RESEARCH ARTICLES

The work process in the context of organ and tissue donation

Milleni Sousa Vieira^I; LídyaTolstenko Nogueira^II

^I Master in Nursing. Federal University of Piauí. Teresina, Piauí, Brazil. E-mail: millenisv@hotmail.com
^II Ph.D.in Nursing. Associated Professor of the Nursing Departmentof the Federal University ofPiauí. Teresina, Piauí, Brazil. E-mail: lidyatn@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.11744

ABSTRACT

This descriptive, qualitative study evaluated aspects of health personnel's work process in the Organ and Tissue Procurement, Notification and Distribution System in Piauí State. The sample of 29 subjects included nurses, doctors, social workers and psychologists. Data were collected by interview between October 2011 and May 2012. Content analysis gave the methodological framework for analysis of the interviewees' statements, after which categories were developed. The results showed that a skilled multidisciplinary team, a convinced family, technical expertise and availability of appropriate physical and material resources are needed to operationalize the donation/transplantation process. Their lack constitutes barriers to this process. Accordingly, identification of weaknesses should guide the planning of strategies to increase the number of donations and transplants in health services.

Keywords: Transplantation; health evaluation; health services; nursing.

INTRODUCTION

Technological evolution relating to procedures involving the transplantation of organs and tissues showed a remarkable development with important effects on the survival of thousands of patients.

Transplants consistof well-established therapy used when there are no other treatments or did not achieve the results. Thus, the transplantation of organs and tissues imposes as a last alternative for patients who are queued. Not performing the transplantations imply negative consequences about the probability of a cure, to the survival of grafts and patients, to the nature and extent of sequelae in patients, in the family and society¹.

The growing development of Brazil in the transplant sector is the result of activities of the National Transplant System (SNT) that regulates the uptake and distribution of organs in the states through the State Transplant Centers, as well as raising awareness among the general population about the importance of the donation/transplantation process. The National Policy ofTransplants of organs and tissues is regulated by Federal Law No. 9,434/97 and No. 10,211/01, having as guidelines the gratuitousness of the donation, the benefit about the receiver, and no loss concerning the live donor^2,3 .

The realization of transplantation of organs and tissues is an achievement for society and the health system. Specifically in Brazil, these procedures are noteworthy in that over 90% of transplants are financed by a public health system.

Also, the work process in the organ and tissue donation should be understood to identify the organizational processes and the factors that contribute to the quality of care and the development of activities involving transplants.

Given the above, this study aimed to evaluate aspects related to the work process of professionals working in the System of Capture, Notification, and Distribution of Organs and Tissues in the State of Piaui.

LITERATURE REVIEW

Since 1990, there have been major advances in the field of transplantation and the consequent increase in the number of procedures. The development in areas of knowledge such as immunology, hematology, blood therapy, nursing and improvement of surgical techniques, allowed the transplants to be considered as an effective therapy, providing improvements for patients with chronic diseases and organ failure^4,5.

The performance of SNT becomes magnified when considering that is one of the largest public transplant systems of the world. However, the system coexists with operational problems; there is a waste of organs and tissues, low levels of notifications and a disproportion between organ donors and receptors waiting in queue⁶.

The lack of organ donors is a major obstacle to the realization of transplants in Brazil. Factors such as structural problems of organization of health services, of the work dynamics of health professionals, and cultural issues contribute to this limitation⁴.

The work process is related to the way the work is done or a set of procedures where the employees work, through the production means, about an object to obtain a product forsome purpose. The main components of the work process are the goals or purposes, means, the object, and agents. The goals or purposes define the working process; the media cover a broad spectrum and can be divided into material and non-material resources. The first include the equipment, instruments, supplies and physical structure. The latter refers to the systematized knowledge or not, and the skills used in the work process. Working conditions are considered means. The object is something about which exerts the transforming action, and the agents are the subject or professionals who perform actions⁷.

Making an analogy to the donation/transplantation process, the objective is to reduce the waiting list obtained by increasing organ and tissue available for transplantation, and increasing the number of transplants. Material means are the supplies and equipment, such as transport, computer, phone line, the Internet, available tests. Non-material resources are the technical knowledge of the process. The work object is the potential donor and families. And the agents are all professionals involved in the process.

