Perception of the Nurse in the Process of Donation of Organs and Fabrics for Transplantation

Conclusion: The research demonstrated the real difficulties of the professionals during the donation process, such as lack of human resources, extensive protocols, and lack of awareness of the society to understand the donation process and the family approach. Perception of the Nurse in the Process of Donation of Organs and Fabrics for Transplantation ORIGINAL Vanessa Matos Vargas1, Miriam Fernanda Sanches Alarcon2, Ana Cândida Martins Grossi3, Marcela Tondinelli1, Kelly Holanda Prezotto3, Maria José Sanches Marin4


Introduction
Rates of organ donation have increased in several countries, but the disproportion between the number of donations and the number of patients in the waiting list for one organ remains a concern [1].Organs and tissues transplant consists of donating a part of the body from one individual to another in order to restore the compromised function [2].Thus the donation of organs is not only an attitude of solidarity with ethical meanings, but an attitude of survival [3].
In Brazil, this practice has been guided by laws and ordinances of the Ministry of Health that support and organize the process.It should be noted that there are some laws that relate to free donation, beneficence with respect to the recipient and not maleficence with respect to the donor if the donor is still alive [4].
The Ministry of Health Ministerial Order No. 1752, dated September 23, 2005, determines the constitution of an Intra-Hospital Commission of Organ and Transplant Tissue Donation in all public, private and philanthropic hospitals with more than 80 beds [4].This commission must be formed through a formal act according to the direction of each hospital.The committees must have at least 3 members in the functional body, one being the Coordinator of the Intra-Hospital Organ Donation Committee.
Also on the legal aspect, the Ministry of Health approves the Technical Regulation of the National System of Transplants, in addition to classifying the Intra-Hospital Commission of organ and tissue donation for transplants in categories I, II and III [4].This document comes to guide the Coordinators by showing them their tasks in detail.If there are still doubts regarding the tasks and responsibilities today in the state of Paraná we have the Organ Procurement Organizations located in Londrina, Maringá, Cascavel, and the Paraná State Transplant Center [5].
The process of organ and tissue donation consists of several steps, starting at the moment when a potential donor is identified by the multidisciplinary team present in the Intensive Care Unit or other hospital wings [6].
The role of nursing is not restricted to the care and maintenance of the body.Such care includes preventing, detecting, treating and rehabilitating individuals with health problems related to pathologies prior to organ transplantation [7].
However, failures in identifying a potential donor, lack of notification, delay in diagnosing a brain death, failures in the care of the potential donor, and family refusal are the main causes of failure in the donation process.For this reason, permanent education becomes important and necessary to improve the skills of these professionals [8].It can be seen that permanent education has not only become effective in the workplace, it is necessary with the population in general and with the help of the existing means of communication, this work can be executed in the best possible way.
Therefore, it is necessary to know the functions that the nurse performs in the process of donating organs and tissues for transplantation, emphasizing the perception of the same based on the theoretical knowledge with the execution of the work.Therefore the objective of this research is to know the nurses' perception in the organ and tissue donation process for transplants

Methods
This is a descriptive research with a qualitative approach, carried out from September to October 2016, with Nurses of a hospital located in the North of Paraná.
The study participants were 16 nurses from the referred hospital.All the hospital nurses who agreed to participate and signed the Informed Consent Term were included in the study.Nurses who were on holiday were excluded.
The data were collected through an interview with a semi-structured script, made up of two parts: the first with questions regarding the characterization of the interviewees and the second with open questions that were recording or written in the area of each interviewees worked between the period from September to October 2016.
The guide of open question was: "What are the care they should have with the potential donor?" "What are the main difficulties during the process?", "How do you handle the donation process?" "Is the approach to the family?""Are you an organ donor?"Whose subjects permeated the central theme of the study: the nurse's experience in the process of organ donation.Thus, the interviews were scheduled according to the availability of the professional.
The interviews were recorded in digital media, had a duration of 30 minutes or written as the professional chose, and were transcribed in full on the same day, right after its end.Although data saturation (recurrence of information) occurred in the tenth interview, it was decided to interview the 16 Nurses.
To analyze the data, the content of the interviews was submitted to content analysis in the thematic modality and followed the phases of pre-analysis, material exploration, treatment of results and interpretation.In the pre-analysis phase, the reading of the speeches was carried out, in order to identify the relevant points for the purpose of the study.In the material exploration phase, codification was performed, codes were assigned to the sense nuclei, which represent the content expressed in the speeches and which were aggregated into units.During the last phase the categorization was carried out, which was configured in the classification of the elements, according to their similarities and differentiation, with the subsequent regrouping according to the common characteristics [9].
In order to guarantee the confidentiality and privacy of the participants, the initials of the professional category were used as code: N (nurse) followed by the order number in which the interview 1 occurred ... and so on.
The study complied with the formal requirements contained in national and international standards for research involving human subjects.

