Occupational Safety · Radiation Protection · NHS Wales
One Size
Fits None
Welsh theatres are finally confronting an uncomfortable truth: the lead aprons protecting staff from ionising radiation were never designed for the diverse bodies wearing them — and the consequences go well beyond discomfort.
T&O surgeons who felt their available PPE did not adequately protect them (EXPOSEd survey, 2024)
Of 677 UK T&O surgeons surveyed across 196 NHS hospitals
Standard lead vests provide no adequate shielding to the upper outer breast quadrant
Reduction achieved with purpose-designed breast–axilla–thyroid (BAT) shielding vs standard apron
01 — Context
The Welsh Theatre Floor Is Finally Speaking Up
Operating theatres are among the highest radiation dose environments in any NHS hospital. Scrub nurses, surgical assistants, anaesthetic practitioners, and the surgeons they support spend thousands of hours a year within metres of fluoroscopic X-ray equipment — equipment that scatters ionising radiation in every direction. The personal protective equipment designed to shield them from that scatter is, in most cases, a lead apron that has barely evolved since the 1970s.
The Royal College of Nursing in Wales has turned the spotlight on what many theatre staff have known for years: that this PPE was built to a template that does not reflect the people wearing it. The RCN's championing of inclusive PPE in Welsh theatres is part of a wider reckoning across the NHS — a recognition that protection, like care, must be person-centred.
This matters not just as a matter of comfort or dignity, but as a matter of safety. An apron that does not fit correctly is not an apron that protects correctly. For theatre staff managing fluoroscopy-assisted procedures — orthopaedic fixations, cardiac catheterisations, vascular interventions — a coverage gap is an occupational health risk, accumulated over years of practice.
02 — The Problem
When the Apron Doesn't Fit, Neither Does the Protection
The conventional lead apron — or its lead-free equivalent — is a one-piece or two-piece garment sized to a narrow range of body shapes. Its design assumes a torso that sits within a band of standard measurements. For a significant proportion of the theatre workforce, that assumption is wrong. Women, shorter or taller individuals, staff with different body compositions, and pregnant workers often find themselves wearing garments that are either too large, too small, too heavy, or simply designed for someone else.
Standard lead aprons do not protect the female breast adequately from radiation exposure — and that shortfall has been associated with elevated cancer incidence in healthcare workers.
Westcott et al., Health Physics, 2025 — citing the BAT shielding study, Baylor University Medical CenterThe anatomical problem is specific and well-documented. The upper outer quadrant of the breast — the most common site of breast cancer — sits in the armhole gap of a standard lead vest. As surgeons lean forward, rotate, and reach during procedures, that gap widens, exposing tissue that carries the highest radiological sensitivity. Studies using dosimeters placed directly at that site have confirmed that standard vests provide essentially no protection to the axillary breast region during fluoroscopy.
Size matters too. Research published in Health Physics found that lead protection that is either too small or too large for the wearer's torso results in measurably higher breast radiation dose-equivalent rates. The fit itself is a clinical variable — and one that is routinely ignored in theatre PPE procurement decisions.
03 — The Evidence
What the Research Tells Us About Theatre Radiation PPE
The EXPOSEd survey — the largest European study of radiation PPE provision among Trauma and Orthopaedic surgeons — surveyed 677 respondents from 196 UK NHS hospitals. Its findings were stark. More than half of all respondents felt that the PPE available to them in their workplace did not adequately protect them. Eight in ten expressed concern about the health effects of ionising radiation. Notably, the survey included a Welsh Deanery representative on its authorship committee — a thread that connects directly to the RCN Wales advocacy highlighted this month.
of UK T&O surgeons reported feeling unprotected by the radiation PPE available to them
were concerned about the health effects of occupational ionising radiation exposure
of those using lead aprons regularly wore a personally-fitted garment rather than a shared pool apron
of EXPOSEd respondents were female — a proportion that underrepresents the theatre nursing workforce
The PPE concern is not confined to surgeons. Theatre nurses — scrub practitioners, anaesthetic assistants, radiographers working in theatre — frequently spend longer in the radiation field than the operating surgeon, and often with less access to personally-fitted garments. The pool apron — a single shared garment selected from a rack and worn over whatever clothing fits beneath it — is still commonplace in Welsh NHS theatres, as it is across the UK.
04 — Diversity & Inclusion
Protection That Excludes Is Not Protection
The RCN Wales campaign situates the PPE issue within a wider conversation about workplace equity. If the only garments available on a theatre rack are standard sizes designed around an assumed default physique, then staff who fall outside that template are being placed at greater occupational risk simply by virtue of who they are. That is a question of inclusion — but it is also a question of employer duty under the Health and Safety at Work Act 1974 and the Personal Protective Equipment at Work Regulations, which mandate that PPE must be suitable for the wearer.
