining diagnostic image quality for four common radiographic projections: antero-posterior (AP) abdomen, AP-knee, AP-lumbar spine, and lateral lumbar spine., Methods: Anthropomorphic phantom radiographs were obtained at varying kVp (standard kVp, +10 kVp, and +20 kVp) and varying Cu filtration thickness (0 mm, 0.1 mm, and 0.2 mm Cu). The Dose Area Product (DAP), mAs and time (s) were recorded as an indication of the emitted radiation dose. Image quality was assessed objectively via Contrast-Noise-Ratio (CNR) calculations and subjectively via Visual Grading Analysis (VGA) performed by radiographers and radiologists., Results: Optimised exposure protocols were established for the AP-abdomen (100 kVp with 0.2 mm Cu), AP-knee (85 kVp, and 0.1 mm Cu), AP-lumbar spine (110 kVp and 0.2 mm Cu), and lateral lumbar spine (110 kVp and 0.2 mm Cu). This strategy resulted in respective DAP reductions of 71.98%, 62.50%, 64.51% and 71.85%. While CNR values decreased as beam hardening techniques were applied, VGA demonstrated either a lack of statistical variation or improved image quality between the standard and the optimised exposure protocols., Conclusions: DAP reductions without compromising image quality can be achieved through beam hardening for the AP-abdomen, AP-knee, AP-lumbar spine, and lateral lumbar spine projections., Implications for Practice: Beam hardening techniques should be considered as an optimisation strategy in medical imaging departments. Research into the applicability of this strategy for other radiographic projections is recommended., Competing Interests: Conflict of interest statement The authors declare no conflict of interest., (Copyright © 2022 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: Advances in Radiotherapy (RT) technology and increase of complexity in cancer care have enabled the implementation of new treatment techniques. Subsequently, a greater level of autonomy, responsibility, and accountability in the practice of Therapeutic Radiographers/Radiation Therapists (TR/RTTs) has led to Advanced Practice (AP) roles. The published evidence of this role is scattered with confusing terminology and divergence regarding the perception of whether a specific role represents AP internationally. This study aims to establish an international baseline of evidence on AP roles in RT to identify roles and activities performed by TR/RTTs at advanced level practice and to summarise the impact., Methods: A systematic PRISMA review of the literature was undertaken. Thematic analysis was used to synthesise the roles and associated activities. Six RT external experts validated the list. The impact was scrutinised in terms of clinical, organisational, and professional outcomes., Results: Studies (n = 87) were included and categorised into four groups. AP roles were listed by clinical area, site-specific, and scope of practice, and advanced activities were organised into seven dimensions and 27 sub-dimensions. Three most-reported outcomes were: enhanced service capacity, higher patient satisfaction, and safety maintenance., Conclusion: Evidence-based AP amongst TR/RTTs show how AP roles were conceptualised, implemented, and evaluated. Congruence studies have shown that TR/RTTs are at par with the gold-standard across the various AP roles., Implications for Practice: This is the first systematic literature review synthetisising AP roles and activities of TR/RTTs. This study also identified the main areas of AP that can be used to develop professional frameworks and education guiding policy by professional bodies, educators and other stakeholders., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus Sector Skill Alliances programme [grant agreement 2018-2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. Helen McNair is funded by a National Institute for Health Research and Health Education England (HEE/NIHR), Senior Clinical Lectureship and supported by the NIHR Biomedical Research Centre at The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Anti-scatter grids efficiently reduce scatter radiation from reaching the imaging receptor, enhancing image quality; however, the patient radiation dose increases in the process. There is disagreement regarding the thickness thresholds for which anti-scatter grids are beneficial. This study aims to establish a thickness threshold for the use of anti-scatter grids to optimise adult knee radiography., Methods: The study consisted of two phases. In Phase 1 phantom knee radiographs were acquired at varying thicknesses (10-16 cm) and tube voltages (60-80 kV). For each thickness and tube voltage, images with and without an anti-scatter grid were obtained. In Phase 2, two radiologists and three radiographers, evaluated the image quality of these images. Visual Grading Analysis (VGA) scores were analysed using Visual Grading Characteristics (VGC) based on the visualisation of five anatomic criteria., Results: The average DAP decreased by 72.1% and mAs by 73.1% when removing the anti-scatter grid. The VGC revealed that overall images taken with an anti-scatter grid have better image quality (AUC ≥0.5 for all comparisons). However, the anti-scatter grids could be removed for thicknesses 10, 12 and 14 cm in conjunction with using 80 kVp,., Conclusion: Anti-scatter grids can be removed when imaging adult knees between 10 and 12 cm using any kVp setting since the radiation dose is reduced without significantly