Psychosocial factors influencing nurses’ involvement with organ and tissue donation

International Journal of Nursing Studies 39 (2002) 429–440

Psychosocial factors influencing nurses’ involvement withorgan and tissue donation

Bridie Kent*

School of Nursing, Midwifery & Health Studies, University of Wales, Bangor, Fron Heulog, Ffriddoed Road,

Bangor, Gwynedd, Wales LL57 2EF, UK

Received 27 November 2000; received in revised form 29 June 2001; accepted 11 July 2001

Abstract

This paper focuses on the first phase of a 3-year study that explored the psychosocial factors that influence nurses’willingness to discuss post-mortem donation intentions with relatives of potential organ and tissue donors. The UnitedKingdom’s donation system is dependent upon such discussions taking place. A cross-sectional survey of 776 randomlyselected nurses, from two health regions in the United Kingdom, found that personal negative attitudes to aspects of

donation and transplantation, fears and misconceptions about the donation process, clinical area of work, pastexperience, and socio-historical factors influence discussion behaviour. Knowledge deficits were discovered, togetherwith requests for general information about the donation process and specific information about the organ and tissue

donor exclusion criteria. r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Organ donation; Transplantation; Theory of planned behaviour

1. Introduction: selected literature

In the United Kingdom (UK) and other Westerncountries, transplantation surgery using human organsand tissue has become an established treatment for a

number of end-stage diseases and demand for suchprocedures continues to rise. Over the past 10 years,from 1990 to 2000, the total waiting list figures have

risen by 58% whilst donation rates and transplantsperformed have remained static (UKTransplant, 2001)causing a mismatch in supply and demand which is notunique to the UK (New et al., 1994). In their review,

New et al. (1994) acknowledged the impact that healthprofessionals can have on the donation-transplantationmismatch. This paper reports on the first phase of a

three-part investigation, undertaken in the UK from1995 to 1998, which attempted to explain further someof the factors that may result in nurses engaging, or

disengaging, in donation-related behaviour. It focusedon nurses’ willingness to participate in the donor

identification, and donation discussion stages of thedonation process to determine which, if any, psychoso-cial factors had the greatest effect on expressed

behaviour among registered nurses working in twohealth regions of the UK.

1.1. UK’s system of donation

In order to contextualise the study, it is necessary tooutline, albeit briefly, the system of donation thatoperates in the UK. It is referred to as ‘opt-in’, andhas voluntarism as its fundamental principle. This

system relies on the goodwill of individuals to offerhuman parts for transplantation as an altruistic act(Prottas, 1994) and consequently, the individual makes a

personal decision to offer organs and/or tissue fortransplantation sometime in the future. Decisions maybe subject to fluctuations in behaviour, which have, in

the past, been influenced, in part, by positive andadverse publicity (Brady, 1990).

*Fax: +44-1248-383114.

E-mail address: [email protected] (B. Kent).

0020-7489/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

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Within this system, health professionals can, perhapsunintentionally, affect the outcome for the potential

donor and recipient. Fears and concerns about thedonation process may be present, even among thosehealth professionals who personally intend to donate

organs or tissue after death (Carbary, 1987; Hibbert,1995; Kent and Owens, 1995; Pearson et al., 1997), andcan discourage the discussion of donation wishes, whichnurses perceive as being stressful (Hibbert, 1995; Justin

and Johnson, 1989). The literature identifies some ofthese including personal beliefs, lack of knowledge ofdonation-related issues, their concerns about the reac-

tions of relatives to a request for donation, and theelement of choice related to involvement in the opt-insystem of donation (Kiberd and Kiberd, 1992; Matten

et al., 1991; Watkinson, 1995; Wolf, 1990).