METHODOLOGY

This is a descriptive study of qualitative approach, developed in Teresina, Piauí State, Northeast Brazil, in the physical spaces of the Notification, Capture and Distribution Center of Organs and Tissues (CNCDO), of the Organ Pursuit Organization (OPO), of the Intra-hospital Committee of Organs and Tissues Donation (CIHDOTT) of a public hospital and the Bank of Ocular Tissues (BTOC).

In a total of 32 professionals,29 participated in the study, including nurses, doctors, social workers and psychologists, working on the mentioned services. The considered inclusion criteria were: working in the institution and act on donation/transplantation process for at least one year. Thus, three professionals did not meet the above criteria.

Data were collected through semi-structured interview, with two parts: the first, with data about the characteristics of workers; and the second, with open questions regarding the purpose of the study. The interviews were conducted from October 2011 to May 2012.

The interviews were recorded, transcribed, and statements were organized and analyzed according to the methodological framework of content analysis ⁸. Then, the following categories were elaborated: elements necessary for the operation of the donation/transplantation process; facilitating factors and barriers existing betweenoperations in the donation/transplantation process; the institution's contribution to the performance of the donation/transplantation process, from the perspective of professionals.

In the presentation of the testimonies, the interviewed professionals were designated as A, from the CNCDO; B, from the OPO; C, from the CIHDOTT and D, from BTOC. Then, an Arabic numeral was placed, following the order interview realization in the respective institution.

Concerning the ethical principles, the research project was approved by the Research Ethics Committee of the Federal University of Piauí (CAAE No. 0159.0.045.000-11), and participants signed a Consent Form.

RESULTS AND DISCUSSION

Twenty nurses were interviewed, two doctors, five social workers and two psychologists, aged between 28 and 55 years old, mean of 43 years. Regarding gender, the female dominated, with 24 (82.7%) professionals. Authors highlight that the increasing number of women in the labor market is something irreversible and growing in the last two decades⁹. Nursing is a profession that provides the largest contingent of the workforce in health care, widely distributed and playing the various roles, functions, and responsibilities. Nurses provide assistance to individuals, families and communities in various institutions, from community centers to hospital environments of high complexity¹⁰.

As for the performance time in the institution, professionals had between 1 and 11 years, and long experience in the donation/transplantation process between 1 and 18 years, with a mean of 6 years, and 19 professionals (65.5%) reported no previous experience in the transplantation sector and 10 (34.5%) reported having this experience.

Necessary elements for the process

The lines showed the means of work materials and not materials as essential to the performance of the donation/transplantation process. The CNCDO professionals highlighted the existence of amultidisciplinaryintegrated and qualified team with technical knowledge, providing physical and material resources, appropriate working conditions and sensitized family.

[...] It is important that we have a trained and aware staff in all phases of the donation/transplantation process [...] the family has to have prior awareness because the family is extremely important, it will only decide that [ ...] we need highly qualified professionals [...] (A13)

[...] It is essential that we have the information system of the Ministry of Health [...] computer [...] also the phone [...] car and driver are also essential! And we have. (A3)

For professionals in the OPO and CIHDOTT, in addition to teamwork, technical knowledge and physical and material resources, ethics and humanization were cited as necessary for the donation/transplantation process.

[...] I would say that the technical knowledge about the donation/transplantation process, professional ethics and, from there, also the question of humanization. Also, to the supplies that are necessary for the development of this work. (B2)

[...] I need a skilled team,I must have professionals from different sectors, but mainly in the sectors where it has invasive mechanical ventilation as ICU, emergencies, and these professionals committed to the maintenance of the potential donor [...] (C6)

Frequently, the health sector has to respond to demands for technological interventions of high complexity and specialty occurring in tertiary care hospitals as well as other demands¹⁰. The donation/transplantation process is complex and requires the availability and investment of material and human resources.

Moreover, the relevance of ethical aspects should be considered in the context of transplantation. Despite the technical and scientific progress and the benefits achieved with the transplants to the health of the population, these procedures still live with ethical questions¹¹.

In this sense, the professionals who work in this process should be supported by the principles of ethics, legality, and humanization. And they should also consider the family as a fundamental element in the donation/transplantation process since accepted and informed will consent or not to donate. The experiences of family members should be considered in the development of care protocols^12,13.

The BTOC professionals reported as necessary elements, the existence of trained staff and necessary supplies to enable the preservation of ocular tissues.

It is important to have a team of professionals [...] and also the issue of our environment preservation, we work with Optisol-GS ®, which is one of preservation means to ocular tissues. (D1)

It highlights the importance of working preferred by the professional staff of the surveyed services.