affecting image quality. For thicknesses >12 cm, the use of anti-scatter grids significantly improves image quality; however, the radiation dose to the patient is increased. The exception is at 14 cm used with 80 kVp, where changes in image quality were insignificant., Implications for Practice: Optimisation by removing anti-scatter grids in adult knee radiography seems beneficial below 12 cm thickness with any kVp value. Since the average knee thickness ranges between 10 and 13 cm, anti-scatter grid can be removed for most patients. Nevertheless, further studies are recommended to test if this phantom-based threshold applies to human subjects., Competing Interests: Conflict of interest statement None., (Copyright © 2022 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: Radiotherapy (RT) professionals are not officially recognised or have formal education in many countries, with RT being often a very short component of a broader programme. This study aims to investigate Belgian stakeholders' perpectives regarding existing barriers and solutions for the education and professional development of Radiation therapists (RTT) which regroups medical imaging technologists (MIT) and nurses working in RT., Methods: Nine experts with vast experience in RT were invited to be interviewed; eight participated (4 heads of the RT departments, 2 school representatives, 2 national society's representatives). A semi-structured questionnaire was used. The first two authors open-coded all interviews using thematic analysis., Results: Five themes and eleven sub-themes were drawn from the analysis. Belgian MIT and nurses in RT perform the same roles, but have different educational backgrounds. The barriers in education and professional development are related to law, education landscape, economics, social-cultural context, politics and professional identity. The main difference between the French and Dutch-speaking parts of the country were at the education level. The proposed solutions included modifying the legislative framework surrounding the RTT profession, setting up financial support, formalizing the educational requirements and increasing professional awareness. Future strategies might include the development of advanced roles and responsibilities., Conclusions: Current law, educational landscape and lack of economic support were the main barriers identified. Except for the educational background, no fundamental differences were found between nurses and MIT in the French and Dutch-speaking parts. Perspectives for both professional groups are linked to future legislative and financial actions, the stakeholders involved and a clear strategic vision. In the upcoming years, increased responsibilities and the creation of a master's degree should be foreseen., Implications for Practice: Regulation of RTT profession and education and an increase in RT-specific training must be implemented in Belgium to ensure professional development and optimized treatment delivery., Competing Interests: Conflict of interest statement The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: The education of Therapeutic Radiographers (TRs) is regulated in some countries but is not standardised across the EU, leading to differences in competencies between and within member states. This study aimed to explore stakeholders' perceptions regarding underdeveloped competencies of TRs practising on the linear accelerator, identified in a previous study by the same research team., Methods: Interviews with stakeholders from four countries (selected based on the characteristics of their degrees) were performed as part of this cross-case study. Stakeholders were asked to provide their perception regarding the least developed competencies identified in a previous study., Results: The 27 stakeholders confirmed that Pharmacology, Quality Assurance (QA), Management and Leadership, Research (from the previous study) were underdeveloped and identified Image Verification and Critical Thinking as additional underdeveloped competencies. Suggested causes included: lack of regulation of required competencies at the national level, lack of training dedicated to radiotherapy (RT) (taught within generic modules) and lack of time within the degree programme. The ideal academic level to develop these competencies and whether they are essential varied between country and stakeholder., Conclusion: It is essential to regulate learning outcomes at the national level to ensure a high level of care is provided to all RT patients and, ideally, standardise it across Europe. Education institutions should review their curricula to ensure that sufficient time is dedicated to RT and that the essential competencies are developed. Due to time constraints within some programmes, some competencies must be developed after graduation., Implications for Practice: Lack of regulation of learning outcomes (at European level and national level in many countries) and lack of RT-specific training lead to underdeveloped competencies that may compromise patient care., Competing Interests: Conflict of interest statement This work was co-funded by the SAFE EUROPE project under the Erasmus+ Sector Skill Alliances programme [grant agreement 2018-2993/001-001]. The European Commission support for the production of this publication does not constitute an endorsement of the contents which reflects the views only of the authors, and the Commission cannot