Impact of organ donation education on US undergraduate nursing students Experts advocate educational programs addressing misinformation regarding donation decisions to increase the potential donor pool. However, few researchers have measured outcomes with nursing students. The purpose of this study was to evaluate the impact of an educational intervention on nursing students’ knowledge, attitudes, registering as an organ donor, and family discussions. This quasi-experimental study used a pretest-posttest design with a control group. The research group consisted of 42 volunteers and the control group consisted of 73 volunteers. The written survey included 15 true-false knowledge items and 8 Likert items asking about attitude toward donation, registering as an organ donor, and family discussion. Normally distributed data showed no significant differences between groups on the pretest. The research group had no change in knowledge level 3 months later, but the control group had a significantly decreased knowledge level at that point. More members of the research group than the control group registered as organ donors after the intervention (χ2 = 4.5, P = .03). The control group had no change in registering as an organ donor between the pretest and posttest. Family discussions did not differ significantly from pretest to posttest in either group. One lecture/laboratory experience did make a difference in registering as an organ donor but not in discussing the decision with family members. Students can learn about organ donation from more than one specific class. Recommendations for educators and future research are provided. (Progress in Transplantation. 2014;24:211-217)
Jane McCausland Kurz, RN, PhD Temple University, Philadelphia, Pennsylvania Corresponding author: Jane McCausland Kurz, RN, PhD, Temple University, 3307 N. Broad St, Philadelphia, PA 19140 (e-mail: [email protected]) To purchase electronic or print reprints, contact: American Association of Critical-Care Nurses 101 Columbia, Aliso Viejo, CA 92656 Phone (800) 899-1712 (ext 532) or (949) 448-7370 (ext 532) Fax (949) 362-2049 E-mail [email protected]
©2014 NATCO, The Organization for Transplant Professionals doi: http://dx.doi.org/10.7182/pit2014624
I
t is well documented that the demand for solid organs exceeds the supply of donors worldwide. An increased supply of donors could correct this gap. In surveys of the general public, registered nurses are consistently among the American public’s most trusted groups.1 Nurses, as the largest group of health care professionals, have the potential to play a leading role in organ donation decisions. Personal attitudes toward organ donation can influence nurses’ interactions with potential donor families as nurses respond to questions, present information, and interact as liaisons with organ procurement organizations.2 Educating future nurses about organ donation and shaping their positive attitude toward donation is a strategy to reduce disparities between the number of donors and the number of transplant candidates. Unfortunately, few studies have assessed attitudes toward organ donation among 21stcentury undergraduate nursing students or the results of educational strategies.
Progress in Transplantation, Vol 24, No. 2, June 2014
The American Association of Critical-Care Nurses, a leader in nursing education, included in their “Essentials for Baccalaureate Education for Nursing Professionals” recommendations for content that addresses end-of-life care issues, including decision making, advance directives, and access to organ donation.3 Most US nursing curricula contain some content regarding transplant, but few include instruction on the donation consent process or discussion of organ donation during a health care visit.4 This topic is also neglected in most medical school curricula in the United States, Europe, and other parts of the world.5 The general public generally supports organ donation when surveyed, but only 45% to 54% actually consent to donation when asked.6 University students also demonstrate a positive attitude toward organ donation when surveyed, but few report registering as an organ donor or discussing their wishes with their families.7 Researchers have proposed strategies to improve
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Kurz organ donation rates with the general public, such as formal presentations, discussions, films, pamphlets, role playing, and meeting organ recipients.8 Effective strategies used with medical students include didactic elective courses, use of standardized patients, clinical electives with a surgical procurement team, and discussion boards.9 One might question how these strategies can be adapted for nursing students in curricula that are tightly constrained by essential content. In this article, I describe a brief intervention that was used with US undergraduate nursing students. This study’s purpose was to evaluate the impact of a researchbased educational class and laboratory that used diverse strategies on nursing students’ knowledge, their registering as an organ donor, and their sharing their decision with their families. Background Researchers in numerous studies involving health care professionals reported high percentages of participants who “support organ donation” but who have not registered as an organ donor or who decline to allow organ donation with a family member. Several researchers focusing on registered nurses cited inaccurate knowledge about donation in their samples, for example, religious support, concerns regarding disfigurement, and transplant successes.10 Regehr and colleagues11 reported that 36% of the operating room nurses who participated in organ retrieval indicated that they would not consent to organ donation for themselves or their family members. Participants cited concerns about the dignity of the patient, well-being of the family, and exposure to death and trauma that added to their own personal distress and negative attitudes. Kim et al12 indicated that 520 intensive care nurses in their study reported both positive and mixed feelings regarding donation with brain-dead donors. With regard to living donations, most often kidney transplants, families will consult health care professionals for advice. Ninety-three percent of primary nurses in a randomized study13 supported living kidney donation, but that number decreased to 75% when the nurses were questioned about deceased donation. Spanish health care professionals (87%), including physicians and nurses in the surgical department, also supported living kidney donation if the donation were restricted to a relative.14 Rios and colleagues concluded from several studies13,14 that a strong relationship exists between attitudes toward living kidney donation and attitudes toward deceased organ donation. Similarly, researchers from 5 countries (England, Italy, Korea, Spain, and Turkey) reported that most student nurses supported organ donation but demonstrated a knowledge deficit regarding the organ donation process in their country.15-19 In a 1998 study20 of US nursing students, 96% supported the concept of
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organ donation but only 82% supported their own or a family member’s organ donation. This group also scored in the poor to moderate range regarding knowledge about organ donation.20 More recently, a survey of nursing and health science students at a Canadian community college revealed that all had a high knowledge of information about organ donation. 21 This knowledge was attributed to several public service message campaigns in the past 10 years that increased levels of awareness of organ donation. However, knowledge deficits were noted with some important information, for example, the need for family approval. To date, no additional organ donation studies have included 21st-century American undergraduate nursing students. This gap needs to be addressed. A subsequent research question is, What is an effective strategy to educate nursing students that would result in increased knowledge and increased registration as an organ donor? A literature review of instructional methods for organ donation sessions revealed the lecture as the most common teaching technique.2 Other strategies used with college students, medical students, and registered nurses were the standardized patient with role playing and small-group discussions.22 Experts suggest that, to increase the number of persons who agree to register as potential organ donors, program planners should address the knowledge deficit regarding organ donation and brain death, mistrust of the medical system, and the families’ lack of discussion about the organ donation decision.8,23,24 There remains a lack of information regarding the best strategy to include the needed information in the shortest time in a tightly constrained curriculum. Currently, few intervention studies have involved nurses or nursing students reporting outcomes. Lopez-Montesinos and colleagues 18 surveyed 48 Spanish nursing students before and after a 32-hour academic course on donation and transplant. They reported an improved knowledge level and a more positive attitude after the course. Rykhoff et al21 surveyed 240 community college students (56 of whom were nursing students) after a lecture that used a PowerPoint presentation and a 7-minute video. They reported a statistically significant increase in knowledge, an increase in the number of persons who were willing to donate, and an increase in the number of persons who were aware of the need for family consent. Neither of these studies had a control group, so one cannot conclude that the intervention was the sole cause of the changes noted. Theoretical Framework In his Theory of Planned Behavior (TPB), Ajzen25 showed that behavioral intentions are antecedents to the behavior and that attitudes about that behavior, subjective norms, and perceived behavioral control Progress in Transplantation, Vol 24, No. 2, June 2014
Impact of organ donation education on US undergraduate nursing students
Behavioral beliefs
Attitude toward the behavior
Normative beliefs
Subjective norm
Control beliefs
Perceived behavioral control
Intention
Behavior
Actual behavior control
Figure Theory of planned behavior. Source: Icek Ajzen. TPB Diagram. http://people.umass.edu/aizen/tpb.diag.html. Accessed April 8, 2014.