Results
Of the 16 nurses who were part of the present study, 15 were female and 1 male, with a time of service in the health area between 3 and 28 years, regarding the length of service as a nurse ranged from 4 months to 18 Interviewees were from all sectors of the hospital.
From the analysis of content emerged four categories that express the perception of nurses in the process of donation of organs and tissues for transplantation and are described below: Organ donation process: nurses' experience; Nursing care for potential donors; Family approach; Main difficulties in the donation process.

Donation process: nurses' experience
The interviewee's speech when asked them about the way the donation process as a whole demonstrates deep knowledge about the stages of this process, evidenced that the process of organ donation is not restricted only in the capture of the same, it begins before, there are in Of protocols, several steps that must be followed carefully and only after performing all the steps, occurs to the capture followed by the return of the body to the family.This is what the following testimony reveals: The process begins with the identification of the potential donor, we open the protocol of Brain Death or Cardiopulmonary Arrest, soon after we collect the laboratory exams and send to the Central, we already started with the tests present in the Brain Death protocol.After confirmation, we move on to the family approach and if it accepts, we will go to the surgical center to perform the capture.

E2.
Other participants said that in addition to the practical part of identifying the potential donor and keeping it in good condition, another step in the donation process is bureaucratic.All forms of Brain Death or cardiorespiratory arrest and those belonging to the coordination of the In-Hospital Commission for the donation of organs and tissues for transplantation must be filled in correctly, so that there are no unnecessary discards.What can be evidenced in the following statements: As soon as I identify the potential donor, I open the protocol of Brain death...

E2.
When we find a cardiorespiratory arrest, I immediately open the protocol for the donation of corneas...

E3.
When we find a cardiorespiratory arrest, I immediately open the protocol for the donation of corneas...

E3.
Still on the process of donation, it is worth noting that for this to happen professionals are needed, a trained team and an organizational structure that gives subsidies.This structure could be the same as the Intensive Care Unit, with its own beds, air conditioning, medication at the disposal, mechanical ventilators, and all the materials needed to support the body of the potential donor until the transplant takes place, as this professional states: Maintains the body in stable conditions for the process of capturing multiple organs is the staff of the Intensive Care Unit sector.I have already had the opportunity to follow up...In the sectors we do not act on brain death, since the structure does not Of the rooms that accommodate multiple patients and the temperature can not control.

E7.
It was noticed that on the experience of each professional in the donation process, there was a variation in the responses, depending on the sector in which these professionals were and degree of experience and affinity with such responsibility.In some sectors of the hospital such experience does not occur or occurs with low frequency, due to the peculiar characteristics present in these sectors.The following statements denote this understanding: In the sector my experience occurs in the opening of the Cardiopulmonary Arrest protocol, I verify if the client fits the profile, protects the PD and makes the procedures to keep the organs protected.Then I'll talk to the family, if I authorize it, I'll go to the surgical center. E7.

In the area of the Intensive Care Unit I carry out the identification of the PD, collect the data to verify if the donor potential is feasible or not, open the protocol of ME or of PCR, perform hemodynamic care, perform clinical exams and request the EEC, Apnea test.
E11.

As the deputy coordinator of the Intra-Hospitalar Commission for donation of organs and tissues for transplantation and nurse of the Intensive Care Unit, I do a daily search for patients with Glasgow less than 7 and notify the central transplant... I evaluate the deaths / month To forward the data to the transplant center and identify the cardiorespiratory arrest leaks to verify if the families were approached.
E19.

