ORIGINAL RESEARCH

 

Intra-hospital commission on organ and tissue donation for transplant: nurses' experience

 

Tatiane Ribeiro da SilvaI; Marcelo da Silva AlvesII; Patrícia Rodrigues BrazIII; Fábio da Costa CarbogimIV

I Nurse. Specialist. MS in Nursing from the Federal University of Juiz de Fora, Minas Gerais, Brazil. E-mail: tatyanejf@hotmail.com
II Nurse. PhD in Public Health. Associate Professor of the School of Nursing of the Federal University of Juiz de Fora, Minas Gerais, Brazil. E-mail: enfermar@oi.com.br
III Nurse. MS in Nursing from the Federal University of Juiz de Fora, Minas Gerais, Brazil. E-mail: patibrazenf@gmail.com
IV Nurse. PhD in Sciences from the School of Nursing of USP. Adjunct Professor I of the School of Nursing of the Federal University of Juiz de Fora, Minas Gerais, Brazil. E-mail: fabiocarbogim@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2018.34120

 

 

ABSTRACT

Objective: to understand the experiences of nurses on the Intra-Hospital Committee on Organ and Tissue Donation for Transplant (CIHDOTT) at a private hospital in the Zona da Mata of Minas Gerais. Method: this descriptive, qualitative study was conducted by semistructured interview of 11 nurses between July and December 2017. Content analysis was used as a methodological frame of reference for studying the transcripts. Results: of the eleven participants, 72% were women and 28% were men; average age was 35 years; and eight declared themselves white, and three, black. Length on service on the committee ranged from two months to six years, and averaged 2 years and 7 months. From the content analysis of the testimonies, three categories emerged: being a nurse on the committee; family approach; and training and capacity building. Conclusion: the study demonstrated that the experience on the committee is permeated by weaknesses, identification of which facilitates the development of strategies to improve the process in the institutions.

Descriptors: Nursing; transplantation; brain death; tissue and organ procurement.

 

 

INTRODUCTION

Organ transplantation has evolved from a risky and unregulated technique to an effective technical-scientific therapy, with promising results for patients with chronic or terminal diseases. This surgical procedure allows the replacement of organs such as heart, lung, kidneys, liver, pancreas, intestine and tissues, bone marrow, bones, valves, muscles, skin, corneas, veins and arteries.1

As reported by the Brazilian Transplant Association (ABTO – "Associação Brasileira de Transplantes", in Portuguese), Brazil has an adequate and structured public organ transplantation program, however, ineffective to meet the full demand, a fact that is justified by the increase in waiting lists (in the 2018 waiting list there are already 32,066 patients) and the high rate of non-authorization for donation of organs and/or tissues by relatives.2

The need to increase the number of transplants is a global priority. In this context, although this number has increased, Brazil remained with a lower than expected number of transplants when compared to other countries. 3-5 Countries such as Spain, Portugal and Italy have been intensifying the improvement of transplant programs.5

In Brazil, in compliance with the Administrative Rule No. 2,600, dated from October 21, 2009, as Intra-hospital Committee on the Donation of Organs and Tissues for Transplantation (CIHDOTT - "Comissões Intra-Hospitalares de Doação de Órgãos e Tecidos para Transplantes", in Portuguese) are internal representations in hospital institutions. Thus, the CIHDOTT is mandatory in institutions included in the following profiles: type I - establishments with up to 200 deaths per year and beds for respiratory care; type II - reference establishments to trauma and/or neurology, with less than 1,000 deaths per year or non-cancer establishment with 200 to 1,000 deaths per year; and type III - non-cancer establishment with more than 1,000 deaths per year or establishment with at least one organ transplantation program. 6

The nurse is directly involved in the organ transplantation process and their action is regulated by the Federal Nursing Council (Cofen – "Conselho Federal de Enfermagem", in Portuguese) through the Resolution No. 292/2004, which provides that it is up to this professional to plan, execute, coordinate, supervise and evaluate the nursing procedures provided to the donor, as well as the planning and implementation of actions that result in the optimization of the donation and capture of organs and tissues for the purpose of transplantation.7

An integrative review study related to the scientific production regarding organ donation and transplantation revealed that nursing publications are mostly related to liver and kidney transplantation. The study shows evidence that there is a gap in the knowledge regarding the experience of health professionals in committees for transplants.8 Thus, studies that describe and discuss the activities developed by CIHDOTT nurses are of great importance in the country. Therefore, due to the scarcity of studies of this type, the importance of researches that describe and discuss the activities developed by CIHDOTT nurses in the country is justified. In view of the above, the research aimed at understanding the experiences of nurses inserted in a CIHDOTT.