1.2. Discussion of donation intentions

Currently, there is no legal requirement in the UK forhealth professionals to discuss future donation inten-

tions with patients, or relatives, however, nurses do havea professional duty to respond to patients’ wishes orneeds (UKCC, 1992). Unfortunately, there is littleempirical data to indicate how frequently nurses do

enquire about death-related issues, even though themodels of nursing commonly used in the UK (reportedto be those of Roper, Logan and Tierney and Orem) do

include such concepts (McKenna, 1997).New et al. (1994) suggested that health professionals

could do more to increase the supply of transplantable

organs and tissue. They argued that nurses and doctorsshould be more proactive in the areas of donor

identification and the discussion of donation wishes.However, the lack of detailed information related to thisaspect of care makes solutions to the current shortfall in

donor organs and tissue difficult to identify, given thenon-compulsory nature of organ donation in the UK atthe present time.

2. Theoretical basis for the study

Ajzen’s (Ajzen, 1985; Ajzen and Madden, 1986)theory of planned behaviour formed the theoreticalframework for the survey. Ajzen argued that individuals

hold beliefs that underpin attitudes, subjective normsand perceived behavioural control which affect ability toperform future actions. Factors influencing perceived

behavioural control, how easy or difficult a proposedactivity may seem to be, include beliefs about resources,opportunities and past experiences. The proposed

interrelationships between the individual constructs ofthe model (taken from that devised by Ajzen andMadden, 1986) are highlighted in Fig. 1.This theory has been used widely as a basis for social

psychological investigations, as demonstrated by studiesfocusing on attitudes and behaviour with topics rangingfrom attendance for breast screening (Rutter, 2000), to

understanding exercise motivation in patients withcolorectal cancer (Courneya et al., 1999). However, itsuse in nursing research appears limited, with only three

Fig. 1. Operationalising the theory of planned behaviour.

B. Kent / International Journal of Nursing Studies 39 (2002) 429–440430

studies being located in the BIDS database (Laschingerand Goldenberg, 1993; Pederson, 1993; Renfroe et al.,

1990).

3. The study design

Following ethical approval, a cross-sectional survey of

registered nurses was undertaken in two health regionsof the UK, using postal questionnaires. The Directors ofNursing gave permission for access at each of the data-

collection sites.

4. Sample

The aim of sampling was to generate a sample that

comprised of participants who were representative of thewider population of registered nurses who could beinvolved in caring for a person who wishes to donate

organs or tissue for transplantation purposes (estimatedto be approximately 168,000 (UKCC, 1996). However,as Blacktop (1996) points out, the representativeness ofa sample is difficult to guarantee.

The eligibility criteria for the survey participants aresummarised in Table 1.Registered nurses, who were working in adult acute

care clinical areas of district general hospitals in twohealth regions of the UK regions, formed the focus ofthe study. The population was restricted to the acute

care areas since this is where the majority of adultasystolic, and brain stem, deaths occur (Gore et al.,1992; Victor, 1993). Two geographical areas for data

collection were identified: in Region 1, the researcherhad noted lower than average organ donation figures,when compared with those elsewhere in the UK(UKTSSA, 1994). The second, Region 2, was selected

because the average donation rates were in keeping withthose of the UK as a whole, it was some distance awayfrom the first (approximately 200 miles) and could be

easily accessed by the researcher. Nine acute NHS trustswere initially identified from the Health Services YearBook (Robertson, 1994) and permission to contact

nurses sought. The final data collection sites comprised

of three district general hospitals in Region 1, and two inRegion 2.

