Volume 28, Issue 1 (Winter 2021)                   Intern Med Today 2021, 28(1): 54-69 | Back to browse issues page

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Namdar P, Dehghankar L, Taherkhani M, Yekefallah L, Ranjbaran M. Performance in Organ Donation Process in Nurses Working in Critical Care Units of Hospitals in Qazvin City, Iran. Intern Med Today 2021; 28 (1) :54-69
URL: http://imtj.gmu.ac.ir/article-1-3602-en.html
1- Department of Emergency Medicine, Metabolic Disease Research Center, Qazvin University of Medical Sciences, Qazvin, Iran.
2- Department of Nursing, Social Determinants of Health Research Center, Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran.
3- Student Research Committee, Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran.
4- Department of Nursing, Social Determinants of Health Research Center, Faculty of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran. , leili_fallah@yahoo.com
5- Metabolic Diseases Research Center, Research Institute for Prevention of Non-communicable Diseases, Qazvin University of Medical Sciences, Qazvin, Iran.
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Transplantation of body organs and tissues is one of the outstanding achievements of modern medicine. By replacing a damaged organ or tissue with a healthy one, a definitive or long-term treatment can be achieved. Organs such as heart, lung, liver, kidney, bone marrow, and cornea can be successfully transplanted to another person in need [
1]. Today, organ transplantation has been accelerated with the discovery of immunosuppressive drugs, advances in surgical techniques and management of critical care units [2]. However, it still has serious challenges such as an increase in the number of patients in transplant waiting list, shortage of donated organs, and inequality in access to donated organs [3]. One of the main sources of organ supply for patients with organ failure are donors after brain death [45]. In Iran, about 1-4% of in-hospital deaths and 10% of deaths in critical care units are related to brain deaths, while in the United States, less than 1% of all deaths are related to brain deaths [6]. However, due to low number of donors after brain death, the number of organ transplants in Iran is much lower than those in European and American countries [7]. According to Iranian Organ Transplant Organization, there were 5,000-8,000 brain deaths per year in 2017, of which 2,500-4,000 were eligible for organ donation, but the actual number of donors was only 808 [8]. 
Since most potential organ donors are patients admitted to critical care units, the staff of these units (Doctors, nurses, etc.) have a key role in the optimal control of organ donors and increasing the number of transplanted cases [
9]. Studies also confirm that nurses working in critical care units play a vital role in identifying and caring for potential organ donors and promoting equal access to donated organs [9, 10]. Nurses can have participation in informing the families about their patients’ brain death and request them to donate their organs, and coordinate the organ donation process [4]. Therefore, nurses’ communication skills are vital to ensuring the clarity of information given to the families of brain dead patients [9, 11]. In these situations, nurses should care and emotionally support the families. This is one of the most effective factors in satisfaction of family members with the process of organ donation [4, 10]. Caring for a potential brain dead organ donor is one of the major tasks of nurses during an organ donation process. This care is to preserve the life of organs for transplantation, to save the life of a patient, or improve the quality of life of people who need to transplant organs [9]. After obtaining the consent of families with brain dead member to donate organs, caring for a brain dead patient who is candidate for organ donation is one of the heaviest tasks of nurses in critical care units [6]. If the nurses can act appropriately in informing the families of brain dead patients and in requesting them to donate organs, they can cope more easily with their patients’ death and, hence, the likelihood of their consent to donation can increase. 
Despite the importance of the positive and valuable role of nurses in organ donation process, various studies have shown that the staff of critical care units including doctors and nurses, are not ready to successfully manage the organ donation process [
11, 12]. In a study by Chakradhar et al., the majority of dental students in India had a poor performance regarding organ donation [13], Jothula et al. also showed that, despite high awareness and positive attitude towards the organ donation, most medical students had poor performance regarding organ donation [14]. Similarly, the results of Chung et al. [15] and Vinay et al. [16] showed that most medical students had poor performance in terms of organ donation. However, in the study by Salmani Nadoushan et al., 68% of the physicians had an organ donation card with a positive attitude towards the organ donation process [17]. Ghazanchai et al. showed that the attitude of nurses towards organ transplantation was not significantly different between the hospital wards. This may be because all staff in different wards of the study hospital involved in one transplantation process and, hence, their attitudes towards organ transplantation are almost the same. Therefore, improving the nurses’ working environment and increasing their awareness can be effective in promoting their attitudes towards organ transplantation [18]. 