Teamwork is essential here in this service [...] when it identifies the potential donor there is a need to have someone telling you [...] There is a need for the team that makes the approach to arrive in time for the donation [...] a transplant team should be triggered and also the laboratory conducting the tests [..]. Then, it is a network, and we work only if the exist network. (A6)

The interest in working with a multidisciplinary team has been strengthened since it values the diverse knowledge and practices in the context of a comprehensive approach. The articulation of multidisciplinary teams systematize the work and provides improvements in outcomes¹⁴. Considering the nature of its object, the donation/transplantation process, the multidisciplinary work has a fundamental importance.

Facilitating factors and barriers

As facilitating factors referred to by professionals for activities in the donation/transplantation process, the knowledge about the process, conducting training, the relationship with the interdisciplinary team and the collaboration of healthcare networks, as well as the support of management were highlighted. The following lines explain these results:

[...] The fact to understand and manage the system facilitates [...] Another thing that helps is the fact that we have done, for a long time, the point service, assistance, search, contact with the patient (donor). (A8)

[...] Is the knowledge acquired through theoretical frameworks that we have access, the capabilities that we participate, and our day-by-day [...] (A5)

[...] The understanding and cooperation of professionals greatly facilitate our work, since the notification to an initial family reception[...] another factor is management, an expert management about these processes of CIHDOTT, processes involved in SNT [...] (C2)

The training and qualifications provide the development of specific skills and competencies, direct the professional practice and promote technical development¹⁵. In turn, the existence of an integrated multidisciplinary team allows interaction between the agents involved in the recognition of different types of knowledge and the technical autonomy of each¹⁶. To facilitate the donation/transplantation process, the existence of trained and skilled multidisciplinary teams is necessary¹¹.

The importance of collaboration of care teams is because these are responsible for the notification of a potential donor to commissions or Central, as well as the conduct and proper handling of the potential donor. The maintenance of the potential donor ranges from the recognition and confirmation of brain death (BD), complying with legal formalities, to the prevention, early detection, and handling of the main complications of BD, to ensure that organs and tissues are captured in the best functional conditions¹⁷.

Also, the support of management becomes relevant to the extent that the process of working on a public policy is permeated by conflicts and needs that must be addressed to meet the objectives and purpose of the policy in question¹⁸.

The existence of a law that regulates the process involving the transplantation was also referred to as a facilitating factor.

We have a set of laws and ordinances, an extensive legislation. There is a consolidated of this legislation, and this facilitate us to have the domain of what can and what can not [...] (A6)

The Transplant Policy in Brazil is based on the Federal Law n⁰ 9,434/97 and n⁰ 10,211/01 and contains guidelines that guide the whole process of transplants in the country. There is an extensive legislation that deals about the donations and transplants^2-3.

It should be emphasized the importance of Ordinance n⁰ 2,600/09 to constitute the Technical Regulation of the SNT, establishing specific rules for its operation, of CNCDOs and other system instances¹⁹. The law regulates activities involving transplants improving the functioning and management of this policy.

Concerning to existing barriers to performance in the donation/transplantation process, respondents mainly reported structural difficulties, such as the lack of complementary test for theBD diagnosis available in 24 hours in the public service, and the lack of knowledge and assistance professionals support about the process of organ and tissue donation, as shown by the following statements:

[...] We need hospitals with highly complex equipment to keep these potential donors, we need good intensive therapy and equipment, as Transcranial Doppler, Electroencephalography, cerebral arteriography and unfortunately, our two public hospitals in the state, neither does these tests. (A13)

[...] I put first the late identification of potential donors, the delay in the protocol opening and our greatest callus that is the image test [...] there is a certain fear of professionals in realizing the examination [...] (A12)

[...] The unawareness of what is brain death, what is the process of organ donation [...] disinformation is very high among professionals, media, community, students, teachers [...] the lack of support also of the institutions that we work, the own ICU co-workers [...] (B3)

A study performed in Minas Gerais showed as the main obstacles to the realization of the donation/transplantation process: the lack of hospital structure to prove the diagnosis of BD and to keep a potential donor, inadequate knowledge of the responsible physicians as the BD protocol and legislation of transplants, and the delay of BD notification²⁰.

In Piaui, the complementary test used for the BD diagnosis is arteriography which realization occurs in private clinics of reference of the Unified Health System. In practice, this means the displacement of the potential donor of the hospital, where is hospitalizedin this clinic, mobilizing simultaneously, various professionals and resources²¹.