influence that behavioral intention (see Figure). In this theory, one assumption is that there are no barriers to the behavior. Programs that use TPB typically are aimed at changing attitudes. Using TPB as a foundation for this study, I used an intervention (an educational class and laboratory) to change the knowledge level and attitudes about organ donation. Participants’ subjective norms with the changed attitudes toward organ donation would influence their registration as an organ donor and sharing their decision with family members. The process to self-register was described in the laboratory session, and participants believed that they had control over their registering as an organ donor. Several researchers who used this model in their organ donation studies reported that knowledge, attitude, and altruism were significantly related both to registering as an organ donor and willingness to communicate decisions about organ donation to family members.26,27 Because organ donation in the United States does not occur without permission from the family members, sharing personal decisions about organ donation is essential. This study measured knowledge about and attitudes toward organ donation, registration as an organ donor, and family communication. Hypotheses The study’s purpose was to evaluate the impact of a research-based educational class and laboratory that used diverse strategies on knowledge and registration as an organ donor and intent to share that decision with family. One hypothesis was that students who attend the organ donation/transplant class lecture and
Progress in Transplantation, Vol 24, No. 2, June 2014
laboratory will have higher knowledge levels, higher rates of registration as organ donors, and higher rates of sharing decisions about organ donation with family members after than before the class/laboratory. The second hypothesis was that 4 months after the class was completed, those students who attended the class and laboratory would have higher knowledge levels, higher rates of organ donor registration, and higher rates of sharing the decision about organ donation with family members than other nursing students who did not attend the class/laboratory. Methods This quasi-experimental study at an urban university located on the US East Coast used a pretestposttest design with a control group. Senior nursing students in the research group completed the survey before the scheduled fall class (time 1, n = 42) and 4 months later (time 2, n = 33). Junior nursing students in the control group completed the same survey during the same weeks as the research group. At time 1, the control group had 73 students, and at time 2, it had 47 students. The university’s institutional review board approved this study. All participants gave written informed consent for use of the surveys. Students placed the last 5 digits of their student identification number on the surveys to allow matching of pretests and posttests while maintaining confidentiality. All students received the pretest by electronic mail during the 13th week of a 15-week fall semester. Senior students returned a paper copy before the class. Junior students returned their paper surveys before a
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Kurz scheduled junior class in the same week that the seniors’ organ donation class was delivered. The seniors’ class and laboratory was the last one scheduled for the semester. Four months later, both groups received the same surveys electronically and returned their completed paper copy directly to the investigator, who came to the classroom to collect them in a large envelope. The investigator presented to the senior nursing students a 90-minute lecture with PowerPoint slides that addressed donation and transplant statistics, the donation process, common barriers, nurses’ roles in organ donation, legal-ethical principles related to organ donation and donors’ families, and nursing care of organ donors, transplant candidates, recipients, and families. The next day, the same investigator guided senior students who attended a routinely scheduled 90minute laboratory where they discussed the answers to the pretest items, watched “How Do I Say Thank You,” a film produced by The National Minority Organ and Tissue Transplant Education Program, and role played how to provide organ donation information to various groups, namely, riders at a bus stop, a close friend, a high school driver education class, and unlicensed hospital staff. Junior students did not attend this class or laboratory. However, they did attend a routine immunology class, part of the concurrent pathophysiology course that included biological information related to transplant. The senior students had completed the same course the previous year. Instruments This investigator-created survey reflected the content of the lecture, handouts, and assigned readings. Face and content validity had been established by a panel of nursing faculty. To measure knowledge, 5 matching test items related to immunity and 15 truefalse items from the “Myths Regarding Donation” listed on the United Network for Organ Sharing web page (http://www.unos.org/donation/index.php?topic=fact _sheets) were included. The United Network for Organ Sharing website has been revised recently, so the original fact sheet is no longer available (see Table 1 for survey items). One 4-point Likert scale item asked participants to indicate their level of agreement with the statement, “Most people who receive a transplant gain additional years of healthy life.” Two items addressed knowledge of brain death and potential donor characteristics. The survey also included 4 self-report items about attitude toward organ donation. A Likert scale was used and responses were strongly agree (or very likely or comfortable) to strongly disagree (or not at all likely or most uncomfortable). The items were • Ideally, I prefer not to be involved with potential organ donors and their families.
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Table 1 Items from true-false test • Most Americans say that they would donate organs of their loved ones after death. • Almost one-half of transplant candidates in the United States are from minority groups. • Several major religions discourage or prohibit organ donation. • The types of diseases that lead to the need for transplant are unusual and rare. • A person can recover from brain death. • Health care professionals consider an individual’s organ donation status when they are providing care to critically injured patients. • An open casket funeral is not possible for organ and tissue donors. • Rich or famous people can receive organs or tissues before people with the most need. • Asians wait longer for kidney transplants than Caucasians/whites. • After a transplant, the patient is never healthy enough to return to work or school. • You can donate certain organs while you are alive and healthy. • You could need a transplant at some time in your life. • A national computer system matches and distributes organs to the persons who are the sickest and who have been waiting the longest. • If everyone took better care of his or her own health, transplants would not be needed. • Some cancers can be cured with bone marrow transplants.
