Attitude and Impact Factors Toward Organ Transplantation and

Donation Among Transplantation Nurses in China

J.-F. Xiea,b, C.-Y. Wangb, G.-P. Heb, Y.-Z. Minga, Q.-Q. Wana, J. Liua, L.-N. Gonga, and L.-F. Liua,*
a
Third Xiangya Hospital, Central South University, Changsha, HuNan Province, China; and the bXiangya Nursing School, Central South
University, Changsha, HuNan Province, China

ABSTRACT
Background. Health workers’ awareness and knowledge of transplantation medicine can
improve people’s sensitivity and reduce their degree of opposition to donations. The
medical literature contains numerous examples of attitudes toward organ transplantation
and donation aimed at university students or medical staff members, but rarely for trans-
plantation nurses.
Objective. The purposes of the study were to investigate the attitudes toward organ trans-
plantation and donation among transplantation nurses and to explore the impact factors.
Methods. The study was conducted in 37 transplantation surgery wards in 22 hospitals
using cross-sectional approach. SPSS (International Business Machines Corporation,
Armonk, New York, USA) 7.0 software was used to analysis descriptive and inferential
statistics for data.
Results. Five hundred thirty-six effective questionnaires were received and the effective
rate was 89.33%. Nurses’ mean age was 28.40 years with a mean service length of 6.54
years. Among these nurses, 66.6% and 78.0% were willing to accept organ transplantation
surgery for themselves and their relatives, respectively. Of these nurses, 33.4% would
donate their organs after death; whereas 39.9% were uncertain. Only 38.2% were willing
to register in the national organ donation system. Of these nurses, 28.2% were willing to
sign the organ donation consent forms when their relatives became potential organ
donors, and 45.7% were uncertain. Eight independent variables that affected nurses’
attitudes toward donating their organs from most to least significant were: ratio of nurse
to bed, title, employment form, age, length of service, position, monthly income, and the
highest educational degree earned. Pearson correlation analysis showed a significant
correlation among nurses’ attitudes toward organ transplantation, organ donation, and
online registration.
Conclusion. The attitude toward donation and transplantation in the hospitals was not
too optimistic, and an improvement in the training regarding transplantation and donation
among nurses in China is necessary. Nurses are an important group who generate opinion
in the patient population, and their negative attitudes can have a significant negative
impact on society’s attitudes toward organ donation.

O RGAN transplantation has become the optimal choice

to save and extend lives [1]. After February 2013,
when the human organ donation plan was officially
launched in China, donation after cardiac death has become
the main source of organ donation, which eases the great
tension of the Chinese donor market to a certain extent.
Supported by the National Natural Science Foundation of
China Youth Science Fund Project (NO. 81502701).
*Address correspondence to Li-Fang Liu, Third Xiangya Hos-
pital, Central South University, Changsha, HuNan province,
No.138 Tongzipo Road, Changsha, HuNan Province 410013,
China. E-mail: 2308321132@qq.com

0041-1345/17 ª 2017 Elsevier Inc. All rights reserved.

http://dx.doi.org/10.1016/j.transproceed.2017.02.060 230 Park Avenue, New York, NY 10169

