Abstract
Participating in organ procurement procedures cause emotional stress and risk of long-lasting health problems. These experiences are rarely discussed in plenary, and research specifically aimed at operating room nurses is limited. The aim of this study was to describe how operating room nurses experience participating in organ procurement surgical procedures. A qualitative, descriptive and exploratory design was chosen. The sample consisted of 14 operating room nurses, recruited from The National Transplant Centre, Norway. Data collection was conducted using individual, in-depth interviews. Qualitative inductive manifest content analysis was used. The study is reported according to QUOREC. Four main categories constitute the findings: operating room nurses have experienced emotional and personal impact; they try to handle these emotions using coping strategies; the experiences have promoted professional development; the importance of colleagues, including an open unit culture, is emphasized. Other studies support these findings regarding the impact this surgical procedure has on operating room nurses. This study also emphasizes their need for personal and professional support. Both individual and structural actions are suggested to generate this kind of support. The study may provide a deeper understanding of how participating in the organ procurement process affects those who are involved, and how to facilitate support to them as leader.
Introduction
Organ transplantation is life-saving treatment for patients with irreversible organ failure. 1 The treatment has a major impact on life extension 2 and increased quality of life. 3 According to European Operating Room Nurses (EORN) the role of operating room nurses (ORNs) involves acting as the patient's advocate, by utilizing their knowledge, skills and values to provide the best quality nursing care for the patient during surgical interventions. They work with a healthcare team in an independent and/or dependent role. 4 Thus, they play a vital role in the procuring of organs, 5 and have a pivotal role in the donor team. 3 Attending and participating in organ procurements obviously could be a source of distress, and each professional role in a donor team presents unique features. The aim of this study was to describe the experiences of ORNs in organ procurement situations.
Health professionals who participate in organ procurement procedures work in demanding situations, against the clock, to provide vital organs to recipients. They also take care of deceased donors in both Donation after Brain Death (DBD), and controlled Donation after Circulatory Death (cDCD). 6 This study deals with situations of DBD.
In connection with organ donation, additional statutory conditions are set for the death diagnosis in the event of total brain destruction, including the objective detection of a suspended blood supply to the brain. In this sense, objective imaging as cerebral angiography/archography or computerized tomography (CT) angiography are performed. 7
The role of ORNs is described as demanding, fast-paced and intense. 6 Night work, long surgical procedures, a lack of resources and an unpleasant and stressful work atmosphere characterize organ procurement. 8 How organ procurement can affect ORNs who are often exposed to the surgical procedure, is described in several studies.1,5,8–10 During organ procurement, ORNs witness the donor's death, which makes them feel uncomfortable and even induces trauma.5,8,11 The meaninglessness and tragedy surrounding the donor's death obviously causes strong emotions, and ORNs defend themselves against stress and cope with the issues that arise for them in this emotional type of work.9,12 Some ORNs become sad, and describe the procedure as a terrible 3 and incredibly stressful and disturbing experience. 10 These experiences may contribute to ORNs’ negative attitudes towards organ donation. 3
The role of the ORN includes, as previously stated, being the patient's advocate. In this case, the patient is a donor who is defined as dead. Nurses consider postmortem care as the opportunity to achieve closure with the patient, and they see giving care as providing comfort even postmortem, Wolf has found. 13 Furthermore, ORNs describe feelings of being overwhelmed and burdened with guilt when having to discontinue postmortem care. 6
Long-term effects of ORNs’ experiences are unknown,1,2,5 and how ORNs handle their experiences is only to a small degree described. 2 Questions are asked about who the ORNs’ ‘advocates’ are, or who supports them when the need arises. 3 Globally, there are some studies that explore types of available support, in addition to when and how that support is provided to those who participate in the organ procurement procedure.2,3,5,6
Aim
The aim of this study was to describe how operation room nurses experience participating in organ procurement surgical procedures.