Names and grades of registered nurses were obtainedfrom staffing lists supplied by nurse managers at eachhospital. The grade mix of nurses within each of the

hospitals was examined and an individual averagecalculated to form grade strata ranging from D to I,for these were thought most likely to be makingindependent decisions related to patient care. Each

nurse was allocated a number and, stratum by stratum,these numbers were randomly sorted using a computerprogramme. The first 50% of the stratified randomised

numbers were isolated and the corresponding 776 namesformed the sample for the study. This figure exceededthe calculated minimum, but given the reported pro-

blems of low response rates to postal questionnaires(Kirk-Smith and McKenna, 1998) over-sampling wasadopted to minimise the risk of Type II error, although

it is acknowledged that this served to increase the risk ofType I error. A compromise had to be reached and theadvice heeded was that proffered by Christensen (1988)who argued that the power of statistical tests to detect

differences improves as the number of subjects within astudy increases.The minimum sample was based on the size of the

target population, an estimate of the incidence of non-discussion within that population (approximately 80%),and an acceptable error of 5%. There was a dearth of

literature appertaining to the incidence of discussion ofdonation wishes in the UK and consequently, therequired estimate could not be obtained from previouswork, as suggested by Hillier(1996). Instead nurses from

throughout the UK, attending a donation relatedconvention, were asked to approximate the incidenceof discussion of donation wishes in their own clinical

areas and an average figure of 20% was calculated.

5. Data collection tools

Data were collected using two self-administered

questionnaires: The Organ Donation Attitude Scale,developed by Parisi and Katz (1986) and modified byKent (Kent and Owens, 1995), and the Organ Donation

Attitude and Knowledge Scale, based on a tool devisedby Gaber et al. (1990) in the USA. The former containsquestions that require Likert-type responses rangingfrom ‘strongly agree’ to ‘strongly disagree’. Items

relating to demographics, personal donation and post-mortem intentions, and experience of the donationprocess are also included within this questionnaire.

The second questionnaire assesses knowledge of dona-tion, perception of ability to discuss donation withrelatives, and the frequency of assessment of donor

potential (see appendix for examples of questions), asthese were central to the research aims and objectives.

Table 1

Eligibility criteria for the sample

Nursing qualification recordable with the

UKCC (Parts 1, 2, 7 and 12)

Clinical grading: ‘D’ to ‘I’

Employed in acute general hospitals in two UK regions

Clinically based in ICU, CCU, A&E,

medical or surgical areas

B. Kent / International Journal of Nursing Studies 39 (2002) 429–440 431

Gaber et al.’s original tool was devised to addressknowledge within the USA and consequently major

alterations were required, particularly in the responsesavailable to participants, before it was acceptable forUK testing. Content validity was determined through

consultation with expert colleagues and by reviewing theliterature. However, as Burns (2000) indicated, this isnot a fixed or changeless characteristic and thereforeshould be examined whenever a test is used with a dif-

ferent sample or when the testing environment is altered.Internal reliability of each questionnaire was mea-

sured resulting in the following Cronbach alpha scores:

Organ Donation Attitude Scale: positive scale=0.88;negative scale=0.89.Organ Donation and Transplantation Attitude and

Knowledge Scale=0.65.Both questionnaires appear to offer an acceptable

level of internal reliability, although it could be argued

that these require further testing to identify redundancy(particularly in the first questionnaire) and to improvethe reliability score (for the second questionnaire). Thefirst questionnaire has been used recently by Cantwell

and Clifford (2000) and identical alpha scores obtained,thus strengthening the reliability of this tool.The questionnaires, together with a pre-paid return

envelope and an explanatory letter (which gave assur-ances of confidentiality and anonymity to respondents,and indicated the participant’s right to withdraw from

the study at any time), were distributed by post to theparticipant’s recorded place of work. One set ofreminders was sent out after 4 weeks.

6. Data analysis

Univariate, bivariate and multivariate analyses were

performed, using SPSS for Windows, to identify theexistence of relationships between the independentvariables (see Table 2) and the dependent variable,perception of ability to approach a potential donor

family and discuss donation. The independent variableshad been identified from the existing literature.Any regional differences identified during the descrip-

tive phase of analysis were explored using Chi-SquareTest of Independence (w2) and bivariate relationships,

using the whole and regional sub-sets, were tested usingSpearman’s Rank Order Correlation (rs). Variables were

then subjected to multivariate analyses using logisticregression, as this is a procedure that does not assumemultivariate normality when predicting a categorical

outcome (Polit, 1996). Again both the whole andregional sub-sets of data were used. Probability wasassumed to be 5% or less, to determine the level ofsignificance.