1226 Transplantation Proceedings, 49, 1226e1231 (2017)

TRANSPLANTATION NURSES IN CHINA
However, the organ donor shortage has always been a
problem disturbing transplantation professionals worldwide.
Attitudes about organ donation and volunteerism are
important factors in the lack of donors.
Health care professionals are key elements in facilitating
the cadaveric organ donation process [2], especially the
transplantation nursing professionals who have more con-
tact with patients than any other professionals. The nurses’
awareness and knowledge of transplantation and donation
can affect other people’s sensitivity and attitudes. There
have been many medical studies regarding attitudes toward
organ transplantation and donation aimed at university
students or medical staff members [3e5], but these are rarely
about transplantation department nurses. As direct partici-
pants in the transplantation and donation process, trans-
plantation nurses are thought to have more active attitudes
toward transplantation and donation. Their attitudes and
behaviors are on behalf of the transplantation and donation
organization, which will have significant impact on the
general patient population. The aims of the present study
were to assess the attitudes toward to organ transplantation
and donation among transplantation nurses using a ques-
tionnaire designed by the authors, to identify influencing
factors, and then to provide information for the governor to
make changes to the educational policy and program.
MATERIAL AND METHODS
Design
This study used a cross-sectional approach. Between July 2015 and
November 2015, 600 nurses of transplantation surgery wards
completed a self-designed questionnaire for assessing the attitudes
toward organ transplantation and donation. The study was con-
ducted in 37 transplantation surgery wards in 22 hospitals.
Subjects
The inclusion criteria were as follows: 1) length of service for at
least 1 year; 2) working in organ transplantation surgery ward; 3)
agreeing to participate in the study. The study group consisted of a
convenience sample of 600 nurses. Informed consent was obtained
from each subject and this work was approved by the Ethics
Committee of the Third Xiangya Hospital of Central South
University.
Data Collection Procedure
Each nurse completed a two-part questionnaire. The first part con-
cerns general data (i.e., gender, age, length of service, employment
form, title, first degree, highest degree, and monthly income). The
second part of the questionnaire regarding transplantation and
donation-related data (attitude toward organ transplantation for
yourself or relatives if necessary, attitude toward donating your organs
after death, willingness to sign the organ donation consent when facing
your relatives becoming potential organ donors, attitude toward online
registration for self-donation, understanding of transplantation pro-
cedures, and understanding of donation procedures, had received
specific training in donation and transplantation procedures, and
attitude to receive training). At present, there is no standard ques-
tionnaire to measure the attitude toward organ transplantation and
donation of medical personnel throughout the world. The
1227
questionnaire was self-designed and consisted of several questions.
These types of questionnaires have been proven to be effective tools
for assessing the attitudes of organ transplantation and donation of
hemodialysis patients in our preliminary research [6]. The study team
was comprised of 22 nurse managers and 4 nursing postgraduates.
Firstly, team members explained the purpose of the study and asso-
ciated concepts. All questionnaires were completed anonymously. To
increase the accuracy of the questionnaires, 30 minutes to 45 minutes
were allowed for completion.
Data Analysis
All information from the questionnaires was input to a computer
according to sequential numbers. Both descriptive and inferential
statistics were used for data analysis using SPSS 17.0 software
(International Business Machines Corporation, Armonk, New
York, USA). A value of P < .05 was considered statistically sig-
nificant. An alpha of .05 was determined a priori.
RESULTS
Demographic Information of Subjects
A total of 600 questionnaires were sent out; 591 were
completed and returned, and 536 were valid for our study
(89.33%). The mean age of the study group was 28.40 years
(SD ¼ 4.800, range: 20w51 years), and the mean length of
service was 6.54 years (SD ¼ 5.302, range: 1w31 years). The
mean ratio of nurse to bed was 0.38 (SD ¼ 0.11, range:
0.22w0.59 years). As shown in Table 1, the majority of the
participants were female (96.3%), their ages were between 26
years and 30 years (42.5%), they were temporarily employ-
ment (39.7%), primary nurses (44.4%), with no title (86.2%),
their first degree was junior college (50.4%), their highest
degree was undergraduate (80.2%), they were married
(52.1%), had no children (57.6%), their monthly income was
between 3001w5000 Yuan ($460w$790) (42.0%), their
length of service was less than 5 years (44.2%), the ratio of
nurses to beds was less than 0.4 (58.4%), and their number of
night shifts were more than 8 per month (48.3%).
Attitudes Toward Organ Transplantation and Donation
Attitudes toward organ transplantation and donation
among transplantation nurses were shown in Table 2.
Among these nurses, 66.6% were willing to accept the organ
transplantation surgery for themselves, 14.4% were not, and
19.0% were uncertain. Of the participants, 78.0% were
willing to accept the organ transplantation surgery for their
relatives, 8.6% were not, and 13.4% were uncertain.
Of the nurses, 33.4% would donate their organs after death,
26.7% would not, 39.9% were uncertain, and only 38.2% were
willing to register in the national organ donation system. Of
the nurses, 28.2% were willing to sign the organ donation
consent when their relatives became potential organ donors,
26.1% were not, and 45.7% were uncertain.
Among the replies regarding understanding of the
transplantation procedures of the participants, 22.2%
strongly agreed, 64.0% agreed, 10.1% were uncertain, 3.0%
disagreed, and 0.7% strongly disagreed. Replies regarding
the understanding of donation procedures, 24.6% strongly
1228 XIE, WANG, HE ET AL