Method
The study has a qualitative, descriptive and exploratory design with the aim of achieving the most in-depth knowledge of the study's topic. 14 A descriptive design is about describing the dimensions and meaning of phenomena. The exploratory approach explores and illuminates the different ways in which phenomena are manifested, thereby underlying the processes related to little-explored phenomena. 14 The study is reported according to the COREQ (Consolidated Criteria for Reporting Qualitative Research) checklist. 15
Context
The National Transplant Centre (NTC) is the only department which performs transplantations in Norway, approximately 450 transplantations per year. 7 The donor team from the NTC performs organ procurement at 27 donor hospitals in Norway and several donor hospitals abroad, as members of a Nordic exchange and cooperation organization for organ transplants.
Sample
The recruitment of the participants took place via leaders of the NTC and underlying units. Verbal and written information about the purpose of the study, inclusion and exclusion criteria, data collection method and ethical aspects of the project was given. 16 The unit leaders passed on information to the ORNs. The sampling was purposive, 17 and included ORNs who had worked full time, and actively participated in organ procurement surgical procedures. The exclusion criteria were ORNs employed in the same unit as the researcher, and participants with experience from less than five organ procurement surgical procedures. Out of 36 potential participants, the final sample was 14 ORNs employed by two different units in the department. Seniority ranged from < 1 to > 20 years (median 7 years and mean 8.5 years). The sample had satisfactory variation regarding seniority and the number of times participants had had experience with organ procurement. The gender distribution reflects the distribution of nurses in general in Norway. 18 None of the participating informants dropped out from the study.
Data collection
Qualitative, individual research interview was chosen as the appropriate data collection method, 19 and interviews were carried out by first author. The interviewer was unexperienced, thus two pilot interviews were conducted. The pilots did not meet the inclusion criteria, and were not included in the data material. The interviews were conducted in summer 2019, and took place at the hospital during day-shift working hours. Duration was 31–85 min, mean 50 min.
All the interviews were based on two open-ended interview questions:
Tell about your experiences with organ procurement surgical procedures. How does participating in organ procurement surgical procedures affect you?
Open follow-up questions, such as ‘Tell me more about that’ and ‘How did you feel then?’, were asked. The interviewer carefully avoided using theory-based conceptions, and encouraged the informants to use ‘their own words’. The interviews were recorded on audio tape and transcribed verbatim immediately afterwards.
Data analysis
After transcription, the audio recording was listened to again to ensure correct transcription, and to become acquainted with the material. A repeated reading of the data material, in order to achieve an in-depth study and get a sense of wholeness, is considered as the start of data analysis.20,21 Initially, a manifest conventional content analysis was performed according to Graneheim and Lundman's 21 five analysis steps: identify units of meaning, condensation, coding, subcategories and categories.
Step 1: Identifying units of meaning
This step involved reduction, where the data were reduced to the informants’ statements that were related to the research questions. At this stage, the size of the unit was taken into account to imply a relevant meaning in its entirety, or context. Broad units of meaning, as a paragraph, are likely to contain different meanings, while too narrow a unit, such as a single word, can lead to fragmentation. 22
Step 2: Condensation
In the second step, units of meaning were condensed, that is, shortened. Considering the context, the units of meaning were condensed into a description that still was close to the text. 22
Step 3: Coding
Condensed units of meaning were abstracted and marked with a code. 22 Groups came into view.
Step 4: Subcategories
In the fourth step, the codes were compared on the basis of similarities or differences and sorted into eight subcategories.
Step 5: The subcategories finally resulted in four main categories
Although some informants’ descriptions were deviant from the majority, saturation was experienced as the analysis progressed. Their statements also naturally linked to the final subcategories and categories, as variations (Table 1).
Data analysis.
Ethical considerations
The study is legitimized by the relevance to clinical practice. Both newly hired and experienced ORNs, as well as their leaders, could benefit from this study. General research ethics principles were followed.16,22 The participants were informed according to informed consent guidelines 22 and assured of their right to withdraw from the study. Written consent was obtained prior to the interviews. The Norwegian Centre for Research Data 23 (ref.nr 468964), and the participating hospital's committee for the protection of privacy, approved this study. The researcher is an ORN with experience of organ procurement, but was conscious to put her preunderstandings aside. 8 The transcribed data were anonymized, and the informants were given a number which followed steps 1–3 of the analysis. Audio recordings, the consent statements and a list with the informants’ assigned numbers were stored in a lockable cabinet at the university.