The limited qualitative data generated by eight open-ended questions were analysed for themes or categoriesand then subjected to limited quantification.

7. Key findings

The response rate was 42% (326):44% (163) fromRegion 1 and 40.4% (1 6 3) from Region 2, which didnot improve when reminders were sent out. A further

ten questionnaires were returned too late to be includedin the analyses. Therefore, the potential for responsebias must be acknowledged.

Details of the grade profile of the sample arepresented in Table 3.The slight difference in regional grade profile was not

significant after Chi-square testing and both sub-

samples closely resemble the target population in thedata collection sites.Almost 90% of respondents were female, with a mean

age of 32 years, with 75% of respondents being underthe age of 36 years, a slightly higher figure than in thenational population (UKCC, 1996). Eighty-five percent

Table 2

Independent variables

Age Religious affiliation

Sex Professional qualifications

Post mortem disposal intentions Clinical area of work

Clinical grade Personal commitment to donate organs or tissue

Personal positive and negative attitudes to organ donation

and transplantation

Knowledge of the donation process

Previous experience of organ/tissue donation/transplantation

Table 3

Clinical grade profile of respondents (showing %)

Grade Region 1 (n ¼ 166) Region 2 (n ¼ 166)

D 41.7 44.2

E 34.4 30.1

F 12.3 14.1

G 8.6 7.4

H 0.6 1.8

I 0.6 0


of respondents were enrolled on parts 1 and 12 of theUKCC register, whilst 47% indicated that they pos-sessed additional post-registration qualifications, mainly

specialist diploma or certificate courses. Most respon-dents worked in medical or surgical units within thehospitals although the more acute areas, such as ICU,

CCU and A&E, were also represented (see Fig. 2).

7.1. Assessment for donor potential in clinical areas

The majority of participants (63%) reported thatroutine assessment of donor potential rarely, or neveroccurs, whilst only 18 (5.5%) indicated that assessment

usually takes place.Protocols to guide potential donor assessment were

available in all of the data collection sites and a positive

correlation between knowledge of the presence of aprotocol and the frequency of assessment of deceasedpatients was noted. This suggests that where awarenessis low, or where protocols are unavailable, assessment of

donation potential is less likely to take place:

* Region 1: rs ¼ 0:27; p ¼ 0:001:* Region 2: rs ¼ 0:31; po0:0001:

7.2. Asking about donation

Marginally more nurses from Region 2 (50%)indicated that they felt able to undertake to discussdonation wishes with relatives when compared with

Region 1 (43%). The data suggest that participantsworking in areas where organ donation may be morelikely to occur, such as ICUs, feel more able to discuss

donation than their colleagues working in other areas ofan acute hospital. Reasons explaining their decisionwere given by 120 nurses, and these have been grouped

under the headings ‘able to’, and ‘unable to’, discussdonation (see Table 4).

Knowledge and experience appeared to be vitalfactors in determining perceptions of ability to discussdonation. However, the existence of a close, caring

professional relationship, something that most nurseswould strive to attain, also appears to encourage somenurses to engage in donation discussions, whilst for

others there were concerns expressed about roleboundaries, indicating that such behaviour fell outsidethe nurses’ remit.

7.3. Attitudinal findings

The scores for each of the 23 positive and 23 negativeattitudinal items were summated, as advised by Oppen-

heim (1992), generating a score which reflected thestrength, or weakness, of attitude for that dimension(maximum score=138, minimum score=23). Overall

the mean positive attitude score was 90.8 (SD=13.8)with a range of 108 (min.=23, max.=131). The meannegative score was 49.5 (SD=13.9), with a range of 96(min.=24, max.=120). These suggest that the sample

reported moderately strong positive attitudes and weaknegative attitudes to donation and transplantation.