Considering the different results in several studies and that we live in a country where thousands of patients are in need of organ transplants and are waiting for an organ donor while, while there are increasing number of brain dead patients whose organ donation can improve the quality of life of patients in need [
1920] and given that we found no related study in Iran, and nurses play an important role in the organ donation process, this study aims to determine the performance of nurses working in critical care units in Qazvin, Iran in relation to the organ donation process.
Materials and Methods
This is a descriptive analytical study with a cross-sectional design. The study population consists of all nurses working in the critical care units (ICU, dialysis ward, and emergency department) of hospitals in Qazvin, Iran (n=293), from January 16, 2018 to May 1, 2019. By using the Cochran’s formula and considering a test power of 80% and precision level of 0.06 at 95% confidence interval, the sample size was calculated 165. For more accuracy and considering a 15% sample dropout, the sample size was increased to 190. The sampling was conducted using a stratified random method; the wards of each hospital were considered as strata. The number of nurses included in the study population was determined separately for each hospital and, then, the population of each ward was divided by the total number of hospital population to determine the sampling ratio for each ward. Thus, 56 nurses from Shahid Rajaei Hospital, 71 from Bu Ali Hospital, 55 from Velayat Hospital, and 8 from Kowsar Hospital were selected by simple random sampling method, and the nurses from each ward were selected by drawing cards. Inclusion criteria were: Having at least one year of work experience in critical care units, a history of organ donation or transplantation in family and relatives, the need for organ transplantation, while the lack of cooperation or unwillingness to continue participation were the exclusion criteria. In this study, ethical procedures such as obtaining informed consent from the participants, the right to leave the study at any time were observed. For the frequency of nurses with the organ donation card, the p-value was considered 0.188 [
Data collection tools were two questionnaires. One questionnaire surveys the demographic information including age, gender, marital status, religion, employment type, educational level, organizational position, and work experience in the critical care units. The second questionnaire evaluates the nurses’ performance in organ donation, which had two parts; the first part had 6 items answered “Yes” (1 point) or “No” (0 point) [
14 ,13], and the second part had two scenarios to examine the performance of nurses. The first scenario was related to the advocacy role of nurses and the second scenario was related to the participatory role of nurses in organ donation. Each scenario consisted of 5 descriptive questions. The total score ranges from 0 (poorest performance) to 10 (excellent performance). Based on the scores, the performance were divided into four levels of poor (score 0-3), moderate (score 4-6), good (score 7-9), and excellent (score 9-10). The reliability of this questionnaire was assessed based on the agreement between raters by Masoumian Hosseini et al., and a kappa coefficient of 1.0 was reported [22]. Furthermore, in the present study, in order to assess the validity of the questionnaire, it was sent to 10 experts and their opinions were assessed. Then, this questionnaire was distributed among 30 nurses and a Cronbach’s alpha coefficient of 0.81 was obtained.
After obtaining ethical approval from the Vice-Chancellor for Research and Technology of Qazvin University of Medical Sciences, sending a letter of introduction to the hospitals, and explaining the study objectives to them, the questionnaires were distributed and completed. Nurses were assured of the confidentiality of their information. Meantime, the questionnaires were completed in the clinical wards. After collection, the data were entered into SPSS v. 23 software and analyzed using descriptive statistics and statistical tests (t-test, ANOVA, Pearson correlation test, and Spearman correlation test). The significance level was set as P<0.05. 
A total of 190 nurses participated in this study, most of whom were women (84.7%) and married (77.2%), with Mean±SD work experience of 6.34±4.70 years. Most of them (94%) had a bachelor’s degree and 5.9% had higher degrees (Table 1).