Findings
The findings consist of four categories and eight subcategories (Table 2).
Results.
Emotional and personal impact
Strong emotions and persistent and recurring thoughts due to working with organ procurement were described. Situations in which donors are children and young people were very tough and extra sad to be involved in, according to the informants. When young people who had committed suicide were donors it was even tougher, and expressions such as ‘inexplicably painful’ and ‘a kick in the stomach’, were used. The informants emphasized compassion for the relatives of child donors who have lost their loved ones, but still manage to offer their child's organs to save others.
Strong visual impressions related to organ procurement situations were described as ‘gross’, ‘overwhelming and grotesque to attend’ and ‘abnormal, not an everyday thing’. The silence when the anesthesia machines, the slush machine and the suction are turned off was also highlighted, together with the fact that there is no going back when the organs are harvested.
It was so weird that the anesthesia just turned off the screens and everything. It was very strange. Then we stood alone. (I 4)
The ORNs reflections on what ‘time of death’ means, and the distinction between ‘brain dead’ and ‘clinical dead’ were described.
It's a human being who's dying. Or who is dead then, when it comes to us, in a way. It is special because we operate on someone who, in a way, is kept artificially alive, who is actually dead. (I 10)
In contrast to the above, a few informants commented on the organ procurement as a normal part of the job, and ‘an exciting intervention to take part in’.
Going to donor hospitals was somehow easier to deal with, because then the donors are already covered, and the ORNs do not have to see the face of the donor. Stress related to a lack of time packing the equipment case was described, as well as the availability of equipment and personnel. The organ perfusion was nevertheless described as the most stressful moment, and especially the moment when the aortic forceps had to be put on, and cold compresses and the perfusion solution had to come in.
For some, the first experience with organ procurement was difficult, very strange and the toughest experience ever, but some did not remember their first time. However, the most common reactions were to cry, being stressed and nervous, but also feeling curious. The ORNs were not prepared for what they would encounter.
The first time I experienced that it was so grim. You almost feel like there's just an empty shell left then, when you’re done. (I 12)
I came home and cried and cried. That's what surprises me, since I’m not really a person who otherwise cries so much. (I 5)
Conflicting emotions during the organ procurement were described as both positive and negative. The burden of many sad fates versus a ‘gift for life’; sadness because the person is dead versus happiness because you managed to do the job you are supposed to do. However, sad feelings were not always negative.
They [sad feelings] can be a sign that you are not withdrawn, cynical or completely untouched by human destinies. (I 1)
If I had not had those feelings, I would have felt that I had been a bit blunt, and I do not want to be. (I 10)
Persistent and recurring thoughts about donors, and the tragic events around them, could last a long time after the organ procurement. They could extend over a few hours, days or weeks. The above thoughts appeared long after the organ procurement, due to associations in connection with similar situations one was in.
Just the fact that you read in the newspapers about someone who has died, for example a child who has committed suicide, then you suddenly think back to the donor I was with, and then you go that round again. (I 7)
However, not everyone experienced persistent or recurrent thoughts. Some thought about them for a moment, but had no lasting thoughts.
Change of personality traits and attitude towards being a donor was expressed. The ORNs described that they had become more aware of existential things, in a way they had not been before. Several commented on the unpredictability of life, how it can change quickly and that there is a thin line between life and death.
I cannot help but think about my own life and how fragile life can be. One can get that suffocating fear, because death is unknown, and it can be so brutal. That feeling is burdensome. (I 1)
Some informants described that they appreciated aspects of life more, due to their experiences with organ procurements. The informants pointed out that they identified themselves, family, friends and peers with donors. After a while, several informants expressed, some changes in personality traits arise, such as being more thoughtful, reflective, worried and overprotective towards their loved ones, but also tougher and ‘a better person’. A few ORNs claimed that their experiences had not affected them as people.
Participating in organ procurement over time may change the ORNs’ attitude to becoming a donor. Due to strong experiences with organ procurement, negative attitudes towards becoming a donor were described. However, most of the informants had made the decision to be donors, after gaining a greater understanding and realizing the importance of it. The informants were also happy to address this topic, both in a work context and privately, to inspire others to register as donors.
