Regardless of their area of professional practice, the majority of practicing nurses will encounter issues pertaining to organ donation, whether with transplant recipients, donors, or families. Although nurses' knowledge and attitudes may influence organ donation rates (Hoy, Alexander, & Frith, 2011), a review of the literature revealed few studies investigating knowledge and attitudes of nurses and nursing students toward organ donation. Although limited in number, study results have concluded that donation-related education is associated with improved understanding and support of organ donation (Jones-Riffell & Stoeckle, 1998; Kurz, 2014; Stoeckle, 1990; Whisenant & Woodring, 2012).

In a landmark study, Smith, Dattilo, Chabalewski, and the Advisory Council for the Nursing Curriculum on Organ Donation and Transplantation in Undergraduate Programs of Nursing (1995) conducted a national survey of nursing programs that found organ donation and transplant-related education limited and inconsistent across all levels of nursing education throughout the country. More recent research identified similar findings regionally in both nursing and medical education (Anker, Feely, Friedman, & Kruegler, 2009).

The purpose of this study was to identify graduating nursing students' organ donation and transplantation-related knowledge, particularly knowledge of brain death and knowledge and beliefs regarding organ donation and allocation. Students' feelings of preparedness to work with issues having to do with organ donation and transplantation in their upcoming nursing practice were also studied.

Consistent with Jones-Riffell and Stoeckle's (1998) research, the theoretical framework for this research was Ajzen and Fishbein's (1980) theory of reasoned action. Briefly stated, this theory identifies personal attitudes and subjective norms as motivating behavioral factors. Both attitude, described as perceptions of a behavior as positive or negative, and subjective norms, identified as perceived social pressure to perform an action, are combined behavioral determinants. The theory states that expectation of a positive outcome will increase motivation to perform a behavior, whereas expectation of a negative outcome will decrease motivation. Measuring attitude and subjective norms can aid in predicting and understanding behavioral intentions.

METHOD

Study Design

A cross-sectional, descriptive, correlational survey design was used to assess factual knowledge, attitudes, and perceived knowledge of organ donation in a convenience sample of graduating baccalaureate nursing students at a large East Coast university. All students were invited to participate, and approximately 95 percent responded (n = 124). Institutional review board approval was obtained prior to starting the study, and students were informed that participation was voluntary and unrelated to their grade. Participants were predominately unmarried women ages 20 to 44 (median age = 24.5) pursuing a second degree.

A modified version of the Organ Donation Attitude Questionnaire II-Student Version (ODAQ II-SV), a 39-item survey developed by Stoeckle (1995), was used for this study. Permission to use and modify the instrument was obtained (M. L. Stoeckle, personal communication, June 2012). Content validity for the ODAQ II-SV was established by Jones-Riffell and Stoeckle (1998) in their pilot study of knowledge and attitudes of senior BSN students.

Although the ODAQ II-SV was developed more than 20 years ago, its items continue to reflect contemporary practice. For purposes of the current study, 11 questions were added to assess students' knowledge of brain death, attitudes toward the organ allocation system, thoughts regarding the nurse's role in the organ donation process, and feelings of preparedness to work with organ donation in their careers. Three scales were created from the 50 items of the modified ODAQ II-SV; the analysis included 21 Knowledge, 13 Attitude, and 6 Perceived Knowledge questions. We compared our results to those of Jones-Riffell and Stoeckle (1998) using similar variables in our modified survey.

Correlations among the three scales were positive and significant: between Knowledge and Perceived Knowledge, r = .40, p < .0001; Knowledge and Attitude, r = .29, p < .0008; Attitude and Perceived Knowledge, r = .36, p = .0001. These correlations are very similar to those found by Jones-Riffell and Stoeckle (1998); in addition, correlations between our scales and the original scales were all extremely high (.98 and .99). Cronbach's alphas were as follows: Knowledge, .86; Attitude, .83; and Perceived Knowledge, .78.

RESULTS

Knowledge

Students' state of knowledge was found to be quite low. The mean number of correct responses was 10.09 (21 questions, minimum 0, maximum 18, SD = 4.55). Although 64 percent of respondents (n = 78) agreed that the definition of brain death is the "absence of all brain stem function," only 42 percent (n = 51) agreed that "a person who is declared brain dead is considered dead even though the heart may be beating." Less than half (47 percent, n = 57) agreed that a deceased donor must be brain dead prior to organ donation.

There was also a knowledge deficit related to individual donor scenarios and the identification of who could give consent for organ donation. Nearly 30 percent (29.4 percent, n = 35) disagreed or did not know that a parent could give consent for organ donation; 44 percent (n = 52) disagreed or did not know that a son or daughter could. Half (49.6 percent, n = 59) were unaware that Medicaid recipients were eligible transplant candidates.

Knowledge was frequently low but not significantly related to age (r = .03, p = .77) or gender (t = 0.05, p = .96). Knowledge was, however, related to having signed a driver's license consenting to donation (t = 2.24, p = .03; signers, M = 11.13, SD = 4.29; nonsigners, M = 9.30, SD = 4.55), indicating that those who signed their driver's license had stronger knowledge than those who had not.