7.4. Knowledge findings

The mean total knowledge score=24 (SD=3.78),with a range of 29 (min.=2, max.=31): the maximum

achievable score was 36. There was little variation in thescores from the two sub-samples (see Fig. 3).

7.5. Areas of good knowledge

The data identified issues which achieved a highpercentage of correct responses (over 90%) (seeTable 5).

Overall, 305 (93%) of participants correctly indicatedthat many organs can presently be transplanted and 302

Fig. 2. Clinical area of sample, showing regional variations.


(92%) correctly responded that, in the UK, payment fororgans and tissue is illegal. However, when asked aboutthe legality of selling a kidney, correct responses fell to

76% (251). The data suggest that participants wereaware that established procedures had to be followed inbrain stem death testing, although understanding ofwhat this entailed was less apparent, with only 207

(63%) correctly responding that asystole is not aprerequisite for diagnosing brain-stem death.

7.6. Areas of poor knowledge

The data also revealed issues to which the percentage ofcorrect responses was low (o45%). Questions relating to

the exclusion criteria for organ and tissue donationgenerated the lowest percentage of correct scores (seeTable 5). Regional differences in these figures were

examined, indicating that participants from Region 1had significantly more correct responses for the tissue(w2 ¼ 6:145; p ¼ 0:013) and organ (w2 ¼ 5:42; p ¼ 0:019)exclusion criteria. Overall only 8% of the sample correctly

identified all of the organ donor exclusion criteria (HIVinfection, septicaemia, prolonged hypotension, and ma-lignancy, except primary brain tumour). Similarly, 9%

correctly identified the single criterion that absolutelyrules out tissue donation (HIV infection) (Polit, 1996).Some criteria appeared to be more easily excluded

than others. Over 90% knew that age does not exclude a

Table 4

Perceptions of ability to discuss donation-underlying constructs

Able to discuss donation Unable to discuss donation

Close caring professional relationship with relatives and patient Lack of skills (not defined)

Known to the family Lack of experience

Good interpersonal skills Lack of knowledge

Something good coming out of a bad situation ‘‘Not my responsibility’’

Wanting to meet the needs of the patient and relatives Too distressing

Professional responsibility Personal indecision about donation

Good knowledge of the donation process

Fig. 3. Knowledge scores for the two regional sub-groups.


person from donating tissue whilst septicaemia gener-ated approximately 30% correct responses (101). Thereappears to be greater awareness of the exclusion criteria

for organ donation with only one variable, prolongedperiods of hypotension, generating a low number ofcorrect responses (31%).

7.7. The factors having the most influence on perceived

ability to discuss donation with relatives

Multivariate analyses, using logistic regression,

involving the factors found to have a significantbivariate association with the dependent variablewere undertaken to determine any combined effect (seeTable 6).

Statistically significant predictive models were ob-tained for both regions(Region 1: w2 ¼ 39:36; p ¼ 0:006; n ¼ 163; Region 2:

w2 ¼ 37:08; p ¼ 0:011; n ¼ 163).One predictor variable (knowledge that asystole is not

an essential determinant of death) was statistically

significant in Region 1. However, in Region 2, fourvariables emerged as statistically significant predictors oflikelihood to feel able to participate in donation

discussion, suggesting that respondents who holdrelatively weak negative attitudes to donation andtransplantation, irrespective of the strength of positiveattitude, who understand the non-compulsory nature of

donation request, and who know of the criteriaexcluding a person from being a donor, are more likelyto feel able to discuss donation issues with relatives.

Support for change to a system of required request,rather than opting-out, which was the other option,suggests that discussion of wishes was considered

important and would more likely take place if requiredby UK law.