The issue is intersectional. Pregnancy changes the body's shape and radiation sensitivity simultaneously. Theatre staff who become pregnant face the compounded challenge of aprons that do not accommodate changing anatomy, while the tissues most vulnerable to ionising radiation — including foetal tissue during early gestation — are at heightened risk. Specialist maternity lead aprons exist, and guidance from professional bodies is clear that pregnant workers should have access to them. In practice, access is inconsistent.
Cultural and ethnic diversity adds another dimension. Headwear requirements for religious or cultural reasons, combined with certain apron designs and collar fits, can create conflicts between radiation protection and the right of staff to practise their faith. Thyroid collars, in particular, have been identified as fitting poorly when worn over religious dress — a gap in protection that is also a question of dignity.
05 — Practical Action
What Change Looks Like in the Theatre Environment
Addressing inclusive PPE in theatres is not simply a matter of ordering more sizes. It requires a systematic approach to procurement that begins with wearer involvement — ensuring that theatre staff are consulted on garment selection, that fit testing becomes standard practice for radiation protection as it already is for respiratory protective equipment, and that individual aprons are allocated rather than shared where exposure risk justifies it.
Practical Implications for Theatre Radiation PPE
- Personal lead apron allocation should be standard practice for staff with regular fluoroscopy exposure, not a privilege reserved for consultants
- Fit assessment should be conducted formally — an apron that is too large or too small demonstrably increases radiation dose at vulnerable tissue sites
- Maternity lead aprons must be available in theatre settings and staff aware of their right to request one upon pregnancy declaration
- Axillary and breast supplemental shielding options should be available where female anatomy is at risk — standard vests alone are insufficient
- Garment inspection programmes must account for wearers of all sizes — a damaged or perished apron on a staff member who is wearing the closest available size presents a compounded risk
- Thyroid collar designs and fit should be part of the inclusive PPE assessment — particularly relevant for staff wearing religious headwear
- Theatre managers and RPS advisors should audit current stock against the actual body diversity of their team
The RCN's advocacy in Wales also highlights the broader policy environment. Health Education and Improvement Wales (HEIW) is actively investing in theatre workforce transformation — building pathways, leadership programmes, and inclusive culture as part of its Theatre Transformation Project. Embedding radiation protection equity within that framework is a logical and necessary step.
06 — Looking Ahead
The Protective Gap That Policy Must Close
There is genuine momentum behind this agenda. The EXPOSEd study has catalysed a response from the British Orthopaedic Association, which has reaffirmed minimum lead thickness guidelines and called for improved access to body-specific shielding. The BAT (breast–axilla–thyroid) shield concept, tested in phantom studies, demonstrated a 95% reduction in dose to the upper outer breast compared to standard protection. These are not futuristic technologies — they are available now, and their absence from theatre storerooms is a procurement and awareness failure, not a supply one.
The RCN's championing of inclusive PPE in Welsh theatres is significant precisely because it connects the personal and the professional — it names the experience of staff who have been making do, adjusting too-large aprons with tape, working through fatigue caused by overweight garments sized for someone taller, or simply accepting inadequate coverage as the price of a theatre career. That normalisation of risk is what the RCN is challenging.
An apron that does not fit the person wearing it is not a protective garment. It is a compliance document. The distinction matters — and Welsh theatres are beginning to understand it.
Editorial commentary — Rothband Radiation ProtectionFor radiation protection professionals, procurement leads, and theatre managers in Wales and beyond, the message is clear: inclusive PPE is not a nice-to-have. It is a legal obligation, a patient safety issue, and an occupational health imperative. The diversity of the people working in Welsh theatres deserves protection designed around that diversity — not designed around someone else.
Available at: rcn.org.uk
Donoghue S, Miller C, Chui K, et al. "Evaluation of X-ray Personal Protective Equipment for Orthopaedic Surgeons in theatrE (EXPOSEd) study." PMC12543439, 2025.
Westcott LZ, Ogola GO, Rees CR. "Protecting Our Own: A Method for Reducing Breast Radiation Exposure in Healthcare Workers." Health Physics. 2025;128(4):267–272. doi:10.1097/HP.0000000000001832
Van Nortwick SS, Leonard DA, Finlay AK, Chou L, Valone LC. "Methods for Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons." J Bone Joint Surg Am. 2021;103:1646–1651.
Health Education and Improvement Wales. "Transforming the Theatre Workforce in NHS Wales." HEIW, 2025.