Nursing Care for Potential Donors
With regard to nursing care, these are distinguished according to each sector, such as clinical , administrative and pre-operative planning.It is worth noting that no care is more important than the other, but all complement each other to reach the same end.Thus, such care tends to develop in the potential donor as a whole, being holistic and continuous, never being fragmented.With this, the statements indicate the nursing care before death by cardiorespiratory arrest compared to the care of brain death.
The first care we have to take to the potential donor is with the temperature, it can not be less than 32ºC, collect blood gases to verify blood pH and the amount of gases, laboratory tests to check the blood count and the amount of electrolytes in the potential donor.

E2.
If the exams give altered, we must correct the picture, the doctor will change the parameters of the mechanical ventilator, if it is of electrolytes we will make the replacement, it is necessary to maintain a hydroelectrolytic balance in the Potential donor since many can realize a loss of volume quickly caused by diabetes insipidus. E4.

I maintain good body temperature until the end of the collection, observe the hemodynamic parameters.
E8.

Family Approach
Through the excerpts from the interviews, it is possible to observe that the approach to the relatives of the potential donor is an obstacle faced by the nurse in the continuity of the organ donation process.The following statements denote this understanding The nurse must be very well prepared and confident.It's not easy.Sometimes the family is thick, it acts with ignorance, but you may not take it personally, it is only the moment of mourning that you are experiencing.

E8.
Waiting for the right timing, giving the family time to absorb the news, and giving support in the form of picking are crucial steps in introducing the subject of organ donation.When the professionals were questioned about how they proceeded at that time, the answers were very similar: I take the beings in a reserved room, we give the news of the death.I welcome the family.After the welcome, I introduce the subject, with the family interview, asking if the entity manifested in life the desire to donate...I explain how the process is done and how the body will be delivered and wait for the family answers.

E3.
After taking in a reserved place to give the news and to welcome, I say that it is an obligation of the hospital to approach the family because it is law and that the care will be the same independent of the decision to be made.

Main difficulties in the donation process
The last category comes to portray the difficulties of the nurses in carrying out the process.Among them, the family approach was highlighted, during the interviews this point was what most professionals felt difficult to express their answers.As discussed in the previous topic, dealing with death is not easy for some professionals and this can be distressing for those professionals who do not like or do not have the skills to deal with the topic.When asked about this question we obtained several answers among them: The delay of the laboratories in sending the results, delay of the evaluation of the transplant center to verify the conditions of the potential donor. E2.

Removal team mobilization, which comes by plane, car, ambulance and the weather and traffic conditions can disrupt the process making it take longer.
E8.