8. Discussion

The results generated by this survey support the

relationships proposed by Ajzen (1985) in the theory ofplanned behaviour. It is recognised that the lowresponse rate imposes a bias on the survey, although

this is offset by the similarities found in the sample andtarget population. Attitudinal factors had a limitedeffect on perceptions of ability to discuss donation, with

the influence being primarily exerted by the negativedimension. Negative attitudes appear to exert aninhibitory effect on discussion behaviour, the implica-tion being that where fears about donation exist, nurses

may be more likely to avoid the discussion of donationintentions with the patient’s relatives, an importantfinding given that nurses have a duty to act profession-

ally and be the patient’s advocate (UKCC, 1992). Thesefindings concur with those of Sque (1996), who alsostudied UK nurses’ attitudes to organ donation and

transplantation. However, they also closely resemble theconclusions reached following observations of nurses’general death-related behaviour (Hare and Pratt, 1989;

Kiger, 1994; Townsend, 1995; Youll, 1989).The findings from the current survey identify specific

areas of concern, in particular, issues relating to brain-stem death testing, and the generation of mental images

associated with the organ and tissue retrieval process.These appear to provoke anxiety, and raise doubts, evenamong nurses working in the specialist units such as

intensive care, where most organ donors are identified.Statistically, the influence of knowledge on perceived

ability to discuss donation was weak, despite this being

highlighted as a major deficit by respondents, and thelack of evidence to suggest that respondents hadreceived any specialist educational input related todonation. It may be that the knowledge data reflects

societal awareness of certain donation issues, such as the

Table 5

High and low scoring topics, showing regional variations

Region 1 Region 2

Topic % correct (n) % Correct (n)

Diversity of transplantable organs 95% (155) 92% (150)

Payment for donation is illegal 95.6% (153) 93.8% (149)

Awareness of procedures for

determining brain stem death 90.7% (146) 94.3% (150)

Exclusion criteria for organ donationa 11.8% (18) 4.5% (7)

Exclusion criteria for tissue donationb 13% (21) 5.1% (8)

The law and requesting donation 43.6% (70) 45.6% (73)

Impartiality of medical staff 47.7% (74) 41% (64)

a (w2 ¼ 5:42; p ¼ 0:019).b (w2 ¼ 6:145; p ¼ 0:013).


requirement for tests to be carried out before brain stemdeath can be diagnosed, which are highlighted, periodi-

cally, by the media. However, the findings do revealareas where further educational support is needed, to tryto correct the misconceptions and the informationdeficits. Studies exploring the impact of education on

death-related behaviour suggest that greater knowledge,and awareness of personal feelings explored usingexperiential rather than traditional teaching methods,

may best facilitate behaviour modification (Degner et al.,1991; Durlak and Reisenberg, 1991; Hurtig and Stewin,1990).

The influence of societal pressure, discouraging thediscussion of death-related issues, has not been directlytested in this survey but must still be acknowledged,despite the lack of up-to-date research. If death is not

discussed within wider society, it follows that the

broaching of this subject in the hospital setting will bemore likely to provoke anxiety.

A further subjective norm, that of traditional rolesand responsibilities, emerged from the survey as a factoraffecting nurses’ behaviour and, due to the lack ofopportunity for clarification associated with question-

naire as a method of data collection, it warranted furtherinvestigation. This was explored qualitatively in a laterphase of the research, the findings of which are beyond

the remit of this paper.The survey also revealed the low incidence of donor

assessment, by nurses, of patients other than those

declared brain-stem dead. These findings supportobservations from practice, and from previous researchthat focused on brain-stem dead patients in ICUsin England and Wales (Gore et al., 1992). Donor

assessment, in particular that related to tissue, rather

Table 6

Logistic regression: prediction of likelihood of being able to discuss donation, showing overall (total) and regional sub�sample

