INTRODUCTION

Worldwide, organ and tissue transplantation from patients with brain death is becoming increasingly used for therapeutic purposes. At present, such procedures become safer and more efficient, offering to the organ or tissue receiver a better quality of life.

According to the World Health Organization (WHO), the use of organ and tissue donation has proven to be an effective strategy for the treatment of a wide range of diseases. However, the shortage of organs to meet the demands is a fact experienced by several countries, constituting one of the main obstacles for the accomplishment of a greater number of transplantations¹.

Based on the above, it reiterates the importance of each nation to build and adapt its organ donation program based on the culture and the needs of its citizens. In Brazil, legislation related to donation and transplantation issues is old. However, in 1997 alone, the country began a process of consolidation and structuring of the National Transplantation System, through law N 9434/97, which provides for the removal of organs, tissues and parts of the human body for the purpose of transplantation². This legislation was subsequently amended in 1998 through a Provisional Measure (PM 1718), which adopted the model consented to the presumed model, in force through law N 9434/97. Thus, the decision on organ donation in Brazil became exclusively from the family³.

In the year 2000 there was sanctioned the Ordinance N 905/GM of 16^th August, which established the creation of the Intra-hospital Organ and Tissue Donation Transplantation Commission (CIHDOTT). This document guides the organization and attributions of CIHDOTTs at the hospital level, pointing out that only medical professionals or nurses can be CIHDOTT Coordinators⁴. This legislation was subsequently replaced by Ordinance N 2,600 of October 21^st, 2009, which approves the technical regulation and classification of CIHDOTT⁵.

These committees are composed of multiprofessional teams that play an important role in obtaining organs, since they are allocated within the hospital units, performing an active search by potential donors, who do not yet have a diagnosis of brain death, but with a clinical condition suggestive of such diagnosis. In addition, it has the function of informing the family about its desire to donate organs and tissues of deceased patients⁵.

In this way, the participation of health professionals in this process is essential. Among these, the nurse, who plays a crucial role in establishing a successful transplantation program⁶. In particular, in the field of intensive care units, the nurse stands out as the professional who is closest to a potential donor, because of the care given to him, in addition to maintaining contact with the family, either for a short or long period. In this way, nurses become a reference for family members, being able to keep them informed, comforting them, and experiencing the health conditions of their loved ones hospitalized⁷,⁸.

Also, according to Resolution 292/2004 of the Federal Nursing Council (COFEN), the Nurse is responsible for planning, executing, coordinating, supervising and evaluating the Nursing Procedures provided to donors of organs and tissues. This involves planning and implementing actions aimed at optimizing donation and organ/tissue uptake for transplantation purposes. Also, to apply the Systematization of Nursing Assistance (SAE) in all phases of the donation and transplantation of organs and tissues to the receiver and family, this includes pre- and post-transplantation follow-up⁹.

However, a study carried out in Sweden emphasizes that there are difficulties on the part of professionals to deal with adequate psychological support for the family and, at the same time, to raise the issue of organ donation, which is more frequently perceived in the professional nurse⁷. Another research originating in the United States (USA) points out that approximately one-third of critical care providers have not been formally educated for the organ donation process¹⁰.

In view of the above, research that deepens the debate about this issue can bring contributions, especially, by demonstrating how nurses join the donation commissions of organs and tissues and obtain knowledge to perform activities in them. It is hoped that the reflections will help to establish measures that not only favor the participation of nurses in these committees, but also stimulate the training about the subject, and the adoption of positive attitudes of nurses towards the potential donor, family and care team.

Therefore, the present research was developed based on the following research question: How do the insertion of the nurse in hospital commissions of donation of organs and tissues for transplants and the obtaining of knowledge to act in the same one? Thus, this study aims to recognize how the insertion of the nurse in the in-hospital commission of donation of organs and tissues for transplantation, as well as the obtaining of knowledge to act in this one.

METHOD

It is a qualitative research approach, of an exploratory and a descriptive type. In the investigations of qualitative approach, the attitudes, beliefs, behaviors and actions of the researched individuals are approached, trying to understand the human being in his relations with the world¹¹.

The study was carried out in five large hospitals in the city of Porto Alegre, located in the state of Rio Grande do Sul (Brazil), which have CIHDOTTs registered in the Ministry of Health. Following inclusion criteria: to have CIHDOTT in its dependencies duly registered in the National Transplantation System and to be located in the City of Porto Alegre. Exclusion criteria were: hospitals that are only for transplantations, hospitals with which telephone and / or Email was not possible, and health institutions that pointed out difficulties in obtaining institutional authorization to carry out the study.

Nurses working in CIHDOTT were considered as participants in the research. In order to do so, the following criteria were included: being a professional nurse duly registered with the Regional Nursing Council and appointed to work in CIHDOTT through an official internal document of the hospital, and who had experience in CIHDOTT for at least six months, due to the greater experience and contact with situations involving the theme in question. Exclusion criteria were nurses who were members of an in-hospital commission of donation of organs for transplantation that were in an award for health treatment or other leave during the period of data collection.