Table 1. Characteristics of the Participants (n [ 536) Table 1. (continued)

Characteristics N % Characteristics N %
Gender Number of night shifts per month (day)
Male 20 3.7 0 64 11.9
Female 516 96.3 1e8 213 39.7
Age, yrs >8 259 48.3
<25 172 32.1
26e30 228 42.5
31e35 100 18.7 agreed, and 45.9% agreed, 22.0% were uncertain, 5.4%
36e40 20 3.7 disagreed, and 2.1% strongly disagreed.
>40 16 3.0 With regard to training, 39.7% of respondents said they
Employment form had received specific training on donation procedures at some
Temporary 213 39.7 time during their job training, although 77.1% acknowledged
Contractor 141 26.3 that they would like to receive training in this area.
Employee 181 33.8
Missing 1 0.2 The Influence of Basic Characteristics on Attitudes to Organ
Title Donation
Nurse 208 38.8
Senior nurse 238 44.4
The influence of basic characteristics on nurses’ attitudes
Supervisor nurse 86 16.0 toward organ donation was analyzed (Tables 3 and 4).
Associate chief nurse 4 0.7 Different employment forms (temporary, contract, etc.),
Position positions, highest degrees earned, and ratios of nurses to
General nurse 462 86.2 beds groups had statistical significance in the difference of
Team leader 46 8.6 the attitudes toward donating their own organs after death
Head nurse 24 4.5 (P < .05). Compared with the general nurse group (32.5%)
Supervisor 4 0.7 and the quality control leader group (34.8%), the head
First degree nurse group (46.4%) exhibited significantly greater willing-
Below junior college 70 13.0
ness to donate their organs after death. In the highest
Junior college 270 50.4
Undergraduate 192 35.8
degree earned group, the education level above under-
Master degree or above 4 0.8 graduate group (50.0%) was significantly higher than those
Highest degree whose education levels were undergraduate (34.7%), and
Below junior college 4 0.7 junior college (23.8%). The ratio of nurses-to-beds-greater-
Junior college 80 14.9 than-0.5 group (50.4%) was statistically higher than the
Undergraduate 430 80.2 other two groups. There were no statistical differences
Master degree or above 22 4.1 between males and females regarding self-donations and
Marriage relatives’ donations (P > .05).
Married 279 52.1 Results showed that different employment forms,
Widowhood 4 0.7
positions, ratios of nurses to beds, and lengths of service had
Divorced 2 0.4
Unmarried 251 46.8
statistical significance effect on the attitudes toward signing
Children the organ donation consent forms when their relatives
None 308 57.5 became potential organ donors (P < .05). The ratio of
Had children 224 41.8 nurses-to-beds-greater-than-0.5 group (46.0%) was statisti-
Missing 4 0.7 cally higher than the other two groups. Comparison of pos-
Monthly income (RMB) itive attitude responses based on length of service revealed
<3000 58 10.8 that the length between 11w15 years’ group (45.5%) had a
3000e5000 225 42.0 higher positive attitude as compared to other groups.
5001e7000 167 31.2 The differences of intention to donate among different
7001e9000 60 11.2
understandings of transplantation procedures and donation
>9000 26 4.9
Length of service, yrs
procedures groups were statistically significant (P < .05).
<5 237 44.2 Nurses who were willing donate their own organs and their
5e10 179 33.4 relatives’ organs were statistically higher in the “strongly
11e15 77 14.4 agreed” group for understanding of transplantation
>15 42 7.8 procedures and donation procedures, respectively.
Missing 1 0.2
Ratio of nurse to bed Multiple Linear Regression Equation of Nurses’ Attitudes
<0.4 313 58.4 Toward Their Organ Donation and Associated Variables
0.4e0.5 84 15.7
The F test revealed that F ¼ 2.171, P ¼ .008 which was less
>0.5 139 25.9
than 0.01. That is, the multiple linear regression equation
TRANSPLANTATION NURSES IN CHINA 1229