• How likely are you to want to have your organs donated after your death? • Indicate your comfort level in discussing organ donation with families. • Indicate your comfort level in discussing organ donation with colleagues. To measure the behavior, registration as an organ donor, there was a question: Have you signed an organ donor card? The response was either yes or no. To measure the behavior, sharing information with family, participants responded yes or no to the question: “Have you discussed your wishes with a family member?” Sample Because demographic information was not obtained from the participants, a convenience sample, the following information is provided to describe the undergraduate nursing class from which the volunteer participants originated. The research group was 17% male, 62% white, 17% African American, 18% Asian, 1% Hispanic, and 2% other. The control group was 12% male, 64% white, 23% African American, 11%
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Impact of organ donation education on US undergraduate nursing students Table 2 Response percentages for research group and control group at time 1 and time 2 for specific survey items Response percentage Research group
Control group
Time 1 (n = 42)
Time 2 (n = 33)
Time 1 (n = 73)
Time 2 (n = 47)
Mean knowledge scores (15 items)
78
78
89
79
Believe that transplant recipients gain additional years of healthy life (1 item)
97
56
98
56
Identified correctly clinical death (1 item)
46
46
63
64
Support donation of organs for transplant (1 item)
74
100
84
98
Percentage likely to want to have their organs donated after their death (1 item)
65
85
68
78
Clear understanding of role in caring for potential organ donor (1 item)
57
70
64
83
Comfortable discussing organ donation with families (1 item)
89
75
66
66
Comfortable discussing organ donation with colleagues (1 item)
97
84
94
92
Signed organ donor card (1 item)
61
63
43
51
Discussed donation wishes with family (1 item)
49
44
45
59
Asian, and 1% Hispanic. They ranged from 21 to 55 years old. There were 42 research group participants and 73 control group participants at time 1. All students enrolled in the senior class and all students enrolled in the junior class completed the surveys at time 1. At time 2, the research group had 33 participants and the control group had 47 participants. The research group had a 79% retention rate, and the control group had a 64% retention rate. Analysis All data were entered and analyzed by using the Statistical Package for the Social Science 13.0 for Windows. Measures of central tendency and frequencies were used to describe responses. To detect differences between groups, 2-tailed t tests were used with interval data and χ2 tests were used with ordinal data. To detect changes within the groups, paired 2-tailed t tests were used. Other researchers had reported significant associations between variables, so relationships between variables in the treatment group were explored with Pearson product correlations. Level of significance was established at P ≤ .05. Results Normally distributed data showed that the control and the research groups did not differ significantly at the pretest on any item. All participants in all groups stated that they supported organ donation. Pretest knowledge scores for the research group ranged from 65% to 90% with a mean of 78% (SD, 7.6%). Posttest
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scores ranged from 50% to 95% with a mean of 78% (SD, 9.3%). Pretest knowledge scores for the control group ranged from 50% to 100% with a mean of 89% (SD, 11.0%). Posttest knowledge for the control group ranged from 45% to 100% with a mean of 79% (SD, 12.6%). Knowledge scores for the research group did not change from time 1 to time 2. However, knowledge scores for the control group decreased between time 1 and time 2. The 3 items that were answered incorrectly most often at both time 1 and time 2 included the religious organizations’ support for organ donation, the trend that most Americans state that they would donate their loved one’s organs and, finally, the fact that individuals from minority groups comprised more than half the candidates. Registering as an organ donor was significantly higher at time 2 than time 1 among research group participants. A higher percentage of the research group than the control group registered as organ donors at time 2 (χ2 = 4.5, P = .03). The control group had no statistically significant change in “registering as an organ donor” between time 1 and time 2. No statistically significant differences in family discussions about donation were apparent in either group at either data collection time (see Table 2 for frequencies). Statistically significant correlations between several variables in the research group also were noted (Table 3). Knowledge scores at time 1 were associated with organ donor registration at time 1 and knowledge scores at time 2. Similarly, knowledge scores at time
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Kurz Table 3 Correlations among paired research group’s organ donation survey variables
Knowledge Knowledge Signed donor Signed donor Likely to be T1 T2 card T1 card T2 a donor T1 Knowledge T2
0.29a
Signed donor card T1
0.26a
0.26
Signed donor card T2
0.008
0.28a
Likely to be a donor T1
Clear Comfortable understanding with family of role T2 discussions T2
0.84b 0.56
0.61b
Clear understanding of role T2
0.06
0.07
0.06
0.06
0.15
Comfortable with family discussions T2
0.20
0.04
0.12
0.03
0.13
0.42b
Comfortable with colleague discussions T2
0.30
0.15
0.01
0.22
0.29a
0.26a
a
0.32c
P ≤ .05.
b P ≤ .001. c P ≤ .01.
