Experiential Learning Not Enough for Organ Procurement Surgery: Implications for Perioperative Nursing Education

Abstract

Context—

Perioperative nurses play a vital role in assisting in surgical procedures for multiorgan procurement, receiving little education apart from on-the-job experiential learning when they are asked to participate in these procedures.

Objectives—

Within an Australian context and as part of a larger study, this article describes issues that hindered perioperative nurses' participatory experiences as a result of lacking education, previous exposure, and preparation for assisting in surgical procedures for organ procurement.

Design—

The grounded theory method was used to develop a substantive theory of perioperative nurses' experiences of participating in surgical procedures for multiorgan procurement.

Participants—

Thirty-five perioperative nurses who had experience in surgical procedures for organ procurement from regional, rural, and metropolitan hospitals of 2 Australian states, New South Wales and Western Australia, participated in the research.

Results—

Levels of knowledge and experience emerged from the data as an influencing condition and was reported to affect the perioperative nurses' participatory experiences when assisting in procurement surgical procedures. Six components of levels of knowledge and experience were identified and are described.

Conclusion—

The findings from this study provide a unique contribution to the existing literature by providing an in-depth understanding of the educational needs of perioperative nurses in order to assist successfully in multiorgan procurement procedures. These findings could guide further research with implications for clinical initiatives or education programs specifically targeting the perioperative nursing profession both locally and internationally.

The need to acquire organs for transplant and a growing public awareness of the benefits of organ donation have led to a gradual increase in organ procurement procedures conducted internationally and more recently within Australian operating rooms.^1,2 Although research in the past 2 decades has been focused on boosting organ donation rates and on ways to enhance organ preservation rates, evidence of how health professionals involved in these surgical procedures are trained and educated about aspects of the donation process and the actual surgical procedure for procurement is still sparse.^2–4 As the demand for organ supply and procurement procedures continues, educating health professionals is key to the overall success of these procedures.

Numerous international studies have acknowledged the need for more specialized education (theoretical and practice-based) for health professionals closely involved in the organ procurement process and surgical procedures.^3,5–8 Education and training of health professionals closely involved in organ donation and transplant continues to be a problem not only in Australia but internationally, with reports of insufficient or no education or preparation provided to health professionals.^4,8–11 Several authors have presented research evidence, both quantitative and qualitative, that explores health professionals' levels of education and knowledge related to the organ donation and procurement process. The results indicate that health care professionals are often uninformed or lack knowledge about aspects of the organ donation process, the procurement surgical procedure, or diagnosis of brain death.^2,5,7–14 Collectively, these research studies have identified the need for increased knowledge, clinical education, and training in order to ensure that health professionals are knowledgeable about all aspects of the organ donation processes, thereby enhancing positive attitudes toward these procedures.^5,7,9,15 Several authors have documented the need for all health professionals in the process of organ donation and transplant to continue engaging in continuing education and to update their knowledge and clinical skill base related to these demanding and emotionally challenging procedures.^3–5,7,8

From a perioperative nursing context, it is acknowledged worldwide that perioperative nurses assist in surgical procedures for organ procurement and transplant, usually acquiring skills to participate through informal clinical mentorship and experiential learning when these specialized procedures are required.^2,16–18 Nonetheless, published reports confirm that little research or anecdotal evidence is available about how perioperative nurses are trained to undertake these surgical procedures, their levels of knowledge of these procedures, and the process of organ donation.^2,4 For perioperative nurses, acquisition of knowledge and education about surgical procedures for procurement largely occurs within the clinical environment of the operating room.^2,19 Research studies globally have provided evidence of the traumatic experiences of perioperative nurses involved in these procedures and their abilities to cope clinically.^{2,16,18,20–24} Other authors have written articles highlighting what perioperative nurses should expect when participating during the procedure, the instrumentation requirements in order to conduct the surgical procedure,^25–27 and personal accounts of nurses' participation.²⁸

Recent Australian research² specific to the perioperative specialty identified that perioperative nurses largely undertook these procedures via experiential learning throughout their careers, with no formal training or knowledge about the organ donation process and surgical procedure, which markedly influenced their overall experiences. This research has also validated that no formal or consistent education approach to education is used for perioperative nurses from one health care facility to another and from one state to another across Australia, other than continued experiential learning.^2,4,19 One can ask, Is this enough preparation for such an integral and important role? In this article, we present the findings from a larger study² of the impact of lacking education and knowledge on perioperative nurses and the overall effects on their performance and abilities to feel comfortable on a professional and personal level.

Methods

Study Design

The original grounded theory method developed by Glaser and Strauss was used. This method is based on the symbolic interactionist school of thought and has a purpose of studying social and psychological processes and interactions, generating an explanatory theory of human behavior.^29,30 This research method was chosen for its qualitative, inductive research method, used for theory development in an area where little is understood of a phenomenon. The method is grounded in data that have been systematically gathered and analyzed by using the constant comparative method.^29,30 Further, the method allows researchers to identify a main concern of the participants, their thoughts, perceptions, and behaviors as well as their actions used to resolve their concerns.^29,30 Hence grounded theory was chosen for this study for its potential to reveal new perspectives on perioperative nurses' experiences of participating in multiorgan procurement surgery as a phenomenon not currently explored within the scientific literature.

