George A Jelinek, MD, DipDHM, FACEM, Director, Professorial Fellow; Claudia H Marck, BSc, MSC, Research Officer; Tracey J Weiland, BBSc(Hons), MPsych(Health)/PhD, Senior Research Fellow; Sandra L Neate, MBBS, DA (UK), FACEM, Emergency Physician and Hospital Medical Co-Director, Clinical Senior Lecturer; Bernadette B Hickey, MBBS FRACP, Intensive Care Physician and Hospital Medical Co-Director.
Organ and tissue donation-related attitudes, education and practices of emergency department clinicians in Australia
Article first published online: 28 FEB 2012
© 2012 The Authors. EMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine
Emergency Medicine Australasia
Volume 24, Issue 3, pages 244–250, June 2012
How to Cite
Jelinek, G. A., Marck, C. H., Weiland, T. J., Neate, S. L. and Hickey, B. B. (2012), Organ and tissue donation-related attitudes, education and practices of emergency department clinicians in Australia. Emergency Medicine Australasia, 24: 244–250. doi: 10.1111/j.1742-6723.2012.01535.x
[Correction added after online publication 28 February 2012: On page 247, in Table 1, in reference to the number of ACEM members in Australia, it reads that there are 254 ACEM members in the ACT, whereas this number should read 54. The percentages displayed in the table are correct.]
- Issue published online: 3 JUN 2012
- Article first published online: 28 FEB 2012
- Accepted 12 December 2011
- emergency department;
- organ donation;
- tissue donation
Objective: The ED is emerging as a priority for efforts to improve rates of organ and tissue donation (OTD) in Australia, but little is known of ED clinicians' attitudes, education or practices in the area. We aimed to determine the attitudes and OTD-related educational background and practices of Australian ED clinicians.
Methods: This was a national cross-sectional survey of members of the Australasian College for Emergency Medicine (ACEM) and the College of Emergency Nursing Australasia (CENA); online questionnaire of 133 items, graded responses using Likert and ordinal multi-category scales, plus open-ended qualitative questions.
Results: Of 2969 ACEM members, 599 (20.2%) responded; of 1026 CENA members, 212 (20.7%) responded. Respondents were broadly representative of the membership, with male trainee specialists underrepresented. Most ED staff supported OTD, although many were not certain that facilitating OTD was their role, or that the ED was the right place to identify donors. Around a quarter of medical and nursing staff had received no education regarding OTD. Having received education was related to professional status, cultural background, place of work and years of experience, and was significantly associated with attitude towards OTD and whether staff participated in OTD-related tasks.
Conclusions: More education on OTD is needed and requested by ED clinicians in Australia, particularly on OTD after cardiac death, management of a donor, brain death and obtaining consent. Postgraduate curricula should reflect this need for more OTD-related education in emergency medicine and nursing.
Health-care professionals with a positive attitude towards organ and tissue donation (OTD) are more likely to refer potential donors as well as elicit family consent for donation.1,2 However, many health-care professionals feel uncomfortable performing donation-related tasks, such as approaching donor families, referring potential donors, explaining brain death to family members and providing support to the grieving family. The reasons for this discomfort appear to be related to age and/or educational status: younger and less experienced health-care professionals experience greater discomfort3–5 as do those with poor knowledge.6–8 Results from an international survey among almost 20 000 critical care staff in 11 countries, including Australia, showed that optimal donation rates were associated with support for donation, acceptance of the concept of brain death, confidence levels and some educational background in OTD-related tasks.5
An audit of missed potential donors in Australian hospitals revealed a substantial missed potential donor pool from EDs,9 which has also been recognized internationally.10 Emergency clinicians are often the primary instigators of donor referral, and the first point of contact for potential donor families. International data suggest that referral of potential organ donors from the ED is associated with an increased likelihood of successful organ retrieval compared with inpatient units.11 In Australia, this has been recognized as a high priority with the introduction of the GIVE Trigger9 into Australian EDs, a tool designed to optimize recognition and referral of potential donors. To assist in optimizing national OTD rates, we felt it important to assess the barriers to OTD initiated in Australian EDs. This study, part of a larger national study into OTD in Australia, aimed to assess attitudinal and educational barriers of ED clinicians to OTD, and the interaction between these factors.
The study was overseen by a steering committee, consisting of representatives from St. Vincent's Hospital Melbourne (SVHM), Melbourne, Australia, and an external member from DonateLife, and was chaired by the SVHM Co-Medical Director of Organ and Tissue Donation. The SVHM members comprised representatives from the ED, intensive care unit, hospital consultants and trainees, and a project officer. The committee held meetings throughout the project and maintained email contact to review the questionnaire design, pilot data collection, national data collection and data analysis phases.