2 correlated with organ donor registration at time 2. Organ donor registration at time 1 correlated with organ donor registration at time 2. Understanding their role at time 2 was associated with participants’ feeling comfortable talking about organ donation with colleagues and with families at time 2. Discussion One lecture and laboratory did make a difference in registering as an organ donor but not in the family discussions regarding the donation decision. Students can gain knowledge about organ donation in several classes rather than one specific, donation-focused class/ laboratory. This was apparent in the control group, which had higher knowledge scores on the pretest than the research group had. The control group was completing their pathophysiology course requirement, and content related to immunity and organ donation/ rejection was covered before the first data collection. The research group’s knowledge was unchanged over time. One might postulate that knowledge stabilized as misinformation was corrected during the class. Participants answered several knowledge items incorrectly at both times 1 and 2. One was the false statement that several major religions discourage or prohibit organ donation. The additional 2 were “Most Americans say that they would donate organs of their loved ones after death” and “almost one-half of transplant candidates in the United States are from minority groups.” Although students received a pamphlet about religious support and a web page link to several organ donation sites, the information gained was either not accepted as true or students reverted to old knowledge over time. Other researchers found similar findings and suggested that organ donation presentations include
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religious leaders who represent the affiliations of the target group.23,28 The intervention did have a positive effect on organ donation attitudes. The percentage of research group participants who stated that they supported organ donation increased, as did the percentage who wanted to have their own organs donated after death. The control group also demonstrated a similar, but weaker, increase. This result would support the conclusion that other environmental factors influenced students’ attitudes toward organ donation. In the research group, knowledge about their role was associated with the attitudes items: comfort with discussing organ donation with family members and colleagues. Other researchers reported similar associations between knowledge and attitudes.5,7,9,16 A surprising finding with the research group was the decrease in reported comfort in discussing organ donation with families and colleagues. Although this finding was not explored here, one might consider that the intervention highlighted knowledge gaps for participants and reduced self-confidence in this area. Several limitations are noted. The sample was small and not randomized. No individual data are available on those who did not complete the survey at time 2, so it is unclear whether participants’ mortality weakened the study. Demographic data were not collected at the time of the survey and could not have been correlated with responses. The length of time between the pretest and posttest might have threatened the study’s internal validity. Students might have gained new information from sources other than the class and laboratory that contributed to any change in outcomes. Measuring outcomes immediately after the intervention, as well as 4 months later, might
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Impact of organ donation education on US undergraduate nursing students capture changes in actual organ donor registration more accurately. Conclusion Educators should discuss organ donation routinely in several classes throughout the curriculum in addition to offering a class focused specifically on organ donation so that knowledge about organ donation can be maintained. The intervention should include a mechanism to facilitate organ donation registration. Because state registries provide individuals the ability to register as an organ donor electronically, laboratory time should be provided so that participants can register before leaving the laboratory. Instructors might also want to consider adding an exercise where participants role play starting the family discussions. Although most researchers use single Likert scale items to measure attitude toward organ donation, it is suggested that more psychometrically robust instruments be used. One example is the Organ Donation Attitude Scale.15,16 Future researchers should replicate this study with larger groups and use incentives to improve participation rates at the posttest. Financial Disclosures None reported. References 1. Jones J. Nurses Top Honesty and Ethics List for 11th Year. http://www.gallup.com/video/166502/nurses-rated-highest -honesty-ethical-standards-2013.aspx. Accessed April 7, 2014. 2. Shebanzadeh A, Sadr S, Ghafari A, Toushih M. Organ and tissue donation knowledge among intensive care nurses. Transplant Proc. 2009;41:1480-1482. 3. American Association for Colleges of Nursing. Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults. http://www.aacn.nche.edu /geriatric-nursing/AACN_Gerocompetencies.pdf. Accessed March 25, 2013. 4. Anker AE, Friedman E, Knuegler J. Teaching organ and tissue donation in medical and nursing education: a needs assessment. Prog Transplant. 2009;19:343-348. 5. Essman CC. Donation education for medical students: enhancing the link between physicians and procurement professional. Prog Transplant. 2005;15:124-128. 6. Volk ML, Warren GJW, Anspach RR, Couper MP, Merion RM, Ubel PA. Attitudes of the American public toward organ donation after uncontrolled (sudden) cardiac death. Am J Transplant. 2010;10:675-680. 7. Feeley T. College students’ knowledge, attitudes, and behaviors regarding organ donation: an integrated review of the literature. J Appl Soc Psychol. 2007;37:243-271. 8. Arriola K, Robinson D, Thompson N, Peryman J. Projects ACTS: an intervention to increase organ and tissue donation intentions among African Americans. Health Educ Behav. 2010;37:264-274.
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9. Zheng P, Sammann A, Qiu M, Lee R, O’Sullivan P, Roberts J. Impact of preclinical exposure to organ donation on knowledge and attitudes of medical student. Prog Transplant. 2012; 22:79-85. 10. Collins T. Organ and tissue donation: a survey of nurse’s knowledge and educational needs in an adult ITU. Intensive Crit Care Nurs. 2005;21:226-233. 11. Regehr C, Kjerulf M, Popova S, Baker A. Trauma and tribulations: the experiences and attitude of operating room nurses working with organ donors. J Clin Nurs. 2004;13:430-437. 12. Kim J, Fisher J, Elliott D. Attitudes of intensive care nurses towards brain death and organ transplantation: instrument development and testing. J Adv Nurs. 2006;53:571-582. 13. Conesa C, Rios A, Ramirez PJ, et al. Attitudes of primary care nurses toward living kidney donation. Transplant Proc. 2005;37:3626-3630. 14. Rios A, Conesca C, Ramirez PJ, et al. Attitude survey of hospital workers in the surgical services toward living kidney donation. Transplant Proc. 2005;37:3621-3625. 15. Cantwell M, Clifford C. English nursing and medical students’ attitudes towards organ donation. J Adv Nurs. 2000;32:961-968. 16. Zampieron A, Corso M, Frigo A. Undergraduate nursing students’ attitude towards organ donation: a survey in an Italian university. Int Nurs Rev. 2010;47:370-375. 17. Kim JT, Fisher M, Elliott D. Undergraduate nursing students’ knowledge and attitudes towards organ donation in Korea: implications for education. Nurse Educ Today. 2006; 26:465-474. 18. Lopez-Montesinos MJ, Saura JT, Mikla M, et al. Organ donation and transplantation training for future professional nurses as a health and social awareness policy. Transplant Proc. 2010;42:239-242. 19. Goz F, Goz M, Erkan M. Knowledge and attitudes of medical, nursing, dentistry and health technician students towards organ donation: a pilot study. J Clin Nurs. 2006;15:1371-1375. 20. Jones-Riffell AJ, Stoeckle ML. Attitudes of upper division nursing students toward organ donation. J Contin Educ Nurs. 1998;29:274-281. 21. Rykhoff ME, Coupland C, Fudge JD, et al. A clinical group’s attempt to raise awareness of organ and tissue donation. Prog Transplant. 2010;20:33-39. 22. Bramstedt K, Moolia A, Rehfield P. Use of standardized patients to teach medical students about living organ donation. Prog Transplant. 2012;22:86-90. 23. Sininoff L, Burant C, Ibrahim S. Racial disparities in preferences and perceptions regarding organ donation. J Gen Internal Med. 2006;21:995-1000. 24. Breitkopf C. Attitudes, beliefs, and behaviors surrounding organ donation among Hispanic women. Curr Opin Organ Transplant. 2009;14:191-195. 25. Ajzen I. Behavioral Interventions Based on the Theory of Planned Behavior. http://people.umass.edu/aizen/pdf/tpb .intervention.pdf. Accessed March 25, 2014. 26. Hyde M, White K. Communication prompts donation: exploring the beliefs underlying registration and discussion of the organ donation decision. Br J Health Psychol. 2009; 14:423-435. 27. Park H, Smith S. Distinctiveness and influence of subjective norms, personal descriptive and injunctive norms, and societal descriptive and injunctive norms on behavioral intent: a case of two behaviors critical to organ donation. Health Communic Res. 2007;33:194-218. 28. Randhawa G, Brocklurst A, Pateman R, Kinsella S, Parry V. Faith leaders united in their support for organ donation findings from the UK organ donation taskforce study. Transplant Int. 2009;23:140-144.