Research Sample, Setting, and Recruitment

The research study was advertised via research flyers where 35 perioperative nurses (33 women and 2 men) were recruited to the study from 2 Australian states: New South Wales (n = 12) and Western Australia (n = 23), from a broad cross-section of clinical areas in metropolitan, rural, and regional areas. Participants were required to meet the initial inclusion criteria of previous participation in at least 1 multiorgan procurement surgical procedure and were recruited on the basis of a purposive and theoretical sampling method. An information sheet was provided to each participant outlining the purpose of the study with informed consent obtained before each interview. Participants in the study were predominantly experienced perioperative nurses with professional experience ranging from 3 to 39 years. Participants' ages ranged from 27 to 64 years, with most participants 40 to 50 years of age.

Ethical Approvals

In order to conduct the study, ethical approval was initially obtained from Curtin University's Human Research Ethics Committee HR 152/2008 and the participating health services Human Research Ethics Committees within Western Australia: Royal Perth Hospital EC 2009/029 and Sir Charles Gairdner Hospital 2009–082. In New South Wales, recruitment of participants took place after the study was advertised via a flyer that enabled participants to contact the researcher independent of their health services. Formal written consent was obtained from all participants, and confidentiality was ensured by deidentifying each participant and assigning them a number. The researcher ensured that participants were protected from any undue harm or distress related to recounting their experiences by disclosure of a counseling support should they need this service. During the study, no participants sought or required this service.

Data Collection and Analysis

Data were collected from 6 sources: participants' demographics, semistructured interviews, the use of memos, reflective journaling, diagrams and conceptual models, and the use of existing literature and documents pertinent to the subject area. The interviews were semistructured and open-ended in order to obtain rich experiential data, with interviews ranging from 30 minutes to 130 minutes long (mean, 60 minutes). Interviews were transcribed verbatim and, together with the researcher's memoing, were analyzed and organized into codes and categories.²⁹ These codes and categories were further compared and contrasted for similarities and differences with other participants' interviews. Theoretical sampling, the process of where to go next in order to compare data,^29,30 refined the open-ended questions as these became more focused, leading to saturation of the data when no new information was being supplied by the participants.^29,30

Participant interviews were allocated a numerical code (eg, participant 13 [P13]), and this code was assigned to each participant's transcribed interviews code or category responses. Throughout participants' quotes, three dots “…” denotes a word or a few words omitted from a quote. Similarly four dots “….” were used when a sentence or a few sentences were omitted from a quote. Brackets [ ] were used when the researcher added additional information for clarity. Last, the asterisk symbol was used to deidentify and omit names of organizations, health facilities, or locations in order to preserve confidentiality.

Results

Using the grounded theory method, the substantive theory “finding meaning to overcome hiding behind a mask” was identified from the data.² The process of identifying the main categories and a schematic diagram of the theory have been published previously in whole.^2,4 Within this substantive theory, levels of knowledge and experience was identified as an influencing condition of the study participant's experiences of both hiding behind a mask (the basic social psychological problem) and their ability to be finding meaning (the basic social psychological process) as a result of their participation in surgical procedures for multiorgan procurement (see Figure). Four components of levels of knowledge and experience were identified as influencing the problem of hiding behind a mask: (1) participants' prior experience and exposure to procurement, (2) lacking professional development opportunities, (3) lacking education resources, and (4) limited mentoring opportunities. Two components of levels of knowledge were identified as influencing the process of participants finding meaning: (1) having prior knowledge and experience with procurement procedures and (2) sharing knowledge through team mentoring.

Figure

Levels of knowledge and experience related to the substantive theory of finding meaning to overcome hiding behind a mask. Based on information from Smith² and Smith et al.⁴

To complement the qualitative data, demographic data revealed the limited sources of education provided to the participants in order to undertake their roles in these surgical procedures. It was noted that 26 of the 35 participants had no formal education provided to them before their participation, 6 participants had some form of education via on-the-job training, 2 participants obtained education via a hospital in-service training session, and 1 participant was provided information about organ donation at a perioperative course overview.

Participants' Prior Experience and Exposure to Procurement Surgery

Participants' prior experience and exposure to procurement surgery was reported as a major issue in their ability to manage these emergency procedures when they came to the operating room. Several participants reported not having had any preparation through prior exposure to procurement surgery at the time of their first participation: “I was overwhelmed, like ‘my god, what am I doing?’” (P16). Many nurses viewed these procedures as difficult to master for both experienced nurses and inexperienced or junior perioperative nursing staff. One nurse emphasized this point, stating: “I think it would be very difficult for nurses with limited [operating room] experience to cope with; they would probably need a greater level of support and preparation to be involved in those cases” (P13). Hence the majority of participants expressed the view that some years of postregistration experience within the perioperative nursing setting was essential before undertaking such procedures in order to meet the surgical demands and expectations of local or visiting procurement surgical teams.