Based on the answers in the first part of the performance questionnaire, for the question “Have you committed or signed to donate an organ?”, 76.8% answered No and 23.2% answered Yes. For the question “Have you ever received a transplanted organ?” all participants answered No. For the question “Do you have an organ donation card?” 22.8% answered Yes and 77.2% answered No. For the question “In your family, is anyone a member of the organ transplant organization?” 20.2% answered Yes and 79.8% answered No. For the question “Would you like to receive money if you donate an organ?” 4.1% answered Yes and 96.9% answered No. 
Based on demographic variables, the results (Table 2) showed that the performance score of nurses was higher in females (1.62±0.68) than in males (1.59±0.60) and higher in married nurses (1.64±0.69) than in single nurses (1.55±0.58) but these differences were not statistically significant.

Furthermore, the performance score was higher in nurses with master’s degree or higher degree (1.82±0.95) than in nurses with bachelor’s degree (1.60±0.63) and was higher in nurses with organ donation card (1.68±0.59) than in nurses with no organ donation card (1.58±0.68), but these differences were not statistically significant. Moreover, the performance score was higher in supervise nurses (2.03±1.00) than in nurses (1.58±0.64) which was statistically significant. 
Based on the working place, the highest score belonged to the nurses working in ICU of Kowsar Hospital (2.75±0.61) and the lowest score belonged to those working in dialysis ward of Velayat Hospital (0.85±0.48). Furthermore, the results showed no significant relationship between age (P=0.23) and work experience in ICU (P=0.25) with nurses’ performance in organ donation. 
The high prevalence of chronic diseases in Iran such as hypertension, diabetes, obesity, and kidney disease can greatly increase the need for organ transplants in the upcoming years. The results of the present study showed that nurses in critical care units had poor performance in organ donation. In our study, only 22.8% of nurses had an organ donation card. In the study by Chakradhar et al., the majority of dental students in India (95.9%) had poor performance regarding organ donation process [
13] and Jothula et al. in their study on knowledge, attitude and practice on organ donation among medical trainees in Telangana, India, reported that, despite high knowledge and a positive attitude towards the organ donation process, only 5.5% of the subjects had an organ donation card and their performance was poor in relation to organ donation process [14]. Babaei et al. investigated the knowledge, attitude, and performance of nurses in the organ donation process, where 96.6% of nurses had no organ donation card [23]. Results of studies by Sarveswaran et al. [24], Mani et al. [25], Adithyan et al. [26], Chung et al. [15], and Vinay et al. [16] also showed that most of subjects had no organ donation card. .
In the present study, regarding the intention to receive money for organ donation, 4.1% of nurses considered it as an immoral behavior. In the study by Jothula et al., 3.7% of medical students had willingness to receive money for organ donation [
14]. Masoumian Hosseini et al. showed that the majority of nurses (96.7%) had poor performance related to organ donation [22], which is consistent with the present study. However, in the study by Salmani Nadoushan et al., 68% of the physicians had organ donation cards and a positive attitude towards the organ donation [17].
In the present study, female nurses had higher performance in organ donation than males, but no significant relationship was found between gender and nurses’ performance. Babaei et al. evaluated the knowledge, attitude, and practice of nurses in organ donation where it was reported that the performance of females was higher than males, which was significant [
23]. In the study by Chakradhar et al., no significant difference was found between performance score and gender [13]. A study by Ghazanchai et al. on nurses’ knowledge, attitude and practice in organ transplantation conducted in Dr. Masih Daneshvari Hospital in Iran, showed no relationship between nurses’ gender and their attitude towards transplantation and caring for a brain dead patient [18], which was consistent with the present study. Bardell et al. [27] and Saleem et al. [28] also reported no relationship between gender and organ donation performance.
In the present study, nurses’ marital status, educational level, type of employment, and having an organ donation card had no significant relationship with their performance in organ donation. In the study by Chakradhar et al., the mean score of performance was higher in male dental students but it was not significant [
13]. Ghazanchai et al. reported no significant relationship between nurses’ marital status and their opinion on the effectiveness of organ transplantation [18]. Manzari et al. [4] in a study on the effect of education based on the dynamic nursing model and continuous improvement of reliability and verification on nurses’ knowledge, attitude in the organ donation process, there was no significant statistical difference in the scores of knowledge, attitude, and practice in terms of demographic variables [10], which is consistent with the present study. In the study by Masoumian Hosseini et al., there was a positive and significant relationship between work experience and nurses’ performance [22], which is against our results. Moreover, in their study, marital status and gender had significant relationship with the performance of nurses, which is consistent with the results of present study. Kiani et al. stated that organ donation is a complicated issue for all people, and several factors such as knowledge and positive attitude of community, nurses and families, having donation cards, culture, and existing laws affect it [8]. Developing educational programs for all people for increasing their awareness and positive attitude can lead to their increased trust in organ donation process. 
In the present study, the highest performance belonged to ICU nurses and the lowest belonged to dialysis ward nurses. It can be because the ICU nurses are highly in contact with both brain dead patients and those in need of organ transplantation, while nurses in dialysis wards have no contact with brain dead patients. The results of Ghazanchaei et al. showed that the type of ward was not significantly related to the nurses’ attitude towards organ transplantation [
19]. The reason for the discrepancy between their results and the results of our study is that all staff in different wards of the hospital in their study were somehow involved in the process of organ transplantation and, therefore, the attitude of nurses in different wards was almost the same. 
Considering the poor performance of nurses in critical care units of hospitals in Qazvin city regarding organ donation and since most of them have no organ donation card, informing them about their roles in the organ donation process and promoting their performance in this area is necessary. It is recommended that coherent and purposeful training courses be held in this field and a field of study for this issue be considered for nursing students before graduation. 

Ethical Considerations
Compliance with ethical guidelines

This study was approved by the Ethics Committee of Qazvin University of Medical Sciences (Code: IR.QUMS.REC.1397.250).

The present paper was extracted from the research project of third author. The study received financial support from Qazvin University of Medical Sciences.

Authors' contributions
Conceptualization: Peyman Namdar, Leila Dehghankar, and Leili Yekefallah; Design and data curation: Peyman Namdar, Mahnaz Taherkhani, Leila Dehghankar, Leili Yekefallah; data interpretation: Mehdi Ranjbaran; writing original draft, review and final approval: All authors.

Conflicts of interest
The authors declare no conflict of interest.

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Type of Study: Original | Subject: Basic Medical Science
Received: 2020/10/27 | Accepted: 2021/10/9 | Published: 2022/01/1

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