Instrument design and development
Survey development was informed by available literature on organ donation with assistance from the steering committee. The survey included part of the Hospital Attitude Survey, a validated and widely used questionnaire to assess attitudes of hospital staff towards OTD developed by the Donor Action Program.12 Face validity of the draft survey items was ensured through iterative feedback between steering committee staff using a Delphi panel system.
Pilot phase and survey refinement
Content validity was formally assessed during the pilot phase, using a cross-sectional survey of a sample of nurses and doctors working at SVHM ED.
Participants of the pilot phase were requested to complete a survey wherein each survey item was rated according to relevance.13 Participants were asked to provide free text comments regarding the wording and structure of items if they felt there were content areas that required further exploration, and about the survey generally.
Nine doctors and 10 nurses returned a completed survey. Participant responses using the four-point ordinal scales were used to calculate the content validity index of survey items and the instrument as a whole, as outlined by Lynn.13 Participant comments about items and the instrument were considered by the researchers. As a result of the pilot, and consideration by the steering committee, the survey was slightly altered.
National cross-sectional survey
This was a cross-sectional survey of a national sample of nurses and doctors working in Australian EDs.
Eligible participants were fellows and trainees of the Australasian College for Emergency Medicine (ACEM) or members of the College for Emergency Nursing Australasia (CENA), working in an ED in Australia. The survey was sent to 3995 potential participants, comprising 2969 members of ACEM (1169 fellows and 1800 trainees) and 1026 members of CENA.
The final survey comprised 133 items. Graded responses using Likert and ordinal multi-category scales to enable quantitative statistical analysis were used. Open-ended questions were used to elicit qualitative responses.
Assuming a 50% response distribution, 280 CENA and 341 ACEM members were required for a 5% margin of error and 95% confidence level.14
The survey was sent electronically through ACEM and CENA. Fellows and trainees of the ACEM and members of the CENA were emailed an introductory email, which contained an invitation to participate, participant information and a hyperlink to the electronic questionnaire. Responses were collected over 11 weeks in early 2011. Several reminder emails were sent. The online survey package, ‘Survey Monkey’, was used for ease of response and respondent anonymity.
Participation in the survey was voluntary. Participants were advised that partial or full completion of the survey was taken as implied consent. Participants were able to withdraw from completing the questionnaire at any time; however, it was not possible to withdraw their data once they had submitted (part of) the questionnaire, as all data were non-identifiable.
Quantitative data were exported from the web-based survey program to pasw Statistics 18.0 (Chicago, IL, USA). For each survey item summary statistics (%, confidence interval, medians) were calculated for the sample, and by demographics, including staff type (e.g. nursing or medical), level and years working in EDs. Although descriptive analyses were undertaken, we also completed exploratory inferential analyses. For nominal data, comparisons between groups were undertaken using χ2, Fisher's exact test for 2 × 2 contingency tables. Mann–Whitney U- and Kruskall–Wallis tests were used for analyses of ordinal data. Qualitative data were summarized.
The study was approved by the Human Research Ethics Committee of SVHM (protocol 154/10).
Response rates and demographics
A total of 811 participants started the survey; 648 (79.9%) completed the full survey. Two participants were omitted because of data errors. Of 1026 invited CENA members, 212 (20.7%) started and 162 (15.8%) completed the survey; members from NSW were underrepresented, whereas Victorian members were overrepresented. CENA could not provide data on sex or age of members. Of 2969 invited ACEM members, 599 (20.2%) started and 486 (16.4%) completed the survey; members from Queensland and male trainees were significantly underrepresented, and fellows, both male and female, were overrepresented. The representation and demographics of the groups are listed in Tables 1 and 2.