Occupational Safety · Radiation Protection · NHS Wales
One Size
Fits None
Welsh theatres are finally confronting an uncomfortable truth: the lead aprons protecting staff from ionising radiation were never designed for the diverse bodies wearing them — and the consequences go well beyond discomfort.
T&O surgeons who felt their available PPE did not adequately protect them (EXPOSEd survey, 2024)
Of 677 UK T&O surgeons surveyed across 196 NHS hospitals
Standard lead vests provide no adequate shielding to the upper outer breast quadrant
Reduction achieved with purpose-designed breast–axilla–thyroid (BAT) shielding vs standard apron
01 — Context
The Welsh Theatre Floor Is Finally Speaking Up
Operating theatres are among the highest radiation dose environments in any NHS hospital. Scrub nurses, surgical assistants, anaesthetic practitioners, and the surgeons they support spend thousands of hours a year within metres of fluoroscopic X-ray equipment — equipment that scatters ionising radiation in every direction. The personal protective equipment designed to shield them from that scatter is, in most cases, a lead apron that has barely evolved since the 1970s.
The Royal College of Nursing in Wales has turned the spotlight on what many theatre staff have known for years: that this PPE was built to a template that does not reflect the people wearing it. The RCN's championing of inclusive PPE in Welsh theatres is part of a wider reckoning across the NHS — a recognition that protection, like care, must be person-centred.
This matters not just as a matter of comfort or dignity, but as a matter of safety. An apron that does not fit correctly is not an apron that protects correctly. For theatre staff managing fluoroscopy-assisted procedures — orthopaedic fixations, cardiac catheterisations, vascular interventions — a coverage gap is an occupational health risk, accumulated over years of practice.
02 — The Problem
When the Apron Doesn't Fit, Neither Does the Protection
The conventional lead apron — or its lead-free equivalent — is a one-piece or two-piece garment sized to a narrow range of body shapes. Its design assumes a torso that sits within a band of standard measurements. For a significant proportion of the theatre workforce, that assumption is wrong. Women, shorter or taller individuals, staff with different body compositions, and pregnant workers often find themselves wearing garments that are either too large, too small, too heavy, or simply designed for someone else.
Standard lead aprons do not protect the female breast adequately from radiation exposure — and that shortfall has been associated with elevated cancer incidence in healthcare workers.
Westcott et al., Health Physics, 2025 — citing the BAT shielding study, Baylor University Medical CenterThe anatomical problem is specific and well-documented. The upper outer quadrant of the breast — the most common site of breast cancer — sits in the armhole gap of a standard lead vest. As surgeons lean forward, rotate, and reach during procedures, that gap widens, exposing tissue that carries the highest radiological sensitivity. Studies using dosimeters placed directly at that site have confirmed that standard vests provide essentially no protection to the axillary breast region during fluoroscopy.
Size matters too. Research published in Health Physics found that lead protection that is either too small or too large for the wearer's torso results in measurably higher breast radiation dose-equivalent rates. The fit itself is a clinical variable — and one that is routinely ignored in theatre PPE procurement decisions.
03 — The Evidence
What the Research Tells Us About Theatre Radiation PPE
The EXPOSEd survey — the largest European study of radiation PPE provision among Trauma and Orthopaedic surgeons — surveyed 677 respondents from 196 UK NHS hospitals. Its findings were stark. More than half of all respondents felt that the PPE available to them in their workplace did not adequately protect them. Eight in ten expressed concern about the health effects of ionising radiation. Notably, the survey included a Welsh Deanery representative on its authorship committee — a thread that connects directly to the RCN Wales advocacy highlighted this month.
of UK T&O surgeons reported feeling unprotected by the radiation PPE available to them
were concerned about the health effects of occupational ionising radiation exposure
of those using lead aprons regularly wore a personally-fitted garment rather than a shared pool apron
of EXPOSEd respondents were female — a proportion that underrepresents the theatre nursing workforce
The PPE concern is not confined to surgeons. Theatre nurses — scrub practitioners, anaesthetic assistants, radiographers working in theatre — frequently spend longer in the radiation field than the operating surgeon, and often with less access to personally-fitted garments. The pool apron — a single shared garment selected from a rack and worn over whatever clothing fits beneath it — is still commonplace in Welsh NHS theatres, as it is across the UK.
04 — Diversity & Inclusion
Protection That Excludes Is Not Protection
The RCN Wales campaign situates the PPE issue within a wider conversation about workplace equity. If the only garments available on a theatre rack are standard sizes designed around an assumed default physique, then staff who fall outside that template are being placed at greater occupational risk simply by virtue of who they are. That is a question of inclusion — but it is also a question of employer duty under the Health and Safety at Work Act 1974 and the Personal Protective Equipment at Work Regulations, which mandate that PPE must be suitable for the wearer.