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Jane McCausland Kurz, RN, PhD Temple University, Philadelphia, Pennsylvania Corresponding author: Jane McCausland Kurz, RN, PhD, Temple University, 3307 N. Broad St, Philadelphia, PA 19140 (e-mail: [email protected]) To purchase electronic or print reprints, contact: American Association of Critical-Care Nurses 101 Columbia, Aliso Viejo, CA 92656 Phone (800) 899-1712 (ext 532) or (949) 448-7370 (ext 532) Fax (949) 362-2049 E-mail [email protected]
©2014 NATCO, The Organization for Transplant Professionals doi: http://dx.doi.org/10.7182/pit2014624
I
t is well documented that the demand for solid organs exceeds the supply of donors worldwide. An increased supply of donors could correct this gap. In surveys of the general public, registered nurses are consistently among the American public’s most trusted groups.1 Nurses, as the largest group of health care professionals, have the potential to play a leading role in organ donation decisions. Personal attitudes toward organ donation can influence nurses’ interactions with potential donor families as nurses respond to questions, present information, and interact as liaisons with organ procurement organizations.2 Educating future nurses about organ donation and shaping their positive attitude toward donation is a strategy to reduce disparities between the number of donors and the number of transplant candidates. Unfortunately, few studies have assessed attitudes toward organ donation among 21stcentury undergraduate nursing students or the results of educational strategies.
Progress in Transplantation, Vol 24, No. 2, June 2014
The American Association of Critical-Care Nurses, a leader in nursing education, included in their “Essentials for Baccalaureate Education for Nursing Professionals” recommendations for content that addresses end-of-life care issues, including decision making, advance directives, and access to organ donation.3 Most US nursing curricula contain some content regarding transplant, but few include instruction on the donation consent process or discussion of organ donation during a health care visit.4 This topic is also neglected in most medical school curricula in the United States, Europe, and other parts of the world.5 The general public generally supports organ donation when surveyed, but only 45% to 54% actually consent to donation when asked.6 University students also demonstrate a positive attitude toward organ donation when surveyed, but few report registering as an organ donor or discussing their wishes with their families.7 Researchers have proposed strategies to improve
211
Kurz organ donation rates with the general public, such as formal presentations, discussions, films, pamphlets, role playing, and meeting organ recipients.8 Effective strategies used with medical students include didactic elective courses, use of standardized patients, clinical electives with a surgical procurement team, and discussion boards.9 One might question how these strategies can be adapted for nursing students in curricula that are tightly constrained by essential content. In this article, I describe a brief intervention that was used with US undergraduate nursing students. This study’s purpose was to evaluate the impact of a researchbased educational class and laboratory that used diverse strategies on nursing students’ knowledge, their registering as an organ donor, and their sharing their decision with their families. Background Researchers in numerous studies involving health care professionals reported high percentages of participants who “support organ donation” but who have not registered as an organ donor or who decline to allow organ donation with a family member. Several researchers focusing on registered nurses cited inaccurate knowledge about donation in their samples, for example, religious support, concerns regarding disfigurement, and transplant successes.10 Regehr and colleagues11 reported that 36% of the operating room nurses who participated in organ retrieval indicated that they would not consent to organ donation for themselves or their family members. Participants cited concerns about the dignity of the patient, well-being of the family, and exposure to death and trauma that added to their own personal distress and negative attitudes. Kim et al12 indicated that 520 intensive care nurses in their study reported both positive and mixed feelings regarding donation with brain-dead donors. With regard to living donations, most often kidney transplants, families will consult health care professionals for advice. Ninety-three percent of primary nurses in a randomized study13 supported living kidney donation, but that number decreased to 75% when the nurses were questioned about deceased donation. Spanish health care professionals (87%), including physicians and nurses in the surgical department, also supported living kidney donation if the donation were restricted to a relative.14 Rios and colleagues concluded from several studies13,14 that a strong relationship exists between attitudes toward living kidney donation and attitudes toward deceased organ donation. Similarly, researchers from 5 countries (England, Italy, Korea, Spain, and Turkey) reported that most student nurses supported organ donation but demonstrated a knowledge deficit regarding the organ donation process in their country.15-19 In a 1998 study20 of US nursing students, 96% supported the concept of
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organ donation but only 82% supported their own or a family member’s organ donation. This group also scored in the poor to moderate range regarding knowledge about organ donation.20 More recently, a survey of nursing and health science students at a Canadian community college revealed that all had a high knowledge of information about organ donation. 21 This knowledge was attributed to several public service message campaigns in the past 10 years that increased levels of awareness of organ donation. However, knowledge deficits were noted with some important information, for example, the need for family approval. To date, no additional organ donation studies have included 21st-century American undergraduate nursing students. This gap needs to be addressed. A subsequent research question is, What is an effective strategy to educate nursing students that would result in increased knowledge and increased registration as an organ donor? A literature review of instructional methods for organ donation sessions revealed the lecture as the most common teaching technique.2 Other strategies used with college students, medical students, and registered nurses were the standardized patient with role playing and small-group discussions.22 Experts suggest that, to increase the number of persons who agree to register as potential organ donors, program planners should address the knowledge deficit regarding organ donation and brain death, mistrust of the medical system, and the families’ lack of discussion about the organ donation decision.8,23,24 There remains a lack of information regarding the best strategy to include the needed information in the shortest time in a tightly constrained curriculum. Currently, few intervention studies have involved nurses or nursing students reporting outcomes. Lopez-Montesinos and colleagues 18 surveyed 48 Spanish nursing students before and after a 32-hour academic course on donation and transplant. They reported an improved knowledge level and a more positive attitude after the course. Rykhoff et al21 surveyed 240 community college students (56 of whom were nursing students) after a lecture that used a PowerPoint presentation and a 7-minute video. They reported a statistically significant increase in knowledge, an increase in the number of persons who were willing to donate, and an increase in the number of persons who were aware of the need for family consent. Neither of these studies had a control group, so one cannot conclude that the intervention was the sole cause of the changes noted. Theoretical Framework In his Theory of Planned Behavior (TPB), Ajzen25 showed that behavioral intentions are antecedents to the behavior and that attitudes about that behavior, subjective norms, and perceived behavioral control Progress in Transplantation, Vol 24, No. 2, June 2014
Impact of organ donation education on US undergraduate nursing students
Behavioral beliefs
Attitude toward the behavior
Normative beliefs
Subjective norm
Control beliefs
Perceived behavioral control
Intention
Behavior
Actual behavior control
Figure Theory of planned behavior. Source: Icek Ajzen. TPB Diagram. http://people.umass.edu/aizen/tpb.diag.html. Accessed April 8, 2014.