 

LITERATURE REVIEW

The CIHDOTTs, within the scope of health institutions, are responsible for organizing the organ donation protocol, offering relatives of deceased patients the possibility of donating corneas and other tissues, articulating with teams of intensive care units and urgency and emergency to identify potential donors and check brain death. After that, they effect the donation, notifying it and promoting the registration of all cases with a diagnosis of brain death, even if they are not possible donors of organs and tissues. In addition, they register the number of deaths occurred in the institution, articulate with the respective Center for Notification, Collection and Distribution of Organs and Tissues (CNCDO – "Captação e Distribuição de Órgãos e Tecidos", in Portuguese) and/or tissue banks in their region to organize the process of donation and collection of organs and tissues, to carry out the permanent education of the institution's employees regarding this process, to implement quality programs so that it is possible to measure the work developed by the CIHDOTT teams in the institution, as well as to promote the embracement of family members throughout the process.6

The importance of family education is highlighted, since a large part of the population receives information about transplants only through the media during the campaign months. There is not a continuous awareness; little influence is felt by family, friends or health professionals to make people aware of the importance of organ donation to save lives. Thus, it is necessary that there is quality in the information offered, since a well-informed population will favor the discussion about organ donation in family environments and among friends, triggering the promotion of the act of donating.9

In order for successful organ transplantation to occur, it is imperative that all key stages of the process are followed, such as identification of the possible donor, notification of the case to the CNCDO, maintenance of the potential donor, assessment for brain death, communication to the family about the condition and the performance of the family interview, which will result in donation or not. The nurse within the CIHDOTT acts in the mentioned stages and, therefore, it becomes relevant the identification of the fragilities inherent to this process, in order to list strategies aiming at improvements in the process of organ donation and transplantation.10

 

METHODOLOGY

This is a descriptive study with a qualitative approach, developed in the CIHDOTT of a private hospital, located at Zona da Mata Mineira. The CIHDOTT of the institution is composed of 21 nurses, two psychologists and two physicians, among them, two coordinators, one being a nurse and one doctor. From a total of 23 professionals, 11 nurses from the committee participated in the study.

The inclusion criteria of the study were: professional nurses and members of the CIHDOTT who signed the Free and Informed Consent Term (FICT). As exclusion criteria: professionals from other categories, who were on leave, vacation or away and who refused to participate in the research. Thus, during the data collection process, there was a nurse on vacation, three nurses on maternity leave, two were leaving the institution and four refused to participate in the research. The information was obtained through a semi-structured interview, carried out from July to December 2017. The interviews were recorded and transcribed in full, and the statements were organized and analyzed according to the methodological referential of content analysis.11 The following categories were then elaborated: being a nurse in the transplant committee; family approach and training and capacity building.

Bardin proposes three steps for speech analysis, the pre-analysis, which aims to organize the material in order to systematize the initial ideas; the exploration of the material, which consists of defining the categories and identifying the units of meaning and the third step, which consists of the treatment of results, inference and interpretation, it is the moment of critical and reflexive analysis about the data.

In order to preserve the participants' anonymity, the letter E followed by the alphanumeric numbers from 1 to 11 corresponding to each interview was defined as the codename.

The present study was submitted to the Research Ethics Committee (REC) of the Federal University of Juiz de Fora (UFJF) for analysis and opinion, receiving a favorable opinion (CAAE No. 63257316.9.0000.5147) from May 2, 2017. All the precepts were followed in relation to the resolution No. 466/12 of the National Health Council - Ministry of Health, which provides guidelines and standards for research involving human beings.12

 

RESULTS AND DISCUSSION

Of the 11 participants in the study, 72% were women and 28% men; the mean age of the participants was 35 years old, ranging from 28 to 51 years old. As for the ethnicity, eight declared themselves as white and three as black. The working time in the committee ranged from two months to six years, with an average of 2 years and 7 months. The nurses in their totality reported not having a specialization in the area of transplants. The duration of the interviews ranged from thirty minutes to two hours.

From the analysis of the content of the testimonies, three categories emerged as follows.

Being a nurse from the committee

The statements showed that the nurse working at CIHDOTT is considered a reference professional and although there is a multiprofessional team that composes this committee, in the whole process their performance is present, present in the identification of the potential donor, in the family interview and in the end of the process. Therefore, the participants recognize the importance of their role in the CIHDOTT and that they are contributing to make the donation process feasible.

I think the nurse is a person of reference, a person specific to the position, if he or she is not there, the thing gets lost and no one knows who will do the approach at that moment. (E1)

The nurse who works at the CIHDOTT is extremely important, because it is through an assessment and a well-made approach that we are going to have the possibility of an organ donation, culminating in a saved life. Nurses need to understand that we are the "gateway" to the transplants and we have great importance in the CIHDOTT. (E2)

Studies show that the professional involved in the donation and transplant process realizes that their work is extremely significant due to the possibility of saving lives and the opportunity to embrace the family of the donor.13,14

According to the testimonies, the nurses associate the donation process with the help and the professional care to the other, they emphasize feelings like solidarity and gratitude to both protagonists of this process and they also emphasize the importance of the empathic attitude with the aim of raising awareness for the process of organs donation.