Handling emotions
Distance from sad feelings was described as a coping strategy, with feelings being blocked and ‘pushed aside’. Keeping focused on their tasks and the field and being ready for ‘the next step’ enabled the ORNs to do their job.
I thought, do not panic! Because when panic strikes, it can block your thoughts. It does not help to panic. Relax! (I 14)
A common conception was that to consciously choose to know as little as possible about the donors prevents disturbing thoughts afterwards. Furthermore, the informants pointed out that they also distanced themselves from the relatives’ grief.
Development of coping strategies related to dealing with difficult emotions came with experience of what works. Examples of this were riding, watching movies or walking and ‘running until you are tired’. Despite several hours of work and fatigue, it could be difficult for ORNs to fall asleep when they returned home after an organ procurement, and some cleared their minds by doing soothing things, like reading or knitting. The importance of maintaining emotional balance by letting emotions in, but also out, was expressed. To ‘blow out’ or ‘ease the pressure’ a little afterwards, was mentioned. Usually the ORNs spoke with a shift partner or those who had been in the operating room. Some also spoke to their loved ones and friends, but were conscious about duty of confidentiality.
Shifting the focus so that life goes on was highlighted as a coping strategy that made it possible to see the meaning of the organ procurement despite the sad feelings.
It is fundamental that you have both sides of it then. We work both with the organ procurement and helping to insert the organs and see that they work. Otherwise it would probably have seemed completely meaningless. (I 1)
Professional development
Experience of professional strength and pride, and the importance of the work ORNs perform, was expressed. The informants described themselves as more driven, more skilled and professionally stronger. They also experienced more automation and calmness in the procedures, less stress if something should suddenly happen during the procedure, and they ‘threw themselves into things more easily’. The perception of enduring more physically and mentally by working for many hours in a row was also described. Over time, the organ procurement became more routine. To some this was not an undividedly positive experience.
It becomes everyday, in a way. I find it so strange that you get used to everything. (I 12)
Situations where ORNs could not do the job due to having witnessed so many sad fates were also described. One informant thought it was very tough to work during a certain period when many young people had died by suicide, and was emotionally drained.
Several have quit, but I’m not sure why, only that one of them participated in many organ procurements with child donors. (I 10)
The work was also described as rewarding. These informants realized the value in the whole, felt privileged and very proud to be a part of the donor team.
Safeguarding the donor's dignity and the feelings concerning the donor did not change over time. According to the informants, taking care of the donor's dignity throughout the entire organ procurement process was of the utmost importance. It was emphasized that the entire treatment should take place ‘in deep reverence’, with the use of calm movements. The ORNs pointed it out if there was a thoughtless and ‘loose’ atmosphere in the operating room. Participation in the postmortem care of the donor was described as the ‘most complete task performed’, and an opportunity to show respect for the donors and their relatives. One of the informants expressed the need for an extra ten minutes at the ‘last care’, because quick care may seem unworthy. Concern about professionals’ attitudes regarding respect for the donor was described, as the ORNs would not be perceived as ‘sloppy, disrespectful and unprofessional’. In addition, the informants emphasized the importance of appearing professional towards colleagues in the donor hospitals. To show respect by cleaning up after oneself when leaving, was suggested. They had a bad conscience if they left the donor hospital hastily.
Importance of colleagues
Emotional preparation and follow-up of new employees was in demand. The unit climate was by some described as open, even though there were not many open conversations about organ procurement.
We do not talk much in advance. It's probably more if you have some feelings afterwards. There is a lot of openness to be able to say what you feel. (I 12)
Others were more concerned about their colleagues. The significance of taking care of new employees, and establishing a relationship of trust with them, was highlighted.
When you are a new employee, you are a freshman and insecure and there are a lot of emotions associated with it. I think it is difficult for them to take the first initiative. It is us who are established who must open up for conversation. (I 1)
There was a great need for a systematic arrangement regarding conversations and the follow-up of new employees, the informants pointed out. A routine was suggested where the ORNs have an assigned person they can talk to about feelings related to the organ procurement. A kind of ‘buddy’ who has it as a defined task in the unit.