Table 2. Attitudes Toward Organ Transplantation and Donation Table 3. The Influence of Basic Characteristics on Nurses’
Among Transplantation Nurses (N [ 536) Attitudes to Self-organ Donation (n [ 536)
Variables n % Attitude Toward Own Donation
P
Willingness to accept the organ transplant surgery for their relatives Variables Yes (%) No (%) Uncertainty c2 Value
Yes 418 78.0 Employment form
Not sure 72 13.4 Temporary 48 (22.5) 75 (35.2) 90 (42.3) 29.787 .000
No 46 8.6 Contractor 58 (41.1) 39 (27.7) 44 (31.2)
Willingness to donate organs after death Employee 73 (40.3) 29 (16.0) 79 (43.6)
Yes 179 33.4 Position
Not sure 214 39.9 General nurse 150 (32.5) 128 (27.7) 184 (39.8) 12.931 .044
No 143 26.7 Team leader 16 (34.8) 15 (32.6) 15 (32.6)
Willingness to register in the national organ donation system Head nurse and 13 (46.4) 0 (0) 15 (53.6)
Yes 205 38.2 above
Not sure 228 42.5 Highest degree
No 103 19.2 Below junior college 0 (0) 2 (50.0) 2 (50) 12.673 .049
Willingness to sign the organ donation consent when facing their Junior college 19 (23.8) 31 (38.8) 30 (37.5)
relatives becoming potential organ donors Undergraduate 149 (34.7) 106 (24.7) 175 (40.7)
Yes 151 28.2 Master degree or 11 (50.0) 4 (18.2) 7 (31.8)
Not sure 245 45.7 above
No 140 26.1 Ratio of nurse to bed
Willingness to accept a donated organ for transplantation if <0.4 85 (27.2) 87 (27.8) 141 (45.0) 30.543 .000
necessary 0.4e0.5 24 (28.6) 19 (22.6) 41 (48.8)
Yes 357 66.6 >0.5 70 (50.4) 37 (26.6) 32 (23.0)
Not sure 102 19.0 Understanding of transplantation procedures
No 77 14.4 Strongly agree 61 (51.3) 17 (14.3) 41 (34.5) 42.083 .000
Agree 102 (29.7) 105 (30.6) 136 (39.7)
Uncertainty 13 (24.1) 18 (33.3) 23 (42.6)
Disagree 3 (18.8) 0 (0) 13 (81.3)
fitting the data showed statistical significance. The high abso- Strongly disagree 0 (0) 3 (75.0) 1 (25.0)
lute value of the standardized regression coefficient indicated a Understanding of donation procedures
significant effect of corresponding independent variables on Y. Strongly agree 57 (43.2) 16 (12.1) 59 (44.7) 51.485 .000
Eight independent variables that affected nurses’ attitudes to- Agree 88 (35.8) 88 (35.8) 70 (28.5)
ward donating their organs from most to least significant were: Uncertainty 27 (22.9) 33 (28.0) 58 (49.2)
ratio of nurses to beds, title, employment form, age, length of Disagree 4 (13.8) 4 (13.8) 21 (72.4)
service, position, monthly income, and highest degree. Strongly disagree 3 (27.3) 2 (18.2) 6 (54.5)