Being in the CIHDOTT today means more than articulating and organizing the donation process, detecting the possible donor of tissues or organs, the most rewarding thing is to know that the donations will help many who are hopeless, and who, by receiving the transplant, will have quality of life. In this process, the nurse stands at the front, with a humanized work, obtaining knowledge about the death process. (E3)

Being a member of the CIHDOTT means more than an opportunity, but gratitude to be able to contribute so that someone can live in the sadness that is the loss of a loved one. (E2)

The Humanistic Theory of Paterson and Zdrad reinforces the importance of being-with, the interaction between two people through an inter-subjective experience in which true sharing takes place, so that in this dialogue one can relate to being present and finding oneself. 15

For nurses to develop their role in the CIHDOTT, it becomes imperative to establish a humanized care. Thus, it is important to emphasize that the process of humanization encompasses several aspects, such as patient care, working conditions, and the fulfillment of basic institutional needs, such as administrative, physical and human. The nurse inserted in this scenario can contribute so that the care provided to the family and the potential donor is centered in the sensibility, science and art.16

The daily practices related to humanization need a prior knowledge, in addition to having a subjective character, encompassing different meanings. For the professionals, it is a matter of caring with respect, affection, love, empathy, acceptance and dialogue; already within the scope of the academic production, this humanized care involves the creation of bond, quality and appreciation of workers.16

Another aspect mentioned by the participants is the lack of professional recognition of the nurses' performance and their importance to the service. The nurses, although aware of the importance of their work, do not feel valued professionally for being part of the committee, a fact that justifies the lack of motivation in performing this work.

I see that the participation of the nurse when he or she is active makes a lot of difference in the service; first I think you have to know your own importance to that service, because if you know you are important, you value that job. (E1)

I think it is important to make the nurse understand what their role is and how they are inserted in this CIHDOTT, to show them their importance to the CIHDOTT. (E5)

Being a member of the committee does not have great meaning for me, since there was no improvement in anything, I expected the minimum of professional recognition, financial improvement, which unfortunately does not happen. (E6)

The recognition of the profession directly influences the work performance; in addition, the negative implications lead to demotivation and dissatisfaction at the work environment. When the professional feels valued and recognized, they play their role with commitment and satisfaction, influencing the quality of care.17

The nurse is the reference person in the committee, in this context, there is a real need to revisit their practice continuously, in order to refuse the simplification and fragmentation of knowledge, because human care requires, in addition to technique and technology, listening, sensitivity and zeal. Acting in the transplant process requires developing such skills and abilities in order to improve your practice.18

Family approach

The nurses reported their perceptions and experiences related to the moment of approaching the families. For these nurses, the importance of the accompaniment of the relatives in the opening of the Protocol of Encephalic Death (ED) was widely mentioned.

As a member of the CIHDOTT, I perform the family approach. Often, when the diagnosis is of brain death, if the family is already well oriented about the protocol, it facilitates the whole process. (E7)

When one thinks of brain death, when one thinks of opening a protocol, one must communicate to the family, explain what the protocol is, how it will be done, what brain death is. So the CIHDOTT works on it in a better way. When the protocol is closed, the family is not always ready, but when they participate in everything, it is easy for us to approach them; but when the family does not participate, it gets a bit more difficult. (E5)

During the approach I performed, I was able to observe the relative's concern about how they mother would look and about her image during the funeral. (E8)

What I see during the approach is that the family is very concerned about the patient getting disfigured, getting deformed because of the organ withdrawal. (E9)

Many relatives still feel unprepared when approached in case of brain death diagnosis. Life and death are two extremes that nursing faces every day. The nursing work, for the most part, consists of fighting for the maintenance of life, but in the case of encephalic death, even in the face of death, professionals fight for life, which is represented by the donation of organs and tissues.19

The knowledge of the population on the subject of brain death is limited due to the fact that it is little studied, divulged and discussed, which causes a low degree of confidence related to this diagnosis, negatively influencing the decision-making for the donation. Therefore, it is very important that the family members can accompany the process of verification of brain death, not only the communication of the protocol conclusion, but all the tests, so that it is possible to verify the death of their loved one. Therefore, it is necessary that the team is clear and accurate regarding the information shared with this family.20,21