(Region 1 and Region 2 ) results

Predictor Variables b Wald Odds ratio

Total Region 1 Region 2 Total Region 1 Region 2 Total Region 1 Region 2

Age �0.04 �0.08 �0.03 2.29 3.09 0.41 0.96 0.92 0.97

Knowledge �0.06 0.09 �0.25 0.84 0.44 3.26 0.94 1.09 0.78

Qualifications �1.23 �2.06 �0.68 3.68 3.56 0.26 0.29 0.13 0.51

Personal donation intention 0.11 0.17 0.44 0.21 0.13 1.49 1.11 1.19 1.55

Negative attitude 0.02 0.01 0.06 2.28* 0.17 4.22* 1.02 1.01 1.06

Clinical area 0.26 0.43 0.17 5.26 3.79 0.81 1.29 1.54 1.18

Religious support for donation �0.11 0.73 �0.05 0.07 0.71 0.01 0.89 2.08 0.95

Organ donors usually brain

stem dead

0.48 1.42 0.68 1.38 2.08 1.26 1.61 4.13 1.97

Death is not dependent on asystole �0.57 �1.48 0.43 2.19 3.88* 0.36 0.56 0.23 1.53

Death is declared before

organ retrieval

�0.04 �0.67 0.98 0.01 0.71 1.84 0.96 0.51 2.67

Medical impartiality 0.42 1.07 �0.22 0.96 1.71 0.09 1.52 2.92 0.80

Variety of transplantable organs/tissue �1.19 �4.75 �1.55 1.02 0.02 1.33 0.30 0.01 0.211

Sale of kidneys is illegal 0.58 �0.89 1.5 1.36 0.79 3.76 1.78 0.41 4.46

No payment for donation is made

to relatives

�1.05 �1.34 �0.66 1.31 0.57 0.26 0.35 0.26 0.52

Knowledge of law related to request 0.11 �1.32 1.43 0.08 2.63 4.34* 1.11 0.27 4.19

Well established procedures for

determining b.s.da�0.22 �0.96 0.10 0.08 0.54 0.01 0.81 0.38 1.120

Knowledge of exclusion criteria

for tissue donation

0.50 �0.05 9.52 0.58 0.002 0.21 1.64 0.94 error

Knowledge of exclusion criteria

for organ donation

0.05 �0.65 3.41 0.01 0.44 5.76* 1.06 0.52 30.27

Support opting�out 0.45 0.83 0.35 3.99* 3.58 1.06 1.57 2.30 1.42

Support required request 0.17 �0.05 0.83 0.71 0.02 5.64* 1.18 0.95 2.28

Constant 5.04 16.5 �2.11 1.75 0.05 0.12

�2 Log likelihood 193.44 67.27 86.57

Model Chi-square 37.06 39.36 37.08

p 0.011 0.006 0.011

Overall rate of correct classification 69.5% 83.1% 77.8%

ab.s.d=brain stem death.

*po0:05:


than organs, is an area where further research is requiredsince failure to assess donor potential can result in the

non-discussion of donation wishes, unless this issue israised by the relatives or the patient prior to death.

8.1. Limitations

Limitations do exist within this study, and includefactors such as the lower than expected response rate,

the convenience element influencing the choice ofregions, and the extraneous variables that remaineduncontrolled during data collection. These may have

exerted some effect on the significance of the findings.However, the survey did identify links between Ajzen’sattributes of attitudes, subjective norms, and perceived

behavioural control and nurses’ perceived ability toparticipate in the donation process, thereby realising oneof the initial objectives of the study.

9. Conclusions and recommendations

The survey suggests that nurses in the UK find thediscussion of donation issues difficult and that theirwillingness to raise this matter may be influenced by

traditional practices, personal attributes, and societalfactors, as well as their knowledge of the donationprocess. Few regional differences were found and

consequently, the reasons why Region 1 had lower thanexpected donation figures, when compared with Region2, remains unclear. However, it is apparent that thewidespread unwillingness to discuss donation wishes or

failure to assess a patient’s potential for donation of

tissue, or organs if appropriate, could be having asignificant impact on the supply demand mismatch

discussed at the beginning of the paper.A more focused investigation into the phenomena

of donation discussion formed the second phase of

this 3-year study, the results of which are beyond theremit of this paper. However, one recommendationarising from the findings presented here is that issuesrelated to donor assessment, in particular that related to

tissue, rather than organs, require further exploration.There is also an apparent need for further educationalinterventions, greater preparation for health profes-

sionals through experiential learning and role modell-ing, and the provision of readily available supportmechanisms.