influence that behavioral intention (see Figure). In this theory, one assumption is that there are no barriers to the behavior. Programs that use TPB typically are aimed at changing attitudes. Using TPB as a foundation for this study, I used an intervention (an educational class and laboratory) to change the knowledge level and attitudes about organ donation. Participants’ subjective norms with the changed attitudes toward organ donation would influence their registration as an organ donor and sharing their decision with family members. The process to self-register was described in the laboratory session, and participants believed that they had control over their registering as an organ donor. Several researchers who used this model in their organ donation studies reported that knowledge, attitude, and altruism were significantly related both to registering as an organ donor and willingness to communicate decisions about organ donation to family members.26,27 Because organ donation in the United States does not occur without permission from the family members, sharing personal decisions about organ donation is essential. This study measured knowledge about and attitudes toward organ donation, registration as an organ donor, and family communication. Hypotheses The study’s purpose was to evaluate the impact of a research-based educational class and laboratory that used diverse strategies on knowledge and registration as an organ donor and intent to share that decision with family. One hypothesis was that students who attend the organ donation/transplant class lecture and
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laboratory will have higher knowledge levels, higher rates of registration as organ donors, and higher rates of sharing decisions about organ donation with family members after than before the class/laboratory. The second hypothesis was that 4 months after the class was completed, those students who attended the class and laboratory would have higher knowledge levels, higher rates of organ donor registration, and higher rates of sharing the decision about organ donation with family members than other nursing students who did not attend the class/laboratory. Methods This quasi-experimental study at an urban university located on the US East Coast used a pretestposttest design with a control group. Senior nursing students in the research group completed the survey before the scheduled fall class (time 1, n = 42) and 4 months later (time 2, n = 33). Junior nursing students in the control group completed the same survey during the same weeks as the research group. At time 1, the control group had 73 students, and at time 2, it had 47 students. The university’s institutional review board approved this study. All participants gave written informed consent for use of the surveys. Students placed the last 5 digits of their student identification number on the surveys to allow matching of pretests and posttests while maintaining confidentiality. All students received the pretest by electronic mail during the 13th week of a 15-week fall semester. Senior students returned a paper copy before the class. Junior students returned their paper surveys before a
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Kurz scheduled junior class in the same week that the seniors’ organ donation class was delivered. The seniors’ class and laboratory was the last one scheduled for the semester. Four months later, both groups received the same surveys electronically and returned their completed paper copy directly to the investigator, who came to the classroom to collect them in a large envelope. The investigator presented to the senior nursing students a 90-minute lecture with PowerPoint slides that addressed donation and transplant statistics, the donation process, common barriers, nurses’ roles in organ donation, legal-ethical principles related to organ donation and donors’ families, and nursing care of organ donors, transplant candidates, recipients, and families. The next day, the same investigator guided senior students who attended a routinely scheduled 90minute laboratory where they discussed the answers to the pretest items, watched “How Do I Say Thank You,” a film produced by The National Minority Organ and Tissue Transplant Education Program, and role played how to provide organ donation information to various groups, namely, riders at a bus stop, a close friend, a high school driver education class, and unlicensed hospital staff. Junior students did not attend this class or laboratory. However, they did attend a routine immunology class, part of the concurrent pathophysiology course that included biological information related to transplant. The senior students had completed the same course the previous year. Instruments This investigator-created survey reflected the content of the lecture, handouts, and assigned readings. Face and content validity had been established by a panel of nursing faculty. To measure knowledge, 5 matching test items related to immunity and 15 truefalse items from the “Myths Regarding Donation” listed on the United Network for Organ Sharing web page (http://www.unos.org/donation/index.php?topic=fact _sheets) were included. The United Network for Organ Sharing website has been revised recently, so the original fact sheet is no longer available (see Table 1 for survey items). One 4-point Likert scale item asked participants to indicate their level of agreement with the statement, “Most people who receive a transplant gain additional years of healthy life.” Two items addressed knowledge of brain death and potential donor characteristics. The survey also included 4 self-report items about attitude toward organ donation. A Likert scale was used and responses were strongly agree (or very likely or comfortable) to strongly disagree (or not at all likely or most uncomfortable). The items were • Ideally, I prefer not to be involved with potential organ donors and their families.
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Table 1 Items from true-false test • Most Americans say that they would donate organs of their loved ones after death. • Almost one-half of transplant candidates in the United States are from minority groups. • Several major religions discourage or prohibit organ donation. • The types of diseases that lead to the need for transplant are unusual and rare. • A person can recover from brain death. • Health care professionals consider an individual’s organ donation status when they are providing care to critically injured patients. • An open casket funeral is not possible for organ and tissue donors. • Rich or famous people can receive organs or tissues before people with the most need. • Asians wait longer for kidney transplants than Caucasians/whites. • After a transplant, the patient is never healthy enough to return to work or school. • You can donate certain organs while you are alive and healthy. • You could need a transplant at some time in your life. • A national computer system matches and distributes organs to the persons who are the sickest and who have been waiting the longest. • If everyone took better care of his or her own health, transplants would not be needed. • Some cancers can be cured with bone marrow transplants.