The issue is intersectional. Pregnancy changes the body's shape and radiation sensitivity simultaneously. Theatre staff who become pregnant face the compounded challenge of aprons that do not accommodate changing anatomy, while the tissues most vulnerable to ionising radiation — including foetal tissue during early gestation — are at heightened risk. Specialist maternity lead aprons exist, and guidance from professional bodies is clear that pregnant workers should have access to them. In practice, access is inconsistent.
Cultural and ethnic diversity adds another dimension. Headwear requirements for religious or cultural reasons, combined with certain apron designs and collar fits, can create conflicts between radiation protection and the right of staff to practise their faith. Thyroid collars, in particular, have been identified as fitting poorly when worn over religious dress — a gap in protection that is also a question of dignity.
05 — Practical Action
What Change Looks Like in the Theatre Environment
Addressing inclusive PPE in theatres is not simply a matter of ordering more sizes. It requires a systematic approach to procurement that begins with wearer involvement — ensuring that theatre staff are consulted on garment selection, that fit testing becomes standard practice for radiation protection as it already is for respiratory protective equipment, and that individual aprons are allocated rather than shared where exposure risk justifies it.
Practical Implications for Theatre Radiation PPE
- Personal lead apron allocation should be standard practice for staff with regular fluoroscopy exposure, not a privilege reserved for consultants
- Fit assessment should be conducted formally — an apron that is too large or too small demonstrably increases radiation dose at vulnerable tissue sites
- Maternity lead aprons must be available in theatre settings and staff aware of their right to request one upon pregnancy declaration
- Axillary and breast supplemental shielding options should be available where female anatomy is at risk — standard vests alone are insufficient
- Garment inspection programmes must account for wearers of all sizes — a damaged or perished apron on a staff member who is wearing the closest available size presents a compounded risk
- Thyroid collar designs and fit should be part of the inclusive PPE assessment — particularly relevant for staff wearing religious headwear
- Theatre managers and RPS advisors should audit current stock against the actual body diversity of their team
The RCN's advocacy in Wales also highlights the broader policy environment. Health Education and Improvement Wales (HEIW) is actively investing in theatre workforce transformation — building pathways, leadership programmes, and inclusive culture as part of its Theatre Transformation Project. Embedding radiation protection equity within that framework is a logical and necessary step.
06 — Looking Ahead
The Protective Gap That Policy Must Close
There is genuine momentum behind this agenda. The EXPOSEd study has catalysed a response from the British Orthopaedic Association, which has reaffirmed minimum lead thickness guidelines and called for improved access to body-specific shielding. The BAT (breast–axilla–thyroid) shield concept, tested in phantom studies, demonstrated a 95% reduction in dose to the upper outer breast compared to standard protection. These are not futuristic technologies — they are available now, and their absence from theatre storerooms is a procurement and awareness failure, not a supply one.
The RCN's championing of inclusive PPE in Welsh theatres is significant precisely because it connects the personal and the professional — it names the experience of staff who have been making do, adjusting too-large aprons with tape, working through fatigue caused by overweight garments sized for someone taller, or simply accepting inadequate coverage as the price of a theatre career. That normalisation of risk is what the RCN is challenging.
An apron that does not fit the person wearing it is not a protective garment. It is a compliance document. The distinction matters — and Welsh theatres are beginning to understand it.
Editorial commentary — Rothband Radiation ProtectionFor radiation protection professionals, procurement leads, and theatre managers in Wales and beyond, the message is clear: inclusive PPE is not a nice-to-have. It is a legal obligation, a patient safety issue, and an occupational health imperative. The diversity of the people working in Welsh theatres deserves protection designed around that diversity — not designed around someone else.
Available at: rcn.org.uk
Donoghue S, Miller C, Chui K, et al. "Evaluation of X-ray Personal Protective Equipment for Orthopaedic Surgeons in theatrE (EXPOSEd) study." PMC12543439, 2025.
Westcott LZ, Ogola GO, Rees CR. "Protecting Our Own: A Method for Reducing Breast Radiation Exposure in Healthcare Workers." Health Physics. 2025;128(4):267–272. doi:10.1097/HP.0000000000001832
Van Nortwick SS, Leonard DA, Finlay AK, Chou L, Valone LC. "Methods for Reducing Intraoperative Breast Radiation Exposure of Orthopaedic Surgeons." J Bone Joint Surg Am. 2021;103:1646–1651.
Health Education and Improvement Wales. "Transforming the Theatre Workforce in NHS Wales." HEIW, 2025.
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