Radiographers’ awareness, understanding, and implementation of diagnostic reference levels in medical imaging: A scoping review

Introduction: Diagnostic reference levels (DRLs) are essential for optimising ionising radiation use in medical imaging and minimising patient exposure. Radiographers play a key role in implementing DRLs to ensure dose optimisation and high-quality imaging. However, gaps in awareness and understanding can hinder effective application. This scoping review explores radiographers’ knowledge of DRLs and identifies key themes and knowledge gaps to inform practice, policy and research. Methods: Following Arksey and O'Malley's framework and the PRISMA-ScR guidelines, a systematic scoping review was conducted. A comprehensive literature search was conducted using PubMed, Google Scholar, ScienceDirect and EBSCOhost for studies published between 2010 and 2025. A total of 659 articles were identified, with eight studies meeting the inclusion criteria after duplicate removal and screening. Braun and Clarke's thematic analysis was applied to identify key themes in radiographers’ understanding and application of DRLs. Results: Two main themes emerged: [1] Knowledge and awareness of DRLs among radiographers, and [2] General knowledge of radiation protection and dose optimisation. Although radiographers demonstrate a general awareness of DRLs, their understanding of their definitions, functions and practical application varies. Higher education levels correlate with better DRL comprehension. However, inconsistencies persist in real-world applications. Despite a general awareness of radiation protection, gaps in dose optimisation principles persist. Regional disparities in DRL knowledge were noted because of differences in education, training and institutional policies. Discussion: Challenges in DRL implementation stem from limited practice, practical training, unclear role delineation, and inconsistent regulatory oversight. Strengthening standardised education, enhancing institutional policies and fostering interdisciplinary collaboration are critical for improving adherence to DRLs. Conclusion: This review highlights gaps in radiographers’ DRL knowledge, and emphasises the need for standardised training, regulatory oversight and clear guidelines to enhance patient safety and radiation protection. Further research is needed to develop evidence-based guidelines for global DRL optimisation.