Several participants reported that not all experienced perioperative nurses had exposure to organ procurement procedures, especially if they had previously worked in smaller or private hospital facilities that were not undertaking such procedures. Although these nurses may have had several years of perioperative nursing experience, these nurses voiced similar concerns: “After a long career in [operating room], it had a profound effect on me … it was a tough experience for me” (P26). Other participants explained that regular exposure to these procedures was required to reinforce their knowledge and experience of the procedure, as it took time to develop their clinical knowledge and skills, with a major barrier being the length of time between exposure to these procedures in order to obtain current and up-to-date professional experiences. One nurse explained: “We don't do enough [multiorgan procurement surgical procedures]” (P16). Some hospital facilities undertook more of these procedures than others, which provided limited opportunities to perioperative staff: “We don't do many here at *[name of hospital], so when we do have them everybody is not really quite sure what to do” (P31).

An important insight expressed by several of the participants was the fact that regardless of their prior levels of perioperative nursing experience and number of times exposed to these surgical procedures, they continued to report difficulties mastering these procedures as each donor's procedure was described as uniquely challenging with different experiences and issues always coming up within the clinical environment. One nurse described this as follows: “I think that every case is different in that you are taking different organs [from each donor]” (P12). Similarly, this same viewpoint was highlighted by another participant who commented:

Everything [every procedure] is very different. We did [a multiorgan procurement surgical procedure on] this older man, he had a stroke of some sort … it was just a different situation compared to the young boy [donor], compared to the mother [donor] who was going to have a cardiac death [DCD] retrieval so [I experienced] 3 very different situations [and surgical procedures]. (P27)

Lacking Professional Development Opportunities

Participants within this study articulated that they were lacking professional development opportunities provided by their health care facilities, including no formal education programs to assist perioperative nurses to gain specialist knowledge, understanding, and skills in assisting with these surgical procedures. This problem also entailed no formal opportunities for professional career development and continued learning within this expanding and specialized area. One participant emphasized this point by her comment:

Well, I hadn't had any preparation for it [assisting in procurement procedure] at all and it's not really talked about or anything and no sort of in-services were given in the actual [operating room in] my experience, and I'm not sure if there has been anything formally done since. (P24)

Within the clinical environments of various health care facilities, this study uncovered the widely held assumption that perioperative nurses did not require specialized education, training, or professional development in this area, as it was perceived that if a perioperative nurse were capable of undertaking a basic laparotomy, then they could successfully undertake organ procurement procedures. This view was validated by 1 of the participants as: “It was more I have the skills to do a laparotomy therefore I have the skills to do [an] organ retrieval because it was just another level of the [surgical] process. It's no different from doing an anterior resection” (P8). Participants in the study who held staff development or educator positions also substantiated this by: “No we don't do formal teaching [for procurement]” (P2).

Many participants emphasized the importance of their role to the overall outcomes of the procurement surgical procedure and believed that formal education was the key:

I think the [perioperative] nursing role needs to be looked at in so far as recognizing that it's important in the way of having teams that can do it [the procurement procedure] and more education [for perioperative nursing staff] instead of it is [being viewed as] just another scrub or another scouting [circulating] role because it's much bigger than that. (P18)

Meanwhile, another participant summed up the importance and necessity for more clinical education in order to reduce and alleviate negative initial experiences when participating in these procedures:

I think education is so important. If I'd had some [procurement] education prior to doing my first procurement surgery, I would have probably found I felt a lot better about it afterwards because at least … it was like okay so this is what it involves, I had no idea before that, no idea until I got a phone call in the middle of the night and had to come in and do it [assist in a procurement procedure] … we need more education. (P19)

Another area where participants felt that they lacked education and preparation was how to care for and communicate with the donor patient's grieving family within the operating room environment. Many nurses conceded that they lacked experience in how much information to share, from a surgical context, about the nature of the procedure with families: “There are a lot of things that happen when dealing with [bereaved] families … outside the [operating room] that we have no understanding of” (P12). In addition, nurses acknowledged that they lacked confidence in managing the donor's bereaved family within the operating room, what to say and what not to say: “I have absolutely no idea about how to deal with relatives, how they are approached about organ donation, and how much [information] they are told about what goes on” (P4).