Attitude

The mean on the attitude scale was 6.45 (SD = 1.69); the minimum and maximum were (by design) 0 and 10. Attitudes were generally positive: 82 percent (n = 102) agreed that it is right to prolong life through organ transplantation, specifically, deceased, living-related, and living-unrelated donor transplants. Although fewer than half the sample (45 percent, n = 54) had signed their driver's license, the majority (63.9 percent, n = 78) would donate their own organs. Only 41 percent (n = 50) would donate their adult relative's organs, and 36 percent would donate their child's organs (n = 43).

The majority of respondents agreed that involvement with organ donation is a nursing responsibility (70 percent, n = 83). A minority (14 percent, n = 17) agreed that the organ allocation system is fair, whereas nearly a quarter (24 percent, n = 29) agreed that those with the most money and best insurance receive priority for organ transplants. In addition, 32 percent (n = 39) agreed that "removal of a person's organs before the heart stops is a violation of a person's rights."

Respondents identified their nursing school education as most influential (46 percent, n = 55) in forming their attitude toward organ donation. Attitude was not significantly related to age (Spearman's r = .02, p = .79) or gender (t = 0.56, p = .58, using Satterthwaite correction for unequal variances) but was strongly related to consent to be a donor (t = 7.55, p < .0001). Those who had signed their driver's license had a mean attitude of 7.52 (SD = 1.31); nonsigners had a mean of 5.57 (SD = 1.48), indicating a less positive attitude toward donation than signers.

Perceived Knowledge

Perceived knowledge questions focused on application of students' knowledge of brain death and the organ allocation process to the knowledge and attitudes they would bring to practice. The mean on the perceived knowledge scale was 5.40 (SD = 1.93), with a minimum of 0 and a maximum of 10 (again by design).

The majority of respondents (55 percent, n = 67) agreed that they had been exposed to definitions of brain death; an even larger majority (79 percent, n = 95) agreed that they understood the difference between brain death and cardiac death. A smaller percentage (41 percent, n = 50) agreed to awareness of the various criteria for determining brain death. Sixty-one percent (n = 75) agreed that they were aware of the way donors and recipients are matched for transplant, and 29 percent (n = 35) agreed that they were aware of the organ allocation process. Fewer than half (48 percent, n = 57) felt prepared to deal with organ donation in their nursing career.

Feeling prepared to deal with organ donation was significantly related to knowing that a deceased donor must be brain dead before organs can be donated (z = 2.05, p = .04). Those who knew that an organ donor must be brain dead prior to donation felt more prepared to deal with organ donation.

DISCUSSION

As evidenced by the majority of respondents who considered involvement in the process a nursing responsibility and those who felt unprepared to work with organ donation in their careers, students in this survey seemed uncertain about their upcoming roles in the organ donation process. Of particular interest were findings that more than 30 percent of graduating nursing students were unaware of the definition of brain death and 53 percent were unaware that a deceased donor must be brain dead prior to organ donation. Those who were aware felt more prepared for organ donation and transplant-related practice. Unawareness of the distinction between brain death and a persistent vegetative state may have led some to believe that removal of organs from a heart-beating donor violated a patient's rights.

Despite geographic, time frame, sample size, survey modification, and demographic differences, similarities were identified between the present study results and those of Jones-Riffell and Stoeckle (1998). Respondents in both student groups demonstrated knowledge deficits related to the organ donation process, including who may give consent and potential donor scenarios. The majority of students in both groups agreed that it is right to prolong life through organ donation. In addition, the finding that the majority of Jones-Riffell and Stoeckle's students (67.8 percent, n = 19) identified increased knowledge as most influential on their attitudes is congruent with our finding, that those with the strongest knowledge of brain death felt most prepared to work with organ donation in their careers.

Students in both groups who had signed their driver's license consent for organ donation identified more positive attitudes than nonsigners; in addition, signers in the present study also demonstrated greater knowledge than nonsigners. The knowledge deficit in this sample is not unexpected given that donation and transplantation are not specific content areas of the school's nursing curriculum. Knowledge comparable to that of a transplant practitioner is not expected of undergraduate students, and it is unknown how students in this sample formed their beliefs about the organ donation process; however, whether positive or negative, students' beliefs should be based on factual knowledge that supports their decisions.

Recognizing both the strong influence of nursing education and curricular time constraints, alternative teaching methods, such as interactive online modules, may supplement or replace classroom education while minimizing interruption of classroom time. Regardless of the teaching method, donation-related education would provide nurses with the knowledge and confidence they need to prepare for the challenging donation and transplantation issues that will inevitably arise. Use of a convenience sample from a single university is among the limitations of the study, and replication with a comparative group would be essential to generalizing results.

CONCLUSION

Organ donation is a highly specialized and complex area of practice surrounded by misinformation and misunderstanding, and the influence of nurses on organ donation cannot be overestimated. The finding of a relationship between knowledge and attitude, including knowledge of brain death and increased support for organ donation and preparedness for practice, reinforces the need for organ donation and transplant-related education in nursing curricula.

REFERENCES