• How likely are you to want to have your organs donated after your death? • Indicate your comfort level in discussing organ donation with families. • Indicate your comfort level in discussing organ donation with colleagues. To measure the behavior, registration as an organ donor, there was a question: Have you signed an organ donor card? The response was either yes or no. To measure the behavior, sharing information with family, participants responded yes or no to the question: “Have you discussed your wishes with a family member?” Sample Because demographic information was not obtained from the participants, a convenience sample, the following information is provided to describe the undergraduate nursing class from which the volunteer participants originated. The research group was 17% male, 62% white, 17% African American, 18% Asian, 1% Hispanic, and 2% other. The control group was 12% male, 64% white, 23% African American, 11%
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Impact of organ donation education on US undergraduate nursing students Table 2 Response percentages for research group and control group at time 1 and time 2 for specific survey items Response percentage Research group
Control group
Time 1 (n = 42)
Time 2 (n = 33)
Time 1 (n = 73)
Time 2 (n = 47)
Mean knowledge scores (15 items)
78
78
89
79
Believe that transplant recipients gain additional years of healthy life (1 item)
97
56
98
56
Identified correctly clinical death (1 item)
46
46
63
64
Support donation of organs for transplant (1 item)
74
100
84
98
Percentage likely to want to have their organs donated after their death (1 item)
65
85
68
78
Clear understanding of role in caring for potential organ donor (1 item)
57
70
64
83
Comfortable discussing organ donation with families (1 item)
89
75
66
66
Comfortable discussing organ donation with colleagues (1 item)
97
84
94
92
Signed organ donor card (1 item)
61
63
43
51
Discussed donation wishes with family (1 item)
49
44
45
59
Asian, and 1% Hispanic. They ranged from 21 to 55 years old. There were 42 research group participants and 73 control group participants at time 1. All students enrolled in the senior class and all students enrolled in the junior class completed the surveys at time 1. At time 2, the research group had 33 participants and the control group had 47 participants. The research group had a 79% retention rate, and the control group had a 64% retention rate. Analysis All data were entered and analyzed by using the Statistical Package for the Social Science 13.0 for Windows. Measures of central tendency and frequencies were used to describe responses. To detect differences between groups, 2-tailed t tests were used with interval data and χ2 tests were used with ordinal data. To detect changes within the groups, paired 2-tailed t tests were used. Other researchers had reported significant associations between variables, so relationships between variables in the treatment group were explored with Pearson product correlations. Level of significance was established at P ≤ .05. Results Normally distributed data showed that the control and the research groups did not differ significantly at the pretest on any item. All participants in all groups stated that they supported organ donation. Pretest knowledge scores for the research group ranged from 65% to 90% with a mean of 78% (SD, 7.6%). Posttest
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scores ranged from 50% to 95% with a mean of 78% (SD, 9.3%). Pretest knowledge scores for the control group ranged from 50% to 100% with a mean of 89% (SD, 11.0%). Posttest knowledge for the control group ranged from 45% to 100% with a mean of 79% (SD, 12.6%). Knowledge scores for the research group did not change from time 1 to time 2. However, knowledge scores for the control group decreased between time 1 and time 2. The 3 items that were answered incorrectly most often at both time 1 and time 2 included the religious organizations’ support for organ donation, the trend that most Americans state that they would donate their loved one’s organs and, finally, the fact that individuals from minority groups comprised more than half the candidates. Registering as an organ donor was significantly higher at time 2 than time 1 among research group participants. A higher percentage of the research group than the control group registered as organ donors at time 2 (χ2 = 4.5, P = .03). The control group had no statistically significant change in “registering as an organ donor” between time 1 and time 2. No statistically significant differences in family discussions about donation were apparent in either group at either data collection time (see Table 2 for frequencies). Statistically significant correlations between several variables in the research group also were noted (Table 3). Knowledge scores at time 1 were associated with organ donor registration at time 1 and knowledge scores at time 2. Similarly, knowledge scores at time
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Kurz Table 3 Correlations among paired research group’s organ donation survey variables
Knowledge Knowledge Signed donor Signed donor Likely to be T1 T2 card T1 card T2 a donor T1 Knowledge T2
0.29a
Signed donor card T1
0.26a
0.26
Signed donor card T2
0.008
0.28a
Likely to be a donor T1
Clear Comfortable understanding with family of role T2 discussions T2
0.84b 0.56
0.61b
Clear understanding of role T2
0.06
0.07
0.06
0.06
0.15
Comfortable with family discussions T2
0.20
0.04
0.12
0.03
0.13
0.42b
Comfortable with colleague discussions T2
0.30
0.15
0.01
0.22
0.29a
0.26a
a
0.32c
P ≤ .05.
b P ≤ .001. c P ≤ .01.
2 correlated with organ donor registration at time 2. Organ donor registration at time 1 correlated with organ donor registration at time 2. Understanding their role at time 2 was associated with participants’ feeling comfortable talking about organ donation with colleagues and with families at time 2. Discussion One lecture and laboratory did make a difference in registering as an organ donor but not in the family discussions regarding the donation decision. Students can gain knowledge about organ donation in several classes rather than one specific, donation-focused class/ laboratory. This was apparent in the control group, which had higher knowledge scores on the pretest than the research group had. The control group was completing their pathophysiology course requirement, and content related to immunity and organ donation/ rejection was covered before the first data collection. The research group’s knowledge was unchanged over time. One might postulate that knowledge stabilized as misinformation was corrected during the class. Participants answered several knowledge items incorrectly at both times 1 and 2. One was the false statement that several major religions discourage or prohibit organ donation. The additional 2 were “Most Americans say that they would donate organs of their loved ones after death” and “almost one-half of transplant candidates in the United States are from minority groups.” Although students received a pamphlet about religious support and a web page link to several organ donation sites, the information gained was either not accepted as true or students reverted to old knowledge over time. Other researchers found similar findings and suggested that organ donation presentations include