Lacking Education Resources

Lacking education resources was identified as another component of levels of knowledge and experience. Organ procurement resources, educational materials, or courses were reported by participants as limited and difficult to obtain within all health care settings across the metropolitan, regional, and rural areas. Although it was perceived that perioperative nurses working in the larger metropolitan areas would have better access to education and greater opportunities for experiential exposure to procurement procedures along with training opportunities, according to participants, this was not so. One participant made the following comment:

Considering I've worked and spent a lot of time at 2 of this state's major trauma hospitals, I've not once had any education on organ procurement apart from your little talk [providing a background to the study] when you came, that is the first time it has come up. I had to seek out all of my own information … I have sought out [information] myself, no there has been no discussions beforehand [prior to the procedure], there [are] no discussions after and there is no in-house education, which is a bit of a shame. (P6)

The participants from the regional and rural areas also had to contend with other factors such as a lack of clinical exposure to a range of more complex or specialized surgical procedures often not undertaken within their operating rooms. An example was the specialty of cardiothoracic surgery, where several nurses had not had previous experience and exposure to the techniques of opening the chest cavity in order to expose the heart and lungs: “When I've assisted in the retrieval, more like the cardiac [and] thoracic part[s] of the procedure, that was new to me” (P12).

Education resources related to organ procurement for perioperative nurses were reported as predominantly hospital in-service training sessions run by organ donor coordinators on the peripheral aspects of organ donation, which did not cover the procurement surgical procedure itself. Only a few participants reported attending such an in-service program: “No, just attended [an] in-service” (P32). Another younger participant spoke of attending an in-service session organized through a postgraduate course specializing in the perioperative nursing field: “No, just an in-service during the peri-op course” (P21). Several of these participants stated that although these in-service sessions provided some background information on organ donation itself, the sessions did little to assist them in conducting their intraoperative roles: “We only had a lady come recently; [she] came and gave us an in-service but that was just about saying that it [organ donation] was a good thing” (P25). This view was also reported by another perioperative nurse:

We have had one of the donor coordinators come to us … and give us a talk about their role, our role in [procurement] and talking about organ donation and the criteria for … being able to donate organs and tissue and also … what's involved in their [the donor coordinators] role when they're not actually … involved in organ procurement … as well as … their promotional type work. (P15)

Several participants discussed the lack of in-depth information available as a concern for the perioperative specialty, as any education provided was not specifically targeted to meet their specialty needs. One nurse, who was affected by her participation experiences in procurement surgery, spoke of attending such an in-service training session where an organ donor coordinator in her view had glossed over the operative procedure and the psychosocial aspects and effects of participation for perioperative nurses:

I went to, it felt like a re-education class with the donor coordinators, where they were saying to the nurses, giving them a pep talk because they heard that negativity from the nurses was not good or they needed more positivity from nurses to encourage people to think about donation. It was just the … same white-washing propaganda this woman [the organ donor coordinator] said “You know some nurses actually think that it's a mutilating surgery and it's not at all!” and I just, I gagged and I said “Excuse me, I have spent my entire life in theatre and I've seen everything opened up and pummelled and sutured; what have you seen? … I've never been more traumatized by such a mutilating experience.” (P26)

As a result of lacking education resources, many participants reported seeking their own learning opportunities by resorting to reading policy or procedure manuals about organ donation and procurement surgery within their department in order to ensure they were assisting in these procedures correctly: “I also read [the] hospital policy, reading [about] cardiac death and brain death … [to] make sure we do the right things [when assisting in the procedure]” (P32). Another nurse explained referring to her hospital departmental operating room manual when a procedure was imminent:

I was checking the procedure manual because I had never done any [procurement surgical procedures] before so I just wanted to make sure I was a little prepared … I had none, [no formal education] I've only read the manual … well, I read [up] … about cardiac death (DCD) because I didn't even realize you could do that sort of situation [procedure]. So I read a small section in the little booklet on what to do and what it all involved. (P27)

Nurses identified issues relating to these manuals as they were often out of date and not relevant to current practice. Similarly, the same issue was expressed for surgeon's preference cards detailing the specific needs of procurement surgeons' requirements in order for the perioperative nurses to prepare for the imminent procedure: “Even the preference cards were outdated” (P19).

In Australia, the major form of education provided to health care professionals is through the Australasian Donor Awareness Program (ADAPT), which offers training predominantly in metropolitan areas, limiting attendance by participants working in the regional and rural areas owing to distance or difficulty being released from work duties. Some participants who did attend an ADAPT workshop reported it as useful and beneficial in providing information in order to fill in gaps of knowledge related to organ donation and diagnosis of brain death. One nurse explained:

I went to the … ADAPT workshop and they talked a lot about the brain death and the tests they do and the 2 doctors that do the tests and all that sort of stuff. So I wasn't aware of all that before. (P22)

More importantly, it was emphasized that although such a workshop was available, the ADAPT course was again not specific enough to meet the needs, for example, of perioperative nurses for information about their intraoperative roles:

I did attend a study day though, run by the … national donor program (ADAPT). It's one [where] they go to each state and they do it just once a year. I did go to one of those sessions but it was mostly for [intensive care unit] staff, which covered the family and brainstem death testing and all that sort of thing but [there was] nothing [no specific information] for perioperative [nurses] orany sort of training basically. (P9)

Another participant disclosed a similar viewpoint, stating that although the information was interesting, it was not substantial or adequate to meet the needs of perioperative nurses:

They didn't touch much on [the perioperative aspect]; it was focused on more emergency nurses, you know, basically what happens in … the wards or whatever or when the patients come through from wherever. It wasn't focusing much on us in the [operating room] itself … what … we [are] supposed to do [intraoperatively] … it focused more on critical care [nurses' role] the [donor] patient's family, what they need to do beforehand, the consent and your different types of consents for children and adults and all that sorts of stuff. I know *[Name of Nurse] went with me as well … and we both thought it was really good, it was very, very interesting but we needed more for us in [operating room]. (P22)

Limited Mentoring Opportunities

Limited mentoring opportunities were reported by the participants as another component of levels of knowledge and experience, where opportunities for nurses to obtain experiential learning with a mentor within these procedures were limited because of the very nature and unexpectedness of these procedures presenting to operating rooms. Several nurses explained that the lack of mentoring opportunities compounded their ability to obtain practical on-the-job guidance in procurement surgery in a safe learning environment. It was further identified that not having regular mentoring opportunities exacerbated the participants' need to hide their lack of knowledge and experience when they were required to assist in a procedure. Within the operating room, mentoring is common practice and is undertaken during clinical exposure to different procedures. A common metaphor verbalized within the perioperative setting when participating in a surgical procedure for the first time is: “see one, do one, teach one” (P5, P24, P29). However, for procurement procedures, participants were often put in a position of having to assist with the surgical procedure often before they had had an opportunity to either see one or be mentored clinically. Several nurses expressed that following their initial procedure it was a common expectation that they were then ready to provide mentoring in this area if the situation arose to other staff members.

Factors that affected mentoring opportunities were reported as decreased staffing levels and a lack of experienced staff on the day to assist in the procedure, let alone take on the mentoring role: “Yes, I was anxious and scared because nobody [the nursing team] knew what we were doing” (P31). Increased workloads, the time to conduct mentoring, and being asked to participate in procedures that occurred sporadically and quite unexpectedly also hampered efforts to mentor staff. One participant highlighted this point:

[There] could be a bit more in the training side of things or preparation in … multiorgan [procurement procedures], but then I don't know how they would fit that [education] in, you know. You do rotations in this place *[Name of Hospital] and you never get to actually spend time in your [own surgical] specialty anyway due to extra workloads … you're constantly [working] in other [operating room specialty] areas. (P5)

Lacking staff numbers, in addition to issues of staff retention and turnover of staff within particular operating room environments meant fewer experienced staff were available to provide mentoring in these procedures. This issue was confirmed by the following nurse, who explained:

No, because most of the time you find that because we have such a high turnover of staff, there is … very seldom someone there that has done it before [participated in a procurement procedure] or they can really explain it [the procedure] … you know it's not something [a procedure] that happens all that often, you know. (P14)

The time-critical nature and urgency of these procedures often limited the opportunity for mentoring to take place, with several nurses reporting a quick verbal overview of what was about to take place: “I had nothing [no education or mentoring prior] to begin with, just a senior nurse who said ‘We're harvesting, this is what happens and this is how it goes and this is what you need to do’” (P30). Participants reported that because of these limited mentoring episodes, they were often left on their own to manage the procedure, having to hide their lack of knowledge and get by with what they knew: “You go out on your own [when participating], you know you have got nobody else to fall back on when you are working with inexperienced staff” (P23).

Surgeons were also reported as integral in the mentoring process of perioperative nurses during the intraoperative phase; however, they were not always available to offer full support and mentoring during the busy procurement procedure. Mentoring provided by surgeons was reported in the form of intraoperative instructions and prompts on surgical instruments or equipment throughout certain stages of the procurement procedure. One nurse emphasized the importance of requiring such support and assistance with the instrumentation requirements, at the time of opening the chest and excision of the heart and lungs:

I required mentoring [by the surgeons] especially when they took the heart and lungs as I'd never done cardiothoracic surgery. They took the saw and [the things] they would need so I had to have it ready on the table. If I'm busy, they could just grab it. (P9)

Importantly, it was noted that surgeons would provide limited mentoring to perioperative nurses as they were also often mentoring their own junior medical colleagues during these surgical procedures: “Most of them [the surgeons] are very [busy], they talk to each other more so than [they] talk to us [the perioperative nurses] and they'll explain the anatomy or something like that to each other” (P25). Similarly another participant disclosed: “The cardiac surgeon was … explaining the procedure to the medical student about what he was doing … the surgeon was also teaching the junior reg [surgical registrar] as well” (P21).

The organ donor or transplant coordinator were also reported to provide some forms of mentoring to perioperative nursing staff, as these health professionals were often in the operating room when procurement procedures were being undertaken. However, these mentoring opportunities were often limited, as the coordinators were usually undertaking their own professional roles such as assisting with coordinating the various procurement teams, completing necessary paperwork, and focusing on the appropriate packing of the organs procured for urgent transportation. Although this was the case, they still ensured that they provided some levels of guidance or mentoring to the perioperative nursing staff. Participants described this mentoring as limited but immensely helpful throughout certain stages of the procedure; however, the nurses were mindful that coordinators still had their own duties to fulfil. This situation was described by a participant as: “So we were all fairly new and most of the guidance came from the donor coordinator … we had no one else, but they were not always available” (P14).