|State or territory||CENA members in Australia||CENA members in survey||ACEM members in Australia||ACEM members in survey|
|NT||24 (2.3)||5 (2.4)||42 (1.4)||16 (2.7)|
|ACT||37 (3.6)||7 (3.3)||54 (1.8)||13 (2.2)|
|Tas.||36 (3.5)||8 (3.8)||74 (2.5)||25 (4.2)|
|SA||70 (6.8)||16 (7.5)||210 (7.1)||40 (6.7)|
|WA||98 (9.6)||16 (7.5)||325 (10.9)||69 (11.5)|
|Qld||198 (19.3)||26 (12.3)||698 (23.5)||104 (17.4)|
|NSW||265 (25.8)||37 (17.5)||814 (27.4)||154 (25.7)|
|Vic.||298 (29.0)||97 (45.8)||752 (25.3)||178 (29.7)|
|Male fellows||829 (27.9)||200 (33.5)|
|Female fellows||340 (11.5)||112 (18.8)|
|Male trainees||1078 (36.3)||137 (22.9)|
|Female trainees||722 (24.3)||148 (24.8)|
|Median age in years (interquartile range)||38.0 (33–44)||41.1 (32–49)|
|Female||262 (43.7)||172 (81.1)|
|Male||337 (56.3)||40 (18.9)|
|Duration of living in Australia|
|Born in Australia||252 (42.1)||168 (79.2)|
|Less than 5 years||107 (17.9)||1 (0.5)|
|Between 5 and 10 years||83 (13.9)||4 (1.9)|
|Between 10 and 15 years||47 (7.8)||3 (1.4)|
|Between 15 and 20 years||16 (2.7)||2 (0.9)|
|Between 20 and 25 years||14 (2.3)||5 (2.4)|
|25 years or more||80 (13.4)||29 (13.7)|
|Type of hospital|
|Major referral||344 (57.4)||104 (49.1)|
|Major regional/rural base||127 (21.2)||54 (25.5)|
|Urban district||118 (19.7)||52 (24.5)|
|Private hospital||10 (1.7)||2 (0.9)|
|Average work hours per week|
|Less than 10||35 (5.8)||28 (13.2)|
|10–20||93 (15.5)||29 (13.7)|
|21–30||129 (21.5)||40 (18.9)|
|31 or more||342 (57.1)||115 (54.2)|
|Experience working in EDs in years|
|0–5||177 (29.5)||49 (23.1)|
|6–10||158 (26.4)||66 (31.1)|
|11–15||121 (20.2)||38 (17.9)|
|16–20||68 (11.4)||23 (10.8)|
|21–25||47 (7.8)||24 (11.3)|
|26 or more||28 (4.7)||12 (5.7)|
|Other postgraduate qualification (masters)||19 (9.0)|
|Other nurse||30 (14.1)|
|Grade 2 nurse||34 (16.0)|
|Postgraduate qualification in emergency or critical care||110 (51.9)|
|Other medical specialist||2 (0.3)|
|Provisional trainee in emergency medicine||101 (16.9)|
|Advanced trainee in emergency medicine||184 (30.7)|
|Total||599 (73.9)||212 (26.1)|
Attitudes or beliefs about organ and tissue donation in the ED
Of 685 participants completing this section, almost all medical staff (98.8%) and nursing staff (97.7%) agreed that OTD can save lives. The majority of staff denied that OTD is something they just don't think about (73.7% medical, 67.8% nursing), and the majority agreed that facilitating OTD is a rewarding experience (70.4% medical, 66.7% nursing). Around half of staff (54.5% medical, 50.9% nursing) agreed that the costs of OTD are not high compared with the benefits. The majority of medical (63.4%) and nursing (57.9%) staff disagreed with the statement ‘facilitating OTD is not my role’. Medical and nursing staff were divided over the statement ‘I feel obligated to offer the donor family the option of OTD’, where 44.2% of medical staff disagreed and 39.3% were neutral, 35.1% of nursing staff disagreed and 46.2% were neutral. Most staff disagreed that ‘the ED is not the right place to identify potential donors’ (59.9% of medical staff and 67.7% of nursing staff).
Organ and tissue donation-related training or education
As respondents were asked to tick one or more responses, the percentages reported at each reply correspond to the proportion of the 785 respondents to this section per staff category. The modal response for both medical and nursing staff was that they had received departmental training (37.0% of medical and 38.8% of nursing staff); however, the second most common reply was that no education or training in regards to OTD had been received (29.2% of medical and 23.8% of nursing staff). The type of training received is shown in Figure 1.
Whether staff had received education or training regarding OTD was related to cultural background (P < 0.01); most Australians and New Zealanders had received education (n= 500, 76.4% educated), as had most Europeans and North Americans (n= 144, 69.4%), whereas fewer Asian (n= 70, 54.3%) and Middle Eastern (n= 17, 52.9%) participants had received education. Receiving education was also related to length of living in Australia (P < 0.01), with those living longer than 20 years or born in Australia highest (n= 531, 77.4% educated), compared with those living here 1–10 years (n= 189, 64.0%).
Religious background was associated strongly (P < 0.01) with whether or not clinicians had received education, with high percentages having received education among Christians (n= 320, 76.6%), atheists or those not religious (n= 379, 73.4%) and those who preferred not to say or other religion (n= 31, 71.0%), whereas fewer had received education about OTD among those identifying with Buddhism and Hinduism (n= 30, 40.0%) and Islam (n= 17, 41.2%). Years of experience in EDs were also relevant (P= 0.01), with those working 16–20 years the most likely to have received education (n= 91, 83.5%), and those working 0–5 years the least likely (n= 218, 66.1%).