Discussion
The donation process begins with the identification of the potential donor, this task is often the responsibility of the health professionals who have a greater contact with the patient along with the family.With this, this responsibility is often linked to nursing [10].For this reason nurses along with their staff must be well trained so that no potential donor within their industry is overlooked.
The identification of the Donor Potential should occur through daily visits of the nursing staff of the Intra-Hospital Commission of donation of organs and tissues for transplantation in all sectors where it is possible to find them [11].The visit of the nursing committee is of paramount importance, since in its day to day many professionals have multitasks that depend only on it in the sector, thus, the identification of Potential donors is neglected going unnoticed, and often being underreported what can Indicate a reason for failure during the process.
A classification of nursing functions within the process of organ donation and collection would be an effective way of improving the process as a whole [11].Divided nursing professionals into clinical nurses and nurses coordinating transplants, which facilitates the organization of tasks and minimizes the overload of these professionals.Even if both perform different tasks, the two must walk together during the process Regarding the maintenance of the Potential donor, the Intensive Care Unit is the best environment, since it provides conditions for more aggressive resuscitation with vasopressors, hormonal therapy even before the family consent occurs.In addition, this sector has direct links to the institution's laboratory and to the imaging and electroencephalogram exams, which facilitates the completion of the organ capture process [12].
In the process of organ and tissue procurement, the National Nursing Council of 2004 recommends nurses to plan, execute, coordinate, supervise and evaluate the nursing procedures provided to the donor, as well as to plan and implement actions aimed at optimizing donation and Collection of organs and tissues for the purpose of transplantation, in addition to performing care throughout the process [13].
In the sectors, there is only the opening of the cardiorespiratory arrest protocol, where it is possible to capture the corneas and the heart valves, the corneas being taken in the hospital by a physician or the nurse of the surgical center who performed the specific course for such a function, as Resolution of COFEN-292/2004 that normatize the performance of the Nurse in Organ and Organ Procurement and Transplantation [14].
With regard to the care given to the potential donor is one of the crucial parts of the process of organ donation and collection, it is at this stage of the process that determines whether it will succeed or not.For these reasons the clinical nurse needs to obtain specific knowledge and skills, clinical experience [11].
The nurse who is at the forefront of the ME protocol must know the pathophysiological changes resulting from brain death, in order to perform adequate and satisfactory interventions in the potential donor, thus maintaining the viable organs [15].Among the alterations we may have arterial hypertension, tachycardia and increased demand for oxygen by the myocardium, followed by vasodilation that will lead to severe hypotension and hypovolaemia; Pulmonary edema and alveolar hemorrhage may occur causing imbalance in ventilation perfusion and hypoxemia; Occurrence of Insipidus Diabetes, drop in T3 levels, alteration in insulin secretion, leading to hyperglycemia, disseminated intravascular coagulation and hypothermia [15].As we can see the care varies depending on the cause of death, brain death or cardiorespiratory arrest, depending on where the donor potential is, but all actions will culminate in the same purpose, which would keep the organs kept and ready for the last moments.According to the waiting list.
Another moment in the organ and tissue donation process is the family approach, the moment in which a conversation takes place between the health professionals involved in the donation process and the families of the potential donor in order to consent to the continuity of the process Of organ donation [17].It is not an easy task as it involves news of a loved one's demise and then a question whether family members would like to donate their organs.
Even though it is a very important stage in the donation process, there are few literatures that bring an approach to the theme.Even for the professionals interviewed in the health area who deal with the health and death process, their greatest difficulty is the family approach, since there are no protocols or statements that will serve as a standard for approaches, each case is a case, each loss has A meaning and each person has a particular way of living mourning.People do not want to lose anything, for this reason the donation of organs is often understood as the admission of death of a loved one at a time when the family is still not able to accept it.This phase is important for the continuity of the process, because you can keep the body in perfect condition and even if the tests give positive results, if the family does not authorize the donation process, it ends at the moment of non-consent.When the term is spoken of in the family, the term refers to the spouse or relative of majority, obeying the line of succession, to the second degree, signed in a document signed by two witnesses present at the death check.
Having a reserved and appropriate place to conduct the interview favors dialogue between interviewers and interviewees [19].Leaving the family in an environment that gives them security and comfort, offering water, tea, giving them time to cry and express their feelings may seem like very simple measures, but they can make a difference in the decision.
Still on the topic, a research indicates factors that are classified as facilitators in the familiar approach, among them are the assistance given to the relatives of the potential donor; The enlightenment about brain death; The language used by the interviewer; The location of the interview.But what draws attention to all these factors is that all this will only be positive factors, if the family witness a quality care, kind and safe to their being, considering that the professional that attended that entity did everything for the Even if he recovered [17].These simple attitudes may interfere with a positive or negative response at the time of interviewing the family.

Conclusion
The data showed that the professionals present scientific technical knowledge about the process of donating organs and tissues for transplantation as a whole, knowing how to define and execute each phase: identifying the potential donor, opening the protocol, familiar approach, organ retrieval, Body for the family.
The study brought several problems that the professionals usually face during the process, it was verified the lack of human resources at the time of opening the protocols that are usually extensive and laborious, besides the non identification of the professional to carry out such activity and the refusal of the family members For donation of organs, this being the problem most evidenced by professionals.
Finally, it is emphasized the previous preparation of families, aiming to make society aware of the importance of such an act, which would make it possible for the family members to refuse and thus improve the demand of donors.

Collaborations
Vargas VM e Alarcon MFS contributed to project design, data collection, organization, analysis and interpretation, article writing and final version approval.Grossi AC, Tondinelli M, Prezotto KH e Marin MJS contributed to the writing of the article, critical review of the intellectual content and approval of the final version to be published.International Archives of Medicine is an open access journal publishing articles encompassing all aspects of medical science and clinical practice.IAM is considered a megajournal with independent sections on all areas of medicine.IAM is a really international journal with authors and board members from all around the world.The journal is widely indexed and classified Q2 in category Medicine.