Having Prior Knowledge and Experience With Procurement Procedures

Nurses who had worked in the operating room environment for several years who had some prior exposure to procurement procedures reported increased resilience and ability to cope with the technical nature and the emotional demands of assisting within these surgical procedures. This situation was expressed by a nurse as: “[Perioperative] nurses with a degree of previous or prior [procurement] surgery experience would be able to cope better … with these cases in whatever roles scouting [circulating] or scrubbing” (P13). Those participants working in the metropolitan areas also reported higher levels of knowledge and experience due to the increased frequency of these procedures being completed in metropolitan hospitals: “I have been involved with multiple organ procurement [surgery] … multiple times, probably approximately 10 times all here at *[name of hospital]” (P12). Participants from the rural or regional areas continued to acknowledge having less experience because of the limited exposure to these procedures. This situation thereby lessens their ability to be finding meaning following their participation, as they still struggled to come to terms with their participation: “I've been involved in 4 multiorgan procurement procedures, and it took time to come to terms with my participation in each of those procedures” (P28). Further, several participants explained that each experience made their subsequent participation process a little easier as they were able to establish ways to tackle the technical and sequential stages of the procedure: “The second one I knew … the sequence of events” (P14); “It was better the second time I participated. I had a better understanding of what was happening [the procurement surgical process] because I had such a horrible experience the first time” (P18).

To complement their clinical skills, several participants explained that their drive to increase their level of theoretical knowledge about the organ donation process was a result of self-directed learning in the area by undertaking a professional development workshop such as ADAPT. One nurse commented:

Yes, I went to the ADAPT program; I did that because I wanted to know more and I think that is the only thing I did … I think it was a single-day course, a full study day, but that was well after I had done probably the majority of retrievals or organ procurements that I've actually done already and I chose to do that. (P16)

The same nurse further emphasized the benefits from attending such a workshop as increasing her overall awareness and knowledge about the organ donation process in general:

I'm much more comfortable with it [assisting in the procurement surgical procedure] now because before … I didn't have an awareness of what was exactly going on throughout the whole procedure and now with my education and training I have a greater understanding. (P16)

Sharing Knowledge Through Team Mentoring

Although participants found these procedures difficult, they articulated that they found sharing their knowledge through team mentoring helpful to their overall participation and finding meaning from their experiences. Team mentoring gave participants a purpose and an opportunity to work through their own issues while also sharing their own knowledge and experiences with their peers. Several participants who engaged in mentoring other nurses found this role fulfilling and meaningful. They disclosed that they had an opportunity to make a remarkable and positive difference to other nurses' experiences when participating in procurement surgical procedures:

Professionally, I feel that if I can help other people who have never experienced this [procurement surgery] and … help them be involved and find it a positive experience for them, [then] that's something that I have enjoyed helping others get through the procedure. (P15)

Several nurses also spoke of sharing not only their clinical experiences through mentoring but the increased knowledge that they had gained through further education and training. One nurse disclosed:

With my education and training, I feel now that I can actually teach the staff that are working alongside me, whereas when I first started, I was learning a lot myself so I couldn't actually be involved in the teaching role. (P16)

Again within this study, participants highlighted that more should be done to ensure that perioperative nurses had adequate education, training, exposure to these procedures, and mentoring opportunities in procurement surgery. One nurse emphasized this point by her comment:

There needs to be education. I think you could do education for these [procurement] cases at different levels, and I think some basic education of what to expect would be helpful [to perioperative nurses], whether that [education] would be done internally within the department or whether that could be done by the [organ donor] coordinators [when they visit the operating room]. (P13)

Discussion

This research has uncovered the importance and need for specialized education and professional development opportunities for perioperative nursing health professionals in organ procurement surgery. It can be recognized that levels of knowledge and experience affect the perioperative nurses' ability to participate successfully in these surgical procedures on both a professional and personal level. Although health professionals have a duty to be up to date in clinical practice and to be practicing within their scope of nursing practice, in order for perioperative nurses to contribute effectively as part of the team assisting in surgical procedures for organ procurement, they require more specialized education and support within the clinical environment. The larger study² and this article have revealed that perioperative nurses, within the context of their knowledge and experience with procurement surgical procedures, struggle to obtain relevant and up-to-date information in relation to these important surgical procedures. Moreover, this research highlights that the approach to education has not been consistent across Australian states or territories, and across different health care facilities, in order for perioperative nurses to receive specific education or professional development opportunities in this expanding area of health care.