Involvement with organ and tissue donation-related tasks
Of 785 participants completing this section, 28.7% had no experience with OTD-related tasks at all during the preceding calendar year. Identifying and caring for potential donors were the tasks most frequently experienced, but only 50% of staff had experience with this in the preceding calendar year. Obtaining consent for OTD was the least reported task (Fig. 2). Whether or not staff had experience with OTD-related tasks in the preceding year was related to sex, with men more likely (n= 361, 75.1% vs 68.2%, P= 0.04).
Experience with these tasks was also related to: region (P= 0.03), with Tasmanians the most likely (n= 33, 81.8%) and South Australians the least likely (n= 54, 59.3%); type of hospital (P < 0.01), with those working in major referral hospitals most likely (n= 431, 77.1%) versus those in urban district hospitals (166, 59.6%); and staff type (P < 0.01), with medical staff (n= 579, 78.4%) much more likely than nursing staff (n= 206, 51.5%).
Experience with OTD-related tasks in the previous year was also clearly related to whether or not respondents had received OTD-related education (P < 0.01), with those having received education (n= 569, 76.6%) more likely than those that did not (n= 216, 57.4%). Experience was also related to attitudes: clinicians who agreed or were neutral that facilitating OTD was not their role were less likely (n= 190, 35.4%) to have undertaken OTD-related tasks in the previous year than those disagreeing (n= 347, 64.6%) with this statement (P= 0.02).
The optional last question asked respondents to report any educational needs regarding OTD. Of 648 respondents finishing the survey, 499 (77.0%) responded. OTD after cardiac death was the most often selected area requiring education (79.8%), followed by clinical management of a donor (68.9%), brain death (66.9%), obtaining consent (66.5%), the use of the GIVE Trigger (64.7%), family issues in decision-making (60.1%), coordinating OTD in the hospital (56.7%), religious and cultural beliefs and OTD (56.3%), family grief counselling (47.7%), communication skills (45.1%), and other (6.6%).
This study is the first national Australian study of the attitudes, educational background and practice of ED clinicians in OTD. It identifies a complex interaction between ED clinicians' status, experience, place of work, attitudes and educational background on OTD and their likelihood of being involved in OTD-related tasks in their day-to-day work. Virtually all ED clinicians, medical and nursing, affirm that OTD saves lives, and the majority feel their involvement is rewarding. However, a significant number of clinicians feel that facilitating OTD is not their role and that the ED is not the right place to identify donors, and are sceptical about the cost–benefits of OTD, despite evidence to the contrary.15–19 Crucially, as in previous studies,1,5,20 we have shown OTD-related education to be a key ingredient shaping attitudes and experience.
The data suggest that there are barriers to accessing this education and training. For the average experienced ED clinician in this study, living in Australia, of Australian background, and working in a major referral hospital, there did not appear to be great difficulty in accessing education, albeit with some regional differences. However, for those respondents originally from Asia and the Middle East, identifying with Buddhism, Hinduism or Islam, and relatively new to the ED, there appeared to be barriers to educational opportunities, which translated to lack of engagement with the process of OTD in day-to-day work. Further, education appears to shape attitudes; in turn, a belief that facilitating OTD is indeed the role of an ED clinician clearly influences the likelihood that the clinician will get involved with OTD. If rates of OTD are to improve in Australia, these barriers need to be addressed.
Fortunately, the great majority of ED clinicians appear to recognize that education is a key factor and desire more educational opportunities. There is clearly a need for relevant OTD authorities in Australia and their delegates in hospitals to make the process of OTD after cardiac death more easily understood by clinicians, to further support and disseminate information regarding the GIVE Trigger for EDs, and offer a variety of educational opportunities, particularly for overseas trained doctors and new staff in the ED. ED postgraduate curricula should reflect this need for more OTD-related education in emergency medicine and nursing.
The response rate overall was considerably higher than in previous surveys of this clinician cohort;21,22 however, for the nursing cohort, it was below the calculated sample size. Additionally, the proportion of emergency nurses who are members of CENA is not known. The results might therefore lack generalizability for the nursing cohort. This response rate also affects the margin of error, thereby limiting the precision in some of the estimates made in this study.
Education about OTD is a key component in shaping the OTD-related attitudes and practice of clinicians working in Australian EDs. Our data suggest that providing more educational opportunities may assist in improving OTD rates from EDs in Australia.
This study was funded by a research grant from the Organ and Tissue Authority. GAJ is Editor Emeritus of Emergency Medicine Australasia, and TJW is a statistical consultant for Emergency Medicine Australasia.
- 9National Organ Donation Collaborative N. Review of the national organ donation collaborative. 2009.
- 12DonorAction. The Hospital Attitude Survey Copyright of Eurotransplant International Foundation (NL), Organizacion Nacional de Trasplantes (Spain), and the Partnership of Organ Donation (USA). 1996.
- 14Raosoft. Sample size calculator.