In the five hospitals that composed the study scenarios, there were a total of 14 nurses linked to the CIHDOTT service that met the inclusion and exclusion criteria. It was estimated that all participants were interviewed, but two could not be interviewed, one due to their disengagement from the institution's staff during the data collection period and another due to the impossibility of meeting for the interview, resulting in 12 participants.

The interviews were carried out from May to June 2014. At first, an informal contact was made by telephone and / or Email with the participant to invite him to participate in the study and to clarify the objectives of the research and about the ethical aspects inherent the same. Subsequently, the interviews were scheduled and performed in their own place, and the data recorded in a digital voice recorder, to guarantee the reliability of the data in the transcription.

The authors used a semi-structured interview elaborated by the authors for this purpose, containing guiding questions about their insertion in CIHDOTT, interest and search for knowledge about the topic and beyond the subjective questions, the participants answered about sociodemographic information that made possible a characterization of the participants in terms of length of service, gender, age, time of performance in CIHDOTTs. The interview duration ranged from 15 to 40 minutes. The anonymity of the participants was made possible by the use of the letter "E" of nurses, followed by the numerical sequence (E1, E2...E12). A pilot test was conducted in order to verify if the interview met the research objective and the questionnaire was validated by the members of the research group to which the project is linked.

The analysis of the data was carried out based on the analysis of the thematic content of Minayo, in this sense, obeyed the steps provided by the method of analysis, which are: pre-analysis, from the constitution of the analysis and floating reading corpus; Analysis and categorization of findings; And interpretation, which included discussion with data from the relevant literature¹¹. As a result of this process, the following category emerged: The insertion of the nurse into an in-hospital commission for organ and tissue donation.

The ethical principles of Resolution of the National Health Council N 466/2012 were respected ¹². The study was approved by the Research Ethics Committee under the Certificate of Presentation for Ethical Assessment - CAAE N 26163113.9.0000.5346. The data collection subsequently began with institutional authorization and formal contact with the participants who agreed and made possible to grant the interview, after signing the Informed Consent Term (TCLE). To preserve the identity of the participants, they were coded with the letter E, followed by a number corresponding to the order of the interview.

RESULTS

Among the nurses participating in this research, age ranged from 24 to 53 years old, with prevalence between the ages of 30 and 40 years old (58%), predominantly female (91%). The majority of participants completed a baccalaureate degree in nursing in the years 2001-2012 (75%), with a higher incidence in 2010 and 2012 (33%).

CIHDOTT nurses, in their entirety, have one or more post-graduate degrees, with emphasis on Intensivism (42%), Surgical Center (25%) and Urgency and Emergency (25%). Attention is drawn to the fact that 17% of the participants have a specialization with emphasis on the topic of Organ Donation and Transplantation, evidencing the search for specific knowledge about the topic. It is also worth mentioning the occurrence of two nurses (17%) with post-graduate level stricto sensu.

Most of the study participants are in the job market as a nurse a decade ago (67%). And only two nurses work exclusively with CIHDOTT, the others (83%) in addition to members of CIHDOTT formally named in official documents of the hospitals, perform activities on alert scales in CIHDOTT, performing their main tasks in other hospitalization units as in the intensive care unit with (33%), followed by the surgical block (25%) and, later, emergency, general clinical and neurological units (42%).

Among the institutions researched, nurses are the professionals that make up the largest number of representation in the CIHDOTTs, except in one hospital studied. Based on the approach of the interviewees, it was possible to make some considerations about the way of insertion in this commission and how to obtain knowledge to act on it, which is better explained below.

The insertion of the professional nurse in hospital commission of organ and tissue donation CIHDOTT

When questioned about how they joined the CIHDOTT, some participants reported that there was no initiative of their own, but rather a kind of "call" to take office. The following statements are illustrative of this situation:

Let's do it by gestures (he gestured with his hands). They told me so... there is a vacancy, we think it's your profile (E1).

It was by free and spontaneous pressure (E2).

Well, the insertion was kind of by free and beaten will (E4).

In other cases, professionals joined CIHDOTT because of their interest, or curiosity about the subject. It is noticed that the question of curiosity and interest is related to the sectors where they worked. Thus, when faced with situations of brain death and processes of donation and transplantation, the nurses had their interest aroused by the subject.

[...] due to follow some procedures in the block, I found very interesting. But it was more, therefore, to watch, follow some procedures (E2).

I went in for curiosity, but then I liked it. Then, afterwards, it ended in passion. But at first it was out of curiosity (E5).

And I was always interested, I was always worried about maintaining the potential donor, and then they always called me to participate in the interviews, because they saw that I was interested [...] I was invited (E7).

[...] for curiosity, I was approaching the process, finding it very interesting. I wanted to know how it worked [...] and so, I was inserting myself, was seeking information and after a while I entered (E12)

The search for scientific training after joining CIHDOTT

Other reports expressed by the interviewees relate to prior knowledge about donation, transplantation and training for professional practice as a member of CIHDOTT. In this sense, the lack of training before joining the commission was expressed in the following statements.

Before joining CIHDOTT… it was only for self-interest (E1).

No. Actually, empowerment must be done before, but I have come in without training (E5).