Not surprisingly, this study has uncovered a major assumption that perioperative nurses are adequately prepared to undertake procurement surgical procedures because of their extensive experience and the prerequisite that they have the basic essential skills to undertake a basic laparotomy. The participants in this study have highlighted that this basic assumption has been to the detriment of their professional practice and personal experiences in procurement surgery. To assist in all surgical specialty procedures, perioperative nurses are trained to preempt the needs of the surgeon, hence they need to have background knowledge of the anatomy and physiology, in addition to the surgical approach and instrumentation requirements to undertake each surgical procedure they assist in successfully. The assumption that a basic laparotomy prepares a perioperative nurse to undertake a multiorgan procurement surgical procedure has not rung true within this study or in the culture of “see one, do one, teach one.” Hence the study participants have emphasized the requirement for more in-depth education.

Several participants reported that they had not had prior experience and exposure to procurement surgery, and this was identified as a major influencing condition of participants' hiding behind a mask. Participants reported hiding their lack of knowledge and understanding of these surgical procedures when assisting with procurement teams, as well as feeling uncomfortable taking on the responsibility for teaching and mentoring their colleagues. As noted, many participants themselves felt unprepared for assisting clinically in procurement surgical procedures, lacking knowledge of the procurement process and what was expected of them when participating in these surgical procedures, in addition to feeling unprepared emotionally for what they would see and do as part of their roles. Lack of knowledge and experience also extended to the nurses' own fears and concerns that they lacked knowledge and understanding of the donor's brain death diagnosis and brain death testing. Several nurses felt uncomfortable when they lacked understanding of the donor's brain death diagnosis.⁴ This finding was not uncommon, as several other authors also indicated health professionals' knowledge deficits and doubts related to brainstem testing results.^14,31–33

The incidence of procurement surgical procedures across metropolitan, regional, and rural areas also affects perioperative nurses and health professionals' ability to obtain experience and exposure to these surgical procedures. As reported within this study, having prior experience and exposure was limited for most perioperative nurses who worked in the rural or regional areas, where they were further disadvantaged by staffing issues, propelling them into participating in these procedures with limited knowledge compared with nurses who work in metropolitan areas. The need for health professionals to have some prior experience and exposure was also emphasized in the study by Essman and Lebovitz⁵ on medical students, which described the benefits of allowing these students the opportunity to observe the entire donation process from the intensive care unit to the operating room. Several of the participants within this study reported that they would highly recommend this form of education to fellow students as it was viewed as beneficial within the clinical environment.

A major finding, again overlooked within the literature but identified within this study, was nurses' uncertainty and confidence in dealing with deceased organ donors within the operating room environment and the psychological effects on the nurses given that they usually deal with saving lives and restoring patients' well-being through lifesaving surgical procedures. As noted from the study findings, several participants wanted to avoid the fact that they were operating on a deceased organ donor, as dealing with death was not a common occurrence within the operating rooms. Unfortunately, staff revealed that they did not have the adequate skills or training to deal with such events and felt overwhelmed when dealing with both donor patients and patients' families. Several perioperative nurses therefore reported that they did not have the knowledge base or skills to talk with these bereaved families, and they tried to avoid such encounters. This behavior was evident when nurses reflected that they felt uncomfortable dealing with the families of both brain-dead and DCD donors. Results of this study suggest that within the operating room setting, more education is required to prepare these health professionals to deal with the bereaved family members of organ donors who come into the operating room environment to see their loved ones either before or after their surgical procurement procedure.

The need for professional development opportunities and education was emphasized as pivotal to the overall outcome of these surgical procedures on a professional and personal level for the nurses within this study. Several nurses believed that fundamental education, knowledge, and understanding provided an opportunity to enhance their skills, knowledge, and experience within these procedures positively. As these fundamental resources were lacking, participants described instances where they sought their own learning opportunities by reading policy or procedure manuals about organ donation and the procurement procedure in order to educate themselves. Clearly, further professional development opportunities specific to the perioperative nursing specialty and the intraoperative process of procurement surgery are required across Australian states and territories from metropolitan to regional and rural areas because educational opportunities are limited or insufficient. As reported, only a handful of participants had received some form of education or training before their participation in these surgical procedures, and the effectiveness was inadequate for their professional needs. Surprisingly, most participants in this study disclosed that they had not been provided with any forms of education before assisting in a procurement procedure. Participants also stated that they were never provided with mandatory education on procurement surgery or organ donation as part of their operating room induction or as part of a program of continuing education usually provided by an operating room educator or staff development nurse within their own health care facility's operating rooms.

This study also identifies the dearth of information internationally on specific and targeted education or courses for perioperative nurses, although perioperative nurses make such a large contribution to the success of these surgical procedures. Education as a whole for perioperative nurses is described as undertaken via experiential learning when these procedures are conducted. How much education and whether this was effective training have been validated by the participants' views that experiential learning did not prepare these nurses adequately to perform their professional roles during these procedures. If anything, this study has emphasized that experiential learning alone is flawed, as each new donor and procurement procedure presents different situations, management of donors, and experiences for the health care team. More recent studies and researchers also support the idea of more in-depth clinical and theoretical education on aspects of organ donation and transplant.^{9,11,15,32,34} The current research findings validate that more must be done to educate health professionals at the front line (eg, perioperative nurses) in order to enhance their skills and knowledge when assisting in these surgical procedures.