It was claimed that new employees should have a soft start, and first observe one organ procurement. Also, in addition to receiving good training to acquire satisfactory competence, the ORNs also highlighted the need for emotional preparations.
It does not help to get a binder, 10 pages of procedures, if you do not take the emotional part with you. (I 7)
It was described as important to explain to new employees that it is completely normal to have unexpected emotional reactions, that ‘everyone gets it’, and that they can come and talk about it. Emotional preparation should be individually tailored, because some are more sensitive than others, the informants emphasized.
Development of an open unit culture was expressed as desirable. In some units there had always been little talk about feelings and experiences, since the focus was on the technical aspects. The lack of openness worried these informants.
This is the first time that someone has asked me about my feelings about organ procurement. We are very good at the practical, but no one really takes hold of the emotional, and what touches us. (I 8)
Individual arrangements related to regular employee interviews were suggested. However, the majority of the ORNs pointed out the importance of a structured and common arrangement related to experiences around organ procurement. This was justified by the fact that an open culture is useful for finding out whether colleagues have the same feelings.
A desire to standardize conversations after the organ procurement, in the form of reflection groups or debriefings, was expressed. One informant suggested an open reflection session once a month, for ORNs to talk about what affects them. Open conversations with a priest or psychologist were also mentioned as examples of discussion groups, while another stated that a ‘time-out’ should be introduced before the organ procurement. Talking to new employees about their own feelings related to organ procurement was in general perceived as a measure to create transparency. Nevertheless, the great need for openness about the experiences related to participation in the organ procurement was limited to those involved, because of the duty of confidentiality.
Discussion
ORNs in the current study experienced an emotional impact of organ procurement that, according to Smith et al., can trigger traumatic experiences in ORNs. 5 Organ procurement situations related to young people and child donors are emphasized in the descriptions in this study. Tragic accidents and suicide among young people are situations that arouse particularly strong emotions, as other studies also confirm.1,3
The first organ procurement ORNs participated in is described as special and incomparable. Others have also described it as unforgettable, full of excitement and confusion. 8 The special, ‘weird’ situation gives an unpleasant feeling that is previously unknown to most ORNs. 9 At this point, ORNs are mourning the death, Regehr et al. 10 claim. However, this study shows that the ORNs do not associate this silence with death, because the moment when the respirator is switched off is not the time of death. They are aware that the donor is already dead on arrival, but think it is strange to see that the anesthesia staff leaves the operating room during an ongoing operation. It is described that ORNs doubt that the donor is dead at all, 2 and when death actually occurs. 12 In this study, the ORNs claim that they are in no doubt about this, due to a good understanding and knowledge of criteria for the diagnosis of death. Full understanding of the phenomenon of brain death is important, in order to understand that the donor is dead on arrival. 1
Even experienced ORNs respond to the merciless and cruel nature of the process. 8 The donor's body is perceived as an empty shell, which makes a strong impression. 1 The ORNs in this study describe similar thoughts, and add that if the donor's body has major physical injuries the impression is even stronger. Wolf 13 also found that ORNs feel exhausted, drained and repulsed by caring for the donor postmortem, especially when the body has been exposed to major physical trauma. 3
Regardless of the ORNs’ years of experience, disputes between morality and work responsibilities are particularly related to young donors and tragic events, Carter-Gentry and McCurren found. 1 ORNs may not be morally ready to accept the donor's death. 3 In addition, the ORNs in the current study described a strong compassion for the donor and the donor's family, which other studies also confirm.1,3 The findings show that the ORNs have conflicting feelings related to the organ procurement, as other research also confirms.1,2,8 Despite the feelings of sadness, ORNs describe, both in this and other studies, that they are happy on behalf of the recipients. 1
Most ORNs in this study report persistent and recurrent thoughts. This corresponds with findings by Perrin et al. 12 In the long run, suppressing emotions and not talking about them may cause psychological effects. Nightmares and flashbacks, with intrusive thoughts and dreams of donors may occur long after the organ procurement, sometimes even for months, according to Smith et al. 2 However, some ORNs state that they do not think about work when they go home, and have no persistent or recurring thoughts. The importance of separating work and private life seems to be important, as argued by Wang and Lin. 8