Before entering not. None. Only later when I was aroused interest and then I searched (E8).

After joining us, he was reading [...] he was certified here (he said the name of the Hospital) (E10).

It should be noted that the data below are unanimous among the participants. In this sense, nurses also point to gaps in the process of professional training.

I think it's early in college. It's because they do not see it, I see it, because we have in the (named the hospital) several courses in health, physiotherapy, nursing, medicine and nutrition. And they do not see the protocol; sometimes the protocol is an entire college class and goes away (E1).

I think there is a big government investment in this area, but I think there is a lot of preparation for professionals to make things work better (E7).

It is pointed out that there are still weaknesses in the professional training process in order to prepare nurses for work in donation and transplantation, since, when questioning the theoretical basis or prior qualification to joining the CIHDOTT, the interviewees’ answers were objective and clear, ratifying the lack of knowledge.

No. I had nothing (E7).

Before joining CIHDOTT, only for self-interest (E1).

Before entering, do not (E12).

Before? No, not once (E4).

As there is a lack of formal education on organ donation and transplantation, nurses often become self-taught in the search for knowledge, as presented in the reports below:

Everything I tried in the hospitals where I already had [...] after I started to participate in all the congresses I had, that I knew of transplantation I would, I did not lose one (E3).

[...] each seeks his knowledge. So I started to participate in the discussions, the classes I had here at the hospital, the big round I had about the subject, the congresses, the days, the activities that talked about the theme and the experience in the field of donation (E6).

It is recognized, however, by the nurses that, in charge of the government and institutions for training and training CIHDOTT members are being carried out, in order to improve the teams.

[...] at least here in Rio Grande do Sul we have participated in many courses related to training. Here I see that they are always in search of transmitting information to improve the qualification index (E12).

[...] we took a course through the state transplant center for organ transplants, so it was a two-day course (E11).

Nurses also express in the reports, opportunities for better qualification and information through exchanges of experiences that will add quality in their doing, as members of the CIHDOTT, which, in turn, could facilitate their performance.

[...] Updates more followed, would better qualify the professional nurse. Interview training, even maintenance, all this part (E2).

[...] when we formed the CIHDOTT he (a doctor) showed slides, he did an internal training, for us, where he talked a lot about brain death, how the process is [...] with that we had a theoretical basis. So it was during this process (E10).

Nurses perceive knowledge as essential for effective action in the process of organ donation and transplantation, and know that the nursing professional is allocated in all sectors where there is health service, and therefore places them in a position that requires the search for knowledge.

I think bond and knowledge is everything (E1).

I think the ease, knowledge about the donation process itself (E2).

The CIHDOTT nurse, because it is within this context, he knows the laws, how the transplant center works. He has to know this [...] must have certainty in the process [...] this is not the space for doubts (E6).

The nurse is the soul of the CIHDOTT business, because it is he who end up in the group and end up taking it forward, I do not think there would be CIHDOTT if I did not have a nurse (E9).

The practical training of the CIHDOTT team

Practical knowledge enables the nurse to develop techniques, skills, create bonds and make ties between the elements that participate in the process of donation and transplantation. Many nurses get such experiences, thanks to the help of other nurses from CIHDOTT who have been in the committee for a long time.

Who trained me was the OPO nurse (organ procurement organization), so I followed the cases [...] (E1).

When I was going to follow up on a donation process she would call me, call me [...] and then I started to accompany her on some things. Well then I started to share the warning with her (E6).

I started attending meetings and attending some shifts and then doing the shifts alone (E11).

DISCUSSION

Nursing involves a specific component of scientific and technical knowledge built and reproduced by a set of social, ethical and political practices that are carried out through teaching, research and care. It takes place in the provision of services to the person, family and community in their context and life circumstances. ¹³ In the last decades, nursing has been characterized as a profession in full development, in the conquest of new perspectives and knowledge, through the knowledge of professionals and technological advances, building a concrete and visible space in health systems⁸.

It is worth mentioning the ordinance 2600/2009/MoH, which approves the Technical Regulation of the National Transplantation System. In this, the General Coordination of the National System of Transplantations (CGSNT), through the Center for Notification, Capture and Distribution of Organs (CNCDO) is responsible, among other responsibilities, to participate actively in the training, qualification⁵. However, this ordinance is in agreement with the results found, because when joining CIHDOTTs, nurses report not having training or qualification for such activity, needing to improve their knowledge through self-interest, participating in courses, lectures or accessing available literature about the subject.

Also, in the training of nurses, there is a need to provide teaching-learning situations that enable the acquisition of knowledge so that they can base their work in the sphere of work¹⁴. Studies conducted in Brazil, Qatar, and the USA, address the participation of nurses in the organ and tissue donation process, affirming that educational policies should be inserted during professional training to contribute to the continuous improvement that involves the whole process of organ donation and tissues for transplantation, enhancing the attitudes of these professionals towards the possible organ donor⁶,¹⁵,¹⁶.

As seen in the reports, the nurses' admission to CIHDOTT is permeated by concerns. Because of this, nurses are appointed by the institutions to assume such positions, with no choice, for lack of nurses who wish to join the commission spontaneously