Clearly, this study has emphasized, within an Australian context, that there are currently no effective modes of professional education or specific courses/educational resources for the perioperative specialty related to organ procurement surgery other than the ADAPT course workshops or in-service training sessions run by individual health care facilities or state organ donation coordinators. As mentioned, although the ADAPT course is designed for all health professionals, this training did not address the specific intraoperative surgical procedure or the educational needs of the study participants in their roles as perioperative nurses when required to assist in such procedures. A major problem identified with this form of education was that not all participants could access this workshop because of staffing issues, difficulty getting release from the work environment, and the associated attendance and travel costs to attend workshops that are usually held in major Australian cities. Second, of those participants who attended such a workshop, the majority proclaimed benefits in attendance by gaining theoretical knowledge and understanding on aspects of the process of organ donation; requests for donation and brainstem death testing, however, also explained that content specific to the perioperative environment was lacking. Therefore initiatives for perioperative nurses to access education on all facets of organ donation and procurement surgery must also take into account the educational needs of perioperative nursing work in addition to the possible high demand for workshop access by all nurses across all Australian regions.

In the current study, increased exposure and clinical mentorship was reported as an excellent form of accessing on-the-job clinical skills related to procurement surgical procedures. Participants from the current study benefited from this exposure and found these experiences useful; however, because of limited staffing numbers and opportunities, they were not always able to use such opportunities. This finding supports the earlier descriptive survey study of perioperative nurses by Lloyd-Jones,²⁰ who reported that only 46.9% of study respondents reported some form of teaching during a procurement procedure; however, this lack of teaching was also attributed to lack of time and maintaining focus on the surgical procedure. In the current study, mentoring opportunities were often not available because of staffing shortages or lack of time. Initiatives to increase exposure for perioperative nurses through mentoring in procurement surgical procedures would be beneficial as nurses would feel less stress and strain having to manage these procedures on their own and with limited knowledge and exposure. Increased exposure would in turn help to alleviate the overwhelming clinical skills demands placed on individual nurses at the time of participating in a procurement surgical procedure and would also aid nurses to address and focus on the emotional demands of their participation, which is vitally important to their well-being and their ability to cope. Not surprising, those participants who received mentoring opportunities fared better and reported more positive experiences, finding meaning from their participation in these surgical procedures. Mentoring also reinforced their ability to share their own knowledge gained with other team members and provided an opportunity to assist other nurses to navigate more confidently through the procurement procedure, thereby promoting more positive participation experiences.

Study Limitations

The present study contributes to the literature on the need for education geared toward health professionals such as perioperative nurses by expanding knowledge and providing a perspective from the nurses themselves on what education exists and what more they require. A limitation of the study is the relatively small participant sample, given that only 2 Australian states were recruited from; therefore, it may be difficult to generalize the findings across Australia and internationally. The authors recommend that further studies address this issue by using a larger and more representative sample of perioperative nurses, including different types of health care facilities both in Australia and internationally.

Conclusion

Perioperative nurses continue to assist with multiorgan procurement surgical procedures and although they contribute during these surgical procedures, more in-depth and intensive clinical education is required in order for these nurses to understand and contribute to these specialized procedures. Clearly, having perioperative nurses receive adequate education related to procurement surgical procedures does pose a challenge. Their lack of education has an impact on their professional responsibilities, personal feelings, and attitudes toward their participation. The disparity in the levels of knowledge, experience, exposure, and access to these procedures and nurses' ability to obtain experiential learning through on-the-job mentoring were all identified as contributing to their overall experiences. More importantly, the vulnerability that health professionals feel as a result of lacking education and understanding during these surgical events cannot and should not be ignored.² The results of this study indicate the need for more comprehensive training and mentoring opportunities among perioperative health professionals involved in surgical procedures for organ procurement. Further research is required to look at perioperative nurses' levels of knowledge related to organ donation and procurement at a national and international level. The incorporation of specialized nurses within the perioperative nursing setting who have the necessary skills and knowledge on procurement surgery to educate and support other nurses may be useful. The findings of this study have important implications for perioperative nursing education related to procurement surgical procedures and, as indicated by the current study findings, further targeted education for perioperative nurses is vital to ensure that they are adequately prepared and continually trained to undertake these surgical procedures.

Footnotes

Acknowledgments

The authors acknowledge the participants who took part in this research and willingly shared their experiences.

Zaneta Smith received the following funding during her PhD studies: (1) 2008 Recipient of Helen Bailey Scholarship from Health Department of Western Australia, (2) 2010 Australian Postgraduate Award, and (3) 2010 Curtin University Postgraduate Research Scholarship.

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