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religious leaders who represent the affiliations of the target group.23,28 The intervention did have a positive effect on organ donation attitudes. The percentage of research group participants who stated that they supported organ donation increased, as did the percentage who wanted to have their own organs donated after death. The control group also demonstrated a similar, but weaker, increase. This result would support the conclusion that other environmental factors influenced students’ attitudes toward organ donation. In the research group, knowledge about their role was associated with the attitudes items: comfort with discussing organ donation with family members and colleagues. Other researchers reported similar associations between knowledge and attitudes.5,7,9,16 A surprising finding with the research group was the decrease in reported comfort in discussing organ donation with families and colleagues. Although this finding was not explored here, one might consider that the intervention highlighted knowledge gaps for participants and reduced self-confidence in this area. Several limitations are noted. The sample was small and not randomized. No individual data are available on those who did not complete the survey at time 2, so it is unclear whether participants’ mortality weakened the study. Demographic data were not collected at the time of the survey and could not have been correlated with responses. The length of time between the pretest and posttest might have threatened the study’s internal validity. Students might have gained new information from sources other than the class and laboratory that contributed to any change in outcomes. Measuring outcomes immediately after the intervention, as well as 4 months later, might
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Impact of organ donation education on US undergraduate nursing students capture changes in actual organ donor registration more accurately. Conclusion Educators should discuss organ donation routinely in several classes throughout the curriculum in addition to offering a class focused specifically on organ donation so that knowledge about organ donation can be maintained. The intervention should include a mechanism to facilitate organ donation registration. Because state registries provide individuals the ability to register as an organ donor electronically, laboratory time should be provided so that participants can register before leaving the laboratory. Instructors might also want to consider adding an exercise where participants role play starting the family discussions. Although most researchers use single Likert scale items to measure attitude toward organ donation, it is suggested that more psychometrically robust instruments be used. One example is the Organ Donation Attitude Scale.15,16 Future researchers should replicate this study with larger groups and use incentives to improve participation rates at the posttest. Financial Disclosures None reported. References 1. Jones J. Nurses Top Honesty and Ethics List for 11th Year. http://www.gallup.com/video/166502/nurses-rated-highest -honesty-ethical-standards-2013.aspx. Accessed April 7, 2014. 2. Shebanzadeh A, Sadr S, Ghafari A, Toushih M. Organ and tissue donation knowledge among intensive care nurses. Transplant Proc. 2009;41:1480-1482. 3. American Association for Colleges of Nursing. Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults. http://www.aacn.nche.edu /geriatric-nursing/AACN_Gerocompetencies.pdf. Accessed March 25, 2013. 4. Anker AE, Friedman E, Knuegler J. Teaching organ and tissue donation in medical and nursing education: a needs assessment. Prog Transplant. 2009;19:343-348. 5. Essman CC. Donation education for medical students: enhancing the link between physicians and procurement professional. Prog Transplant. 2005;15:124-128. 6. Volk ML, Warren GJW, Anspach RR, Couper MP, Merion RM, Ubel PA. Attitudes of the American public toward organ donation after uncontrolled (sudden) cardiac death. Am J Transplant. 2010;10:675-680. 7. Feeley T. College students’ knowledge, attitudes, and behaviors regarding organ donation: an integrated review of the literature. J Appl Soc Psychol. 2007;37:243-271. 8. Arriola K, Robinson D, Thompson N, Peryman J. Projects ACTS: an intervention to increase organ and tissue donation intentions among African Americans. Health Educ Behav. 2010;37:264-274.
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9. Zheng P, Sammann A, Qiu M, Lee R, O’Sullivan P, Roberts J. Impact of preclinical exposure to organ donation on knowledge and attitudes of medical student. Prog Transplant. 2012; 22:79-85. 10. Collins T. Organ and tissue donation: a survey of nurse’s knowledge and educational needs in an adult ITU. Intensive Crit Care Nurs. 2005;21:226-233. 11. Regehr C, Kjerulf M, Popova S, Baker A. Trauma and tribulations: the experiences and attitude of operating room nurses working with organ donors. J Clin Nurs. 2004;13:430-437. 12. Kim J, Fisher J, Elliott D. Attitudes of intensive care nurses towards brain death and organ transplantation: instrument development and testing. J Adv Nurs. 2006;53:571-582. 13. Conesa C, Rios A, Ramirez PJ, et al. Attitudes of primary care nurses toward living kidney donation. Transplant Proc. 2005;37:3626-3630. 14. Rios A, Conesca C, Ramirez PJ, et al. Attitude survey of hospital workers in the surgical services toward living kidney donation. Transplant Proc. 2005;37:3621-3625. 15. Cantwell M, Clifford C. English nursing and medical students’ attitudes towards organ donation. J Adv Nurs. 2000;32:961-968. 16. Zampieron A, Corso M, Frigo A. Undergraduate nursing students’ attitude towards organ donation: a survey in an Italian university. Int Nurs Rev. 2010;47:370-375. 17. Kim JT, Fisher M, Elliott D. Undergraduate nursing students’ knowledge and attitudes towards organ donation in Korea: implications for education. Nurse Educ Today. 2006; 26:465-474. 18. Lopez-Montesinos MJ, Saura JT, Mikla M, et al. Organ donation and transplantation training for future professional nurses as a health and social awareness policy. Transplant Proc. 2010;42:239-242. 19. Goz F, Goz M, Erkan M. Knowledge and attitudes of medical, nursing, dentistry and health technician students towards organ donation: a pilot study. J Clin Nurs. 2006;15:1371-1375. 20. Jones-Riffell AJ, Stoeckle ML. Attitudes of upper division nursing students toward organ donation. J Contin Educ Nurs. 1998;29:274-281. 21. Rykhoff ME, Coupland C, Fudge JD, et al. A clinical group’s attempt to raise awareness of organ and tissue donation. Prog Transplant. 2010;20:33-39. 22. Bramstedt K, Moolia A, Rehfield P. Use of standardized patients to teach medical students about living organ donation. Prog Transplant. 2012;22:86-90. 23. Sininoff L, Burant C, Ibrahim S. Racial disparities in preferences and perceptions regarding organ donation. J Gen Internal Med. 2006;21:995-1000. 24. Breitkopf C. Attitudes, beliefs, and behaviors surrounding organ donation among Hispanic women. Curr Opin Organ Transplant. 2009;14:191-195. 25. Ajzen I. Behavioral Interventions Based on the Theory of Planned Behavior. http://people.umass.edu/aizen/pdf/tpb .intervention.pdf. Accessed March 25, 2014. 26. Hyde M, White K. Communication prompts donation: exploring the beliefs underlying registration and discussion of the organ donation decision. Br J Health Psychol. 2009; 14:423-435. 27. Park H, Smith S. Distinctiveness and influence of subjective norms, personal descriptive and injunctive norms, and societal descriptive and injunctive norms on behavioral intent: a case of two behaviors critical to organ donation. Health Communic Res. 2007;33:194-218. 28. Randhawa G, Brocklurst A, Pateman R, Kinsella S, Parry V. Faith leaders united in their support for organ donation findings from the UK organ donation taskforce study. Transplant Int. 2009;23:140-144.
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