DISCUSSION
Public acceptance of routine medical procedures is nearly
universal, but controversy over invasive procedures such as
transplantation is common. Organ transplantation is the
most preferred treatment for end-stage organ disease and
organ failure. It offers a better quality of life with better
survival benefits. Therefore, the magnitude of organ
retrieval is extremely important. Nurses play vital roles in
imparting positive knowledge towards organ transplantation
and donation. The multiple linear regression equation has
shown that the effects of eight independent variables on
nurses’ attitudes toward donating their organs from large to
small were as follows: ratio of nurses to beds, title,
employment form, age, length of service, position, monthly
income, and highest degree. Factors determining attitudes
toward signing the organ donation consent form when
facing their relatives becoming potential organ donors are
similar to attitudes toward self-donation. Ratio of nurses to
beds in human resources management has been a sensitive
topic in China. In this study, there were 58.4% participants
in a ward with a ratio less than 0.4, which exposed a serious
shortage of nurses. The group with a ratio of nurses to beds
greater than 0.5 (50.4%) was statistically higher than the
other two groups on attitudes toward self-donation and
signing the organ donation consent form when facing their
relatives becoming potential organ donors. Thus, the ratio
of nursing beds is the biggest influencing factors on nurses’
attitudes toward organ donation, and it indicates that we
must pay more attention to this issue. In this study, the head
nurse group (46.4%) exhibited significantly greater willing-
ness in attitudes toward deceased donation when compared
to the general nursing group (32.5%) and the quality control
leader group (P < .05). The education-level-above-
undergraduate group (50.0%) was significantly higher than
those whose education levels were undergraduate (34.7%)
and junior college (23.8%). Higher education positively
promotes desirable knowledge and willingness of organ
donation. This is similar to the findings of other study
groups [5,7]. In China, nurses are mostly female. This has
been identified in the present study; the majority (n ¼ 516,
96.3%) of the study participants were females. In our study,
there were no statistical differences between males and
females regarding self-donation of organs and relatives’
organ donation. This finding contradicts with other studies
1230 XIE, WANG, HE ET AL