In the current study, the ORNs describe that experiences at the organ procurement lead to changes in personality traits. Other studies also describe that ORNs reflect on their own mortality.2,12 A confrontation with one's own mortality involves acknowledging the unpredictability of life and the presence of death. The ORNs point out that donors appear to be alive while they are dead. There is a subtle difference in the experience of death in the context of organ procurement, since the body of the donor looks alive. 12 With ORNs feeling the fear that something like this will happen to them or their loved ones, and they identify themselves, family members and friends with donors. The feelings around lost life and meaninglessness form the basis for that identification, 9 and can be based on personal life experiences that can be related to specific donors. 1
The ORNs claim that over time they have different perceptions of organ procurement situations, due to both a deeper insight and a more overall understanding of the context. Negative feelings towards organ donation due to ORNs’ experiences with organ procurement, are described. These perceptions can be transferred to others.3,10 However, Sque et al. 24 and Carter-Gentry and McCurren 1 found that nurses’ participation in different aspects of organ donation and transplantation was associated with positive attitudes. It is important to increase knowledge, develop attitudes and a positive, common culture related to organ donation, and ORNs seem to play an important role in increasing the number of organ donations,25,26 by ‘planting a seed’, providing knowledge, support and discussing with relatives. 27 ORNs in this and other studies also seem to be very committed to organ donation in encounters with other people. 1
The ORNs describe that distancing is a form of dealing with emotions, including before, during and after the organ procurement. According to Carter-Gentry and McCurren, ORNs seem to act ‘robotically’, and are detached from the incident and their own sensitivity. 1 The context of procurement surgery evokes raw, primitive and potentially overwhelming influences. 12 At the same time, ORNs defend themselves against distress by focusing on coping with the issues that arise during the procedure. The ORNs in this study claim that emotions and impressions do not affect their performance during the procedure. They push the emotions aside when they are overwhelmed by them. Others have described that ORNs hide their feelings ‘behind the mask’. 2 They become ‘numb’, and seemingly insensitive. 1 Balancing between emotional closeness and professional distance denotes the nurse's moral practice that characterizes professionalism, according to Martinsen. 28 Professionalism is obviously important for the ORNs, and distancing may seem to facilitate the individual grief of ORNs and protects them from disturbing emotions. 1 This may imply, as previously mentioned, the importance of separating work and private life, as confirmed by Wang and Lin. 8
Perrin et al. 12 also found that perioperative nurses do not want to know much about the donor and the donor's family, probably due to the same reasons. This could also mean that the ORNs accept an organ procurement as one of several sad stories. This is only one more case, a procedure that must be performed, as Carter-Gentry and McCurren claim. 1
Without professional help over time, the ORNs developed their own coping strategies to deal with the above-mentioned strong emotions. They find their own unique coping strategies to improve their psychological well-being.1,3 The ORNs in this study highlight conversations with colleagues, family members and friends as the most commonly used coping strategies, which Lim et al. also confirm. 29 Some also seek professional support. 2 By expressing emotions, one's own thoughts are organized, and a new meaning is reconstructed, as well as the sharing of experiences after the organ procurement releasing stress. 8 All ORNs deal with emotions and stress in their own way. 1 They relieve or ‘ventilate’ the pressure first and foremost with their shift partners, which is not always feasible, due to several hours of night work and haste. This is also due to a low number of staff, according to Regehr et al. 10 ORNs have little time to emotionally prepare for the care of the next patient. 12 Coping strategies related to physical activities are also used by the ORNs in the current study. Leisure activities are representative as a self-mastery strategy. 8 Moreover, the ORNs can also perform soothing coping strategies. As described in Perrin et al. ORNs keep their thoughts to themselves, by performing solitary activities such as long walking tours or writing poems. 12 Some also use spiritual practice such as meditation as a coping strategy.1,2,8 Cognitive strategies involve both ‘clinging to the feeling of happiness’ and avoiding negative feelings associated with transplants. 8 To focus on the positive, which is to save the lives of others, seems to be a beneficial coping strategy.2,10 During the organ procurement, the ORNs in this study think of the recipients. Thus, they work with the philosophical understanding that from the death of each donor, hope arises for an extended life for the recipients, Smith et al. explain, 6 and this can give them the courage to continue with the job.