The donation of organs and tissues for transplantation is an extremely sensitive and complex issue because it is directly related to people's moral, ethical and religious values. Hence, people are also concerned with the matter of the body and the notion of finitude. Historically, the respect given to the body is a feature of our society. The body represents to the family members the memory of a life that should be kept; therefore, not valuing this period would mean disrespect to those people in their moment of life. There is a real need to worry about the body as an organism belonging to a being in its set of emotions and no longer as a machine, in order to undertake a struggle against the mechanization of actions, so as not only to quantify the process of giving, but to qualify it. It is not only a body from which organs will be withdrawn, but a being with a history, beliefs and values hold in life. It is up to the professionals to act in a conscious and ethical way, respecting the concepts, feelings and values of the relatives.22

The nurses highlighted that they lack preparation to approach the relatives of the possible donor, they say they feel insecure before them for the interview, which ends up triggering the loss of a potential donor.

I consider that to take an approach today, I have no preparation to approach the family, because I think success comes through the approach, and the success of this approach depends on security and knowledge. (E10)

The impression I have is that if I ask the nurse what he or she has to tell the family, they will be able to expose it, but when the nurse is faced with the process of approach, the question is how to talk to the family, how to approach this family, how they will respond. I believe that the doubt and the fear is this. (E11)

The family interview is based on a theoretical-practical perspective and there are significant aspects to its accomplishment. It is a moment that has peculiarities and complexities. So it is a very delicate moment, considering that the family faces the emotional impact that can generate resistance due to the loss and, often, that makes them incapable of making the decisions. Thus, it is up to the professional to be able to deal with the fragility of the occasion, which may be one of the obstacles to the donation.5

Faced with such a scenario, it is up to the professionals to gather specific skills and knowledge so that they can handle with respect all the aspects that involve such process, thus obtaining the effective donation.

Training and capacity building

Training and capacity building were reported by the study participants as one of the difficulties in exercising their job in the committee, due to the lack of prior knowledge about the donation process and its functions.

What happens is that I did not have training, I had very quick and superficial guidelines, and they were verbal guidelines about what is done when the death occurs. (E10)

There was no guidance or training to direct us as members of the CIHDOTT, there was no training for me to be guided in my role, all my duties were discovered during the shifts with the help of colleagues. (E6)

I think the focus is really the technical-scientific training, because this will make us able to develop this work in a more effective way and with which we can really achieve prominence within Minas Gerais. (E9)

I have been in the hospital for four years and only recently have I heard about the CIHDOTT within the institution. When I entered the hospital, until they started talking about CIHDOTT, I did not know what the CIHDOTT was, I did not know the work, so I think there are many colleagues who did not know it either. (E10)

I think that the CIHDOTT still needs to be publicized in all meetings or explanatory pamphlets so that it is possible to open the head not only of professionals, but of everyone, to really know the donation process. (E4)

Studies show a deficiency in the professionals' knowledge about the donation process and transplants, together with the lack of information about the existence and functioning of the CIHDOTTs. There is a real need to develop studies that provide enlightening and evidence-based information on the operation of the CIHDOTTs.3,10,18 It is worth highlighting the existence of weaknesses in nursing undergraduate teaching on the subject.22 In this sense, it is important that the nurse operates in this process, updating the knowledge, specializing in order to improve the performance of their activities. In addition, it is up to the CIHDOTT coordination of the institutions to provide and encourage the training of these professionals.

A study carried out at Tuscany ICUs included in the National Transplant System (NTS) of the Ministry of Health (MH) in Italy highlighted the importance of training professionals for transplant. The training was highlighted as a primary factor to prevent family refusal.24 Therefore, the importance of acquiring knowledge related to organ transplantation and donation during training, so that the professionals acquire the skill and knowledge for their performance in the practical field.25,26

The statements of the professionals highlight the lack of preparation and prior knowledge when inserted in the CIHDOTT, their interest in knowledge, but they also point to failures in the coordination, which does not offer permanent education related to the donation process in the institution. In this process, the literature points as essential the permanent education in service to the professionals working in the transplant services in order to improve the work developed.

 

CONCLUSION

From the understanding of nurses' experiences in a CIHDOTT, it was possible to verify that the figure of this professional is paramount for the success of the transplant program in the institutions. However, challenges must be considered to be overcome in the course of their practice, such as the lack of previous training and appreciation of the work carried out in the committee, the lack of knowledge of the professionals about the activities carried out by the CIHDOTT and the awareness of families.

It is important to highlight that it is essential to develop campaigns aimed at publicizing the donation process, as well as conducting research on the subject and continuing education in service for the improvement of the activities developed by the commission.

As a limitation of this study, it is pointed out that through it it was possible to understand nurses' experience of only one CIHDOTT. It should be highlighted the need to carry out new studies addressing the role of the nursing team and the multiprofessional team that make up the committees.

 

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