Table 4. The Influence of Basic Characteristics on Nurses’ organ donation in Southeastern Spain found that there was
Attitudes to Relatives’ Organ Donation (n [ 536) a very favorable attitude toward organ donation, especially
Attitudes Toward Relatives’ Donation among physicians, among who up to 88% are in favor of
P
Variables Yes (%) No (%) Uncertainty c2 Value donation [14]. However, in our study, the attitude toward
donation of the transplantation nurses were not very
Employment form
Temporary 32 (15.0) 73 (34.3) 108 (50.7) 42.516 .000 favorable; only 33.4% of nurses would donate their organs
Contractor 57 (40.4) 38 (27.0) 46 (32.6) after death, which was less than what had been reported by
Employee 62 (34.3) 29 (16.0) 90 (49.7) foreign countries (56.6%w70.8%) [15e17]. The proportion
Position of nurses who would register in the national organ donation
General nurse 128 (27.7) 125 (27.1) 209 (45.2) 12.421 .053 system for cadaveric donation was only 38.2% and less than
Team leader 14 (30.4) 15 (32.6) 17 (37.0) a third of nurses (28.2%) were willing to sign the organ
Head nurse and 9 (32.1) 0 (0) 19 (67.9) donation consent form when facing their relatives become
above potential organ donors. Health professionals are a funda-
Ratio of nurse to bed
mental link between society and the health system when it
<0.4 58 (18.5) 84 (26.8) 171 (54.6) 43.624 .000
comes to fostering donation and transplantation. Several
0.4e0.5 29 (34.5) 19 (22.6) 36 (42.9)
>0.5 64 (46.0) 37 (26.6) 38 (27.3) studies have found that health professionals are not always
Length of service, yrs properly aware of the question of donation and brain death
<5 68 (28.7) 51 (21.5) 118 (49.8) 28.446 .000 and display a lack of knowledge in this area [18]. This lack
5e10 38 (21.2) 65 (36.3) 76 (42.5) may influence the way in which donation is presented to the
11e15 35 (45.5) 17 (22.1) 25 (32.5) relatives of potential donors, resulting in an unfavorable
>15 10 (23.8) 7 (16.7) 25 (59.5) outcome. Other studies revealed that, despite a positive
Understanding of transplantation procedures attitude toward donation, health professionals can be reti-
Strongly agree 55 (46.2) 16 (13.4) 48 (40.3) 40.936 .000 cent when it comes to talking to relatives about donation
Agree 80 (23.3) 103 (30.0) 160 (46.6)
[19]. Almost half of the health workers studied was unde-
Uncertainty 12 (22.2) 18 (33.3) 24 (44.4)
cided regarding transplantation. This implies activities that
Disagree 4 (25.0) 0 (0) 12 (75.0)
Strongly disagree 0 (0) 3 (75.0) 1 (25.0) motivate and encourage positive attitudes through appro-
Understanding of donation procedures priate information dissemination are still needed. With
Strongly agree 52 (39.4) 16 (12.1) 64 (48.5) 34.743 .000 regard to training, 39.7% of respondents said they had
Agree 62 (25.2) 85 (34.6) 99 (40.2) received specific training on donation procedures at some
Uncertainty 29 (24.6) 33 (28.0) 56 (47.5) time during their job training, and 77.1% acknowledged that
Disagree 4 (13.8) 4 (13.8) 21 (72.4) they would like to receive training in this area. Evanisko
Strongly disagree 4 (36.4) 2 (18.2) 5 (45.5) et al [20] reported in their study that less than one-third of
those taking part had received specific training, whereas
Jenilek et al [4] found that only one-quarter of the sample
[8e10] that found that females had more positive attitudes population had received training in donation and trans-
as they may have more emotional values compared to males. plantation. Attitudes and lack of knowledge among health
A possible reason for this may be that the amount of males care workers have been identified as barriers and pivotal to
in our study were so small, which was insufficient to successful organ donation [21]. Knowledge level had a
compare with females. In this study, there were 66.6% significant direct effect on attitudes and an indirect effect on
nurses who would undergo transplantation for themselves if subjective norms and perceived behavioral controls [22]. In
necessary, less than what was reported by foreign countries this study, nurses willing to donate their own organs and
(73.3%) [11]. This finding may be related to the relatively their relatives’ organs were statistically higher in the
young ages, shorter lengths of service, and temporary “strongly agreed” group for understanding of trans-
appointment in transplantation nurses (Table 1). Moreover, plantation procedures and donation procedures, respec-
48.3% nurses’ numbers of late night shifts were greater than tively. When people have a greater understanding of the
8 per month. People tend to have only one job in their transplantation and donation procedures, they are likely to
lifetime in China; therefore, job stability, guaranteed have more active attitudes toward transplantation and
income, and flexible work time were the main factors donation. It shows that transplantation nurses with higher
influencing the nurses’ emotional failure and professional levels of information about transplantation and donation
minds. Thus, temporary appointment is bound to affect showed plausible attitudes toward transplantation and
young nurses’ professional minds [12]. donation.
A study in Poland found that the attitude toward organ More specific education directed toward organ donation
donation of nursing students was favorable in 69% [13]. In rather than general education is more relevant in improving
Georgiadou’s study conducted in Greece, nearly half of the attitude of health workers to organ donation [23,24]. In a
people (48.3%) wanted to become donors and 49.1% would study about knowledge of the brain death concept
donate the organs of their relatives after death [10]. A study conducted by personnel in Spanish and Latin-American
about primary health care personnel faced with cadaveric health care centers, a direct relationship had been found
TRANSPLANTATION NURSES IN CHINA
between understanding of the concept and attitudes toward
deceased donation (P < .001); people who understand the
concept more were more likely to have a positive attitude
toward deceased donation [25].Within 13 years, Portugal
reported more than 100% increases in organ donation by
training health professionals [26]. Medical staff members
are the first to establish contact with potential donors, and if
they are well-informed and convinced, they could engender
successful organ donation [27] d both living and cadaveric.
Nursing plays a fundamental role within the process of
organ donation and transplantation. In this respect, nurses
of transplantation surgery wards have major influence on
the opinions of the rest of the general patient population
regarding organ donation and transplantation, especially
nurse managers [1].
The primary limitation of our study was that it was
questionnaire-based. More valid research tools are needed
to develop more detailed data. Also, the study was
conducted among only 22 hospitals of nurses in trans-
plantation surgery wards. Therefore, our results cannot be
generalized to the community. More studies should be
performed to rectify the decline in organ donation rate.
CONCLUSIONS
This study showed that Chinese transplantation department
nurses have little willingness toward transplantation and
donation in the hospitals. They are a group that generates
opinion in the population, and their negative attitudes can
have a significant negative impact on society’s attitudes
toward organ donation. The proposed line of work to follow
in the future is to ensure that health professionals, especially
the transplantation nurses, are given adequate training
regarding transplantation and donation so as to increase
donation rates. On the other hand, government organiza-
tions should take up the awareness programs to the masses
through social media.
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