Adequate coping strategies, as well as social support, improve the ORNs’ experiences and feelings during organ procurement, Gao et al. 3 found. Finding the meaning and value of one's own contribution to realizing donors’ and relatives’ last desire to save the lives of others strengthens the positive experiences, and reduces the emotional stress. 3 In this study, the ORNs refer to it as ‘finding meaning in the meaningless’. According to Smith et al. 2 the basic social psychological process of finding meaning involves three stages. First, to find meaning in the organ procurement by being the donor's advocate and maintaining focus during the procedure. Second, to preserve themselves with the help of their internal coping strategies, but also external ones. Lastly, to ‘come in handy’ as a result of adaptation over time, due to experiences, reflections, knowledge and the ethical aspects of the organ procurement. In the current study, similar stages were described, as the ORNs point out that it is essential to push away overwhelming emotions by keeping the focus on the field. They use knowledge, and reflect on experiences and thoughts related to the organ procurement. Further, they point out the moral aspect by highlighting the importance of safeguarding the donor's dignity, and they become more positive about becoming donors themselves.
The conception of professional development was linked to reflections on the importance of the work they do and the feeling of being privileged. The trend is that a professional responsibility for excellent performance is increasing, which gives a sense of privilege. 2 Mentally and physically demanding work at the organ procurement can lead to burnout, and ORNs not being able to do their jobs. Emotionally charged, fast-paced surgery can last for several hours, and can lead to ORNs being both physically and emotionally drained.3,10 According to Smith et al. exposure to organ procurement is identified as problematic, with there being a tendency for limited opportunities for ORNs to recover from these experiences. 6 ORNs strive to maintain an emotional balance in order to continue working with organ procurement. 12 Some choose not to participate in organ procurement after their first experience. 10 On the other hand, seniority is no guarantee that you will be able to meet the work requirements without being overwhelmed or overloaded. 12 To help facilitate the process, the need for feedback on a successful transplantation is expressed as a confirmation of good work, and an incentive to continue. 10
Safeguarding the donor's dignity throughout the entire organ procurement process is of the greatest importance to the ORNs in the current study. The message to the health personnel involved in organ procurement may be: ‘First, respect and protect the dying person’. 30 When it comes to this, the ORNs describe themselves as being strict. Although they rarely perceive inappropriate moments, they are not afraid to speak out during the organ procurement if such situations occur. This can be seen as an expression of their professional integrity, or the obligation to follow the ethical guidelines on matters that affect their own work situation or the protection of the patient. 31
The ORNs point out the significance of participating in the postmortem care of the donor. In other studies, ORNs also recognize the importance of performing the last aspect of nursing to the donor, by washing and cleansing the body to remove signs of suffering and to show respect to the donor.3,10 Taking little time during postmortem care for the donor is perceived as a lack of respect. 2 These are concrete actions expressing the ORNs anchoring in the nursing values and professional ethical guidelines. Both at the donor's arrival and at the farewell, it is described that ORNs hold a kind of inner dialogue with the donor built on reverence and gratitude, a form of prayer of thanksgiving to the deceased.2,10
The importance of colleagues and a mutual understanding in the donor team is highlighted, as by Perrin et al. 12 The newly hired ORNs describe the unit culture as open, but both inexperienced and experienced nurses think that there is generally little talk about emotions in the unit, as described by others.27,32 Some feel vulnerable and isolated and are afraid of being judged by their work colleagues if they do not cope with participation in the organ procurement. One ORN suggests that openness might lead to a breach of the duty of confidentiality. A closed unit culture and a lack of collegial and professional support could lead to strain and situations in which ORNs seek support from their family and colleagues outside their own unit. 2 A closed unit culture can also include judgmental attitudes, social isolation and the stigmatization of colleagues who could need extra support. 6 The burdens are aggravated and ingrained, due to stigma and the culture of not showing emotion. 2 An open unit culture involves open communication and a mutual communication of concerns, which creates a supportive and caring work environment, hence ensuring the well-being of staff. 2 However, openness can reveal matters of significance to the staff and leaders, as well as the quality and efficiency of their work performance. The need for an organized support in the unit may emerge, a more systematic facilitated support in the unit as well as educational input may be beneficial, Meyer et al. suggest. 32
The need for emotional preparation, and the follow-up of new employees for organ procurement, is emphasized. Experienced colleagues express responsibility for each other and the less experienced ORNs, by leading with a supportive and caring approach throughout the procedure and giving support when needed. 12 The individual need for support should be identified, as pressure on the job is handled differently. 8
If ORNs are not eager to support each other, 2 and the operating unit lacks both internal and external professional support, 6 the requirement for a continuous, systematic support to ensure psychological well-being is justified. Both inexperienced and experienced nurses would benefit from this, but in particular newly qualified ORNs. 3 This should reduce the negative impact of the organ procurement, and help increase nurses’ resilience and mastery of this emotionally challenging procedure. 6
An extended break after participation in organ procurement provides room for self-care and well-being, not least enough time to cope with stress and deal with one's own feelings and thoughts. 6 The ORNs themselves propose the introduction of either an individual or organized and systematized form of support, such as discussion groups and debriefings. There is a need for mutual support and open communication, counseling and debriefing among members of the surgical team and management. 6 Timely debriefing sessions and adequate staffing levels are also considered as support for ORNs.2,12 Debriefings should be held immediately, or as soon as possible after the incident. When debriefing and counseling are not offered, or are offered with an unrealistic time frame (a two to three-week wait), ORNs feel overworked and burned out, with little ability to take care of their physical and emotional well-being. 6
In this study, the ORNs have expressed a great need for individual support, related to both regular appraisal interviews with leader, and systematic support related to discussion groups and debriefing, preferably immediately after the organ procurement. The need for support and the safeguarding of staff well-being in general must be recognized. To help promote coping, leaders should provide adequate support to employees by building an open culture, emphasizing emotional and physical well-being, and encouraging them to report on their own and question the concerns of others. 6 According to Smith et al., debriefing is a form of psychological first aid. Probably, some ORNs also need professional support, such as counseling and debriefing, either from professional counselors or people who are formally responsible for it, Smith et al. suggest. 6
Limitations
The study's credibility is based on honesty and transparency in the descriptions of all steps in the research process. The results of the study are presented and substantiated with direct quotations from the informants to strengthen authenticity, transparency and credibility.
As researcher and ORN with several years of experience from the field, an attempt was made to set aside one's own preunderstandings. However, the advantage of the preunderstanding was knowledge of the subject terminology and the ‘internal language’, which probably contributed to a faster establishment of trust between interviewer and informants, as well as a deeper understanding of what the informants conveyed.
All the informants were recruited from the same department, but from two different units. This could be considered a weakness. However, this could not be avoided, since the department in question is the only national center for organ transplants in Norway, with different underlying units and sections.
Clarification and systematics in all phases are sought.21,33 All the interviews have been used, and the data material is considered abundant and saturated, which is considered an important dimension of transferability. 14
Conclusions
Organ procurement affects ORNs emotionally, personally and professionally. The strong feelings and impressions due to the organ procurement are handled using emotional distance and various individual coping strategies. The organ procurement characterizes and changes the ORNs’ personality traits over time, which can lead to overload and burnout. The ORNs experience professional strength and pride, with the safeguarding of donor dignity described as the most important aspect of the organ procurement. The ORNs express a need for a more open unit culture in relation to feelings and experiences at the organ procurement, to generate both emotional, personal and professional support. The leaders’ facilitation of this through individual appraisal interviews with a leader, regular discussion groups and debriefings are described as especially important.
The study may provide a deeper understanding of how participating in the organ procurement process affects those who are involved. Management may gain more insight into how the unit staff is affected, and facilitate both emotional, personal and professional support within the unit. The findings also indicate that experienced ORNs may contribute to promoting a positive attitude towards becoming a donor.
Footnotes
Acknowledgements
Conflict of interests
The authors declare that there is no conflict of interest.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Stiftelsen Organdonasjon (The Organ Donation Foundation, Norway).