be held responsible for any use which may be made of the information contained therein. The University of Malta has also provided funding to enable this PhD research., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction: Regulation and education of the professionals administering radiotherapy treatments in the linear accelerator varies across the EU. However, how different programme characteristics affect the level of competency of these professionals has never been studied before. This study also aimed to assess which are the least and most developed competencies in radiotherapy across the EU., Methods: An online questionnaire was distributed to academic staff teaching radiotherapy across the EU. Staff were asked to identify the characteristics of the course programmes and to classify the level of competency of graduates regarding linear accelerator tasks., Results: Fifty respondents from 19 EU countries answered the questionnaire. The least developed competency theme was pharmacology followed by equipment quality assurance and management and leadership. The most developed competency was positioning and immobilisation, followed by radiotherapy treatment delivery and professional and ethical practice. Some competencies are developed at the same level across EU countries, while others vary considerably between member-states. Longer programmes, with more placements, and larger proportions of radiotherapy in the programme showed significant increase in the development of some competencies. Longer placements in skills labs was correlated with a decrease in competency., Conclusion: There is no harmonisation of radiotherapy eduction across the EU and the differences in programme characteristics are reflected in differences in competency levels of radiotherapy radiographers. This may hinder movement of professionals and create disparities in the level of care offered across the EU., Implications for Practice: Longer programmes, with longer clinical practice and adequate proportion of radiotherapy in the course are essential to ensure that these professionals are competent at similar levels across the EU and to ensure patient safety., (Copyright © 2020 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: The literature identifies various competences required for therapy radiographers (TR), however, these are varied and scattered among different publications. The aim of this study was to identify the competences required by therapy radiographers practising on the linear accelerator in the European setting, according to published literature., Methods: A systematic approach was performed to find relevant literature. The literature was then scrutinised for competences practised by linac TRs. Thematic analysis was performed to organise the competences according to themes., Results: A list of 170 competences were generated based on the assessment of 28 publications. The competences were organised in themes, including "delivery of treatment", "verification of patient setup", "patient care" and "teamwork and multidisciplinarity". The competences of the therapeutic radiographers encompass multiple themes, evidence of the complexity of the role of these professionals., Conclusion: Radiographers across Europe must be trained to the highest standards to ensure the best care possible is given to patients, irrespective of the country the radiographer trained in. This will also promote for free movement of professionals across countries. The competences identified can be used as reference for the design of academic curriculum for TRs practising across Europe., (Copyright © 2019 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)

Introduction: Radiography is practised world wide, however, the definition of the profession varies across countries. As there is no regulation of the profession or education at EU level, different national regulations might result in educational differences that can compromise the movement of professionals or the safety of patients. The aim of this study was to identify the commonalities and discrepancies in national regulation of radiography., Methods: National competent authorities from all EU countries where the profession is regulated (n = 27) were invited to identify the legal requirements to practise radiography and the data was analysed using thematic analysis., Results: One country does not regulate the profession in the EU. Although, a single profession is regulated in 83% of the cases, 21% regulate separate professions for different specialisms (diagnostic radiography, radiotherapy and nuclear medicine). All countries (n = 27) define education as requirement to practise, however, the academic level varies from secondary school to Master's degree with required programmes varying from 2 to 4 years and from 120 to 240 ECTS. In addition, the subjects covered in the education programme showed great heterogeneity. These subjects were not identified by 35% of the respondents (n = 23) and only 26% define the subjects in terms of competencies., Conclusion: Education is a requisite to practise all over the EU, however, the lack of EU-wide regulation leads to a variation of national regulations. These differences may lead to inhomogeneity of competencies being developed, compromising the movement of professionals across Europe and patient safety., (Copyright © 2017 The College of Radiographers. Published by Elsevier Ltd. All rights reserved.)