The decision to donate organs or tissue after deathis, in the UK, a personal one, taken for a variety ofreasons. However, it remains to be one that has far-

reaching implications for patients suffering from certaindiseases, for whom a human organ or tissue transplantwould provide an opportunity for enhanced quality oflife. For this reason alone, patients’ wishes should be

elicited.

Acknowledgements

I would like to acknowledge the support of Wales

Office of Research & Development for Health and SocialCare (WORD) who partly funded the doctoral studyfrom which this paper is drawn, and also to thank mysupervisors and the nurses who participated in this

research.

Appendix. Examples of questions included within the Organ Donation Attitude and Knowledge Scale

1. In the UK, it is legal for a live individual to sell one of his/her kidneys.Yes No Not sure

2. In the UK, the family of a deceased patient who donates organs will receive payment for the donation.Yes No Not sure

3. In the UK, health professionals must, by law, make a request for organ donation to families of all suitabledeceased patients.Yes No Not sure

4. In the UK, most religions prohibit organ donation.Yes No Not sure

5. In the UK, organ donors are patients who have been declared brain stem dead.

Always Usually Sometimes Never

6. In the UK, organs, such as the heart, liver or kidneys, can be removed after the donor’s hearthas stopped beating.

Always Usually Sometimes Never


7. In the UK, the organ donor is declared dead before the organs are removed and the ventilator is switched off.Always Usually Sometimes Never

8. In the UK, the doctor who diagnoses and certifies the death of the organ donor can be involved in the removalor transplantation of the organs.Always Usually Sometimes Never

9. In the UK, which of the following absolutely rules out tissue donation? Please mark ‘‘X’’ by all thatyou think apply:(a) Age 50+ (b) HIV infection (c) Septicaemia

(d) Coroner’s cases (e) Prolonged hypotension (f) Cancer

10. In the UK, which of the following absolutely rules our organ donation? Please mark ‘‘X’’ by all that

you think apply.(a) Age 50+ (b) HIV infection (c) Septicaemia(d) Coroner’s cases (e) Prolonged hypotension (f) Cancer

11. Please estimate, for each category, the number of patients who are currently awaiting a transplant in the UK byplacing a circle around the appropriate figures:

(a) Kidney 2000–3000 3001–4000 4001–5000(b) Heart 50–100 101–200 201–300 301–400(c) Liver 50–100 101–200 201–300 301–400

(d) Lung 50–100 101–200 201–300 301–400(e) Heart/lung 50–100 101–200 201–300 301–400(f) Cornea o100 101–500 501–1000 1001–2000>2001

12. Do you personally intend to leave your organs for transplantation?Yes No Not sure

13. Would you donate the organs of a deceased family member?definitely depends on the circumstances unlikely

14. Have you ever cared for a person who became an organ or tissue donor?

Yes No

15. Have you ever approached a family for consent for organ and/or tissue donation?Yes (please state tissue, organ or both) No

16. Would you personally feel able to approach a family for consent for organ or tissue donation?Yes Noplease give reasons:

17. Who do you think is the most appropriate person to discuss organ or tissue donation with the family, and why?

18. How frequently are terminally ill or deceased patients assessed for tissue and/or organ donation suitabilityin your ward?Always Usually Sometimes Never

19. Does your hospital ward have written protocols for organ and tissue donation?

Yes No Not sure

20. If protocols are written, do you feel that these provide adequate guidance for medical and nursing staff?

Yes No

Please give reasons


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Documents

Psychosocial factors influencing nurses’ involvement with organ and tissue donation