There is still a lack of preparation of health professionals in the diagnosis of BD, in the identification of potential donors, in the notification to Transplant Centers, as well as the family interview to request the donation, with important effects on the number of deaths on the waiting list ¹¹.

The contribution of the institution in the process

The CNCDO, according to the interviewed professionals, contributes to the transplant sector being the regulator and coordinator of the donation/transplantation process at the state level. Also, the control of the waiting list and distribution of organs and tissues are exclusive competence of the Transplant Center, as illustrated by the following lines:

[...] Without the Center, transplantation would not be possible, since we regulate the list, we know to whom that body is being designed, we regulate who transplants, who are these teams, who are allowed or not to make the transplantation [...] Central has a role of paramount importance [...] (A6)

[...] Is the regulating center of all stages of the donation/transplantation process and has been from the Central that the CIHDOTTs were created, the OPOs, the assignments began to be redistributed to the new organs [... ] (A12)

The Centers are responsible for coordinating transplants activities at the state level, conducting the registrations and monitoring of receivers, notifications of potential donors in the system and enabling the logistics of the entire donation process, from BD diagnosis to the withdrawal and allocation of organs and tissues²².

The CNCDO must act together to health facilities through the OPOs and CIHDOTTs providing the construction of a support and regulation network of intensive care, emergency, and administrative¹⁹.

For OPO professionals, the contribution to the transplant sector is due to the increase in active searches, donations and captivation to expand the service to hospitals in the capital's health network.

We work doing an active search, and then, this search has increased the number of organ captivation here in the State with the OPO. This has been recognized by the Center for Transplantation [...] (B5)

The creation of the OPOs and CIHDOTTs constitutes a significant advance in captivation organ process. The OPO provided the extension of the geographical and population territoryfor the actions of the donation/transplantation process. But the CIHDOTT, with intra-hospital operations, allowed the direction for the early detection of potential donors and the planning of interviews with family members to meet these users^22-23.

It is Worth mentioning that OPO must have its limits of performance defined by population and geographic criteria, providing detection and viability of the potential donor of organ and tissues for transplantation²⁴.

The CIHDOTT, according to the interviewed professionals, has its contribution guided to the next location to assistance teams, in an active search, in the reception of the families of donors and in promoting the education of professionals.

[...] The Commission gave a boost to the number of State transplants for being at the place where happens,for beingfollowing more closely [...] (C1)

We are in that front line to increase the offer of organs and with quality [...] without causing further damages to the donor family, and also the educational process of the professionals [...] (C2)

The CIHDOTT has an intra-hospital strategic location, favoring active searches, the reception to families and the promotion of continuing education. Both OPO as CIHDOTT should provide permanent education of professionals in the institutions where they work about aspects of the process¹⁹.

According to professionals in the BTOC, one of the main contributions to the donation/transplantation process are guidelines and educational activities of the institution.

[...] We try to work in the neighborhood association, in high schools, universities, guiding professionals [...] the Eye Bank contributed with donations and transplants in this part of the disclosure, lecture, guidance. (D1)

One of the abilities of the Bank of Ocular Human Tissues is to participate, under the coordination of CNCDO of the respective state, promotion actions, dissemination and clarification to the population about the importance of organ and tissue donation with the objective of increasing the number of donations and captivations²⁵.

CONCLUSION

For the interviewees, besides the structural shortcomings, the lack of support from care professionals represents a barrier to actingon the donation/transplantation process. The effective implementation of permanent learning activities directed to health staff about the process of donating organs and tissues and the importance of transplants is essential, aiming at the understanding and cooperation of everyone in the hospital network, especially the emergency and intensive care units.

The interviewed professional demonstrated knowledge and commitment to the donation/transplantation process and noted the importance of teamwork in this process. Multidisciplinary teams trained and available to collaborate with the donation and transplants are one of the foundations for the success of each step in the process.

The role of the professional nurse is present at all stages of the donation/transplantation process, from the identification of potential donors to post-transplant monitoring. This presence demonstrates the importance of actions and Nursing care to users of the transplant sector.

The knowledge of the professional work process in the system highlighted the importance of the activities developed in the context of organ and tissue donation and transplantations, and the identification of fragility should guide the planning of strategies that aim to increase the number of donations and transplants in health services.

As study limitation, the analysis of hospital care teams and transplantation teams and accredited institutions were not contemplated to carry out transplants. Further studies are suggested for addressing such elements.

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