Commentary on Regehr C, Kjerulf M, Popova S &amp; Baker A (2004) Trauma and tribulation: the experiences and attitudes of operating room nurses working with organ donors. <i>Journal of Clinical Nursing</i> 13, 430–437

This paper examines the experience and attitudes of operating room (OR) nurses towards organ donation. It is basically a sound piece of qualitative research with well thought out research questions, method and analysis. The authors have an uncomplicated writing style that makes the piece easy and interesting to read. They found that the ‘process of organ donation is highly stressful and raises many concerns for OR nurses’. This fact is well established by the work of others such as Cantwell and Clifford (2000), Clay and Crookes (1996a, b), Lloyd-Jones (1996) and Wolf (1990). From their findings, they devise a simple thematic model that breaks these stresses into three subgroups: organizational aspects, responsibilities towards the donor and their family and exposure to death and trauma. The coping methods employed by the nurses are also explored very well. In the findings, emphasis is placed on the negative aspects that emerge. However, nine out of the 14 participating nurses would still be willing to become donors themselves (some with provisos), which implies a positive attitude to donation. I would have been interested to know if there was any significance in the spread of the non-donators through levels of experience and number of donations seen. The authors’ assertion is that the experiences of the OR nurses lead to the formation of negative attitudes, which they measure by an unwillingness to donate. However, they do not make it clear whether five out of 14 is a notably large number of non-donators, or if it is comparable with Canada's general public figures. I felt that the fact of those nine would still donate, despite their negative experiences, is of equal interest, and it may have valuable to explore this detail further. A discussion about the unique culture of the OR department may also have been beneficial, because it provides a variable that could influence the findings. The OR is a department in which death is rare. Patients go there to have a lifesaving operation; any death is therefore seen as a failure. Bothamley (1999:528) states, ‘for the theatre nurse observing death is an unusual occurrence’. Hence, the OR nurses experience of death is very different from that of the experience of other nurses. Although the paper found that the nurses’ experience of the patient's death as an upsetting one, it is not clear (at least to me) that it is because of the organ donation process, or the fact that they are witnessing a death. In the conclusion, the authors move from their results, that OR nurses are distressed by the organ donation process, to the claim that this may reduce the willingness of others to approach families about organ donation. This jump is dependent upon three distinct assertions of which I feel there a several questionable elements: ‘OR nurse find the organ donation process stressful and upsetting’ leading to ‘OR nurses have a negative attitude towards organ donation’; ‘OR nurses have a negative attitude towards organ donation’ leading to ‘they may transmit this attitude to others’; ‘They transmit a negative attitude to others’ leading to ‘potential reduction in staff's willingness to approach families’. An attitude can be defined as an enduring belief that influences behaviour. There are three components to attitude formation – affective (the emotional reaction to the idea), cognitive (the thoughts and beliefs about the idea) and behaviours (the actions). I would argue that the affective component certainly occurs; the nurses are emotionally upset by what they see. Does this result in a change in thinking? The answer may rest with the final aspect: is there a change in behaviour? Given that nine out of the 14 nurses would still donate their organs, I feel that there is little evidence of a widespread behavioural change, and therefore by definition, attitudinal change. It may have been useful if the authors had mapped out the pathway between experience and attitude, to support their claim. Secondly who are they referring to when they discuss these ‘others'? I will assume that they mean intensive care staff, and how are attitudes transmitted? Is it plausible that OR nurses can transmit a negative attitude about organ donation to intensive care staff? Personally, I have found the interaction between these two departments is minimal. Nor does this theory allow for the intensive care staff to form their own opinions from their personal experiences when caring for the patients and their families. I agree that OR nurses are often the overlooked members of the organ donation process, and work such as this, that gives consideration to their needs, is very important. From their findings, the authors are able to make suggestions that are realistic, cost effective and may make a genuine difference to the OR nurses experience. However, I feel that it is tenuous to assert that their findings would impact upon the way in which families are approached. One suggestion for further study would be to direct this work at anaesthetists, these are the people who are most likely to make the organ donation request, but they also conduct brain stem death tests and stay with the patient in theatre, making them the only members of the team who regularly experience all aspects of the donation process in this way. I found this to be a good and well-written piece of research, which supports the existing knowledge base, but does not necessarily expand on it, and I feel that it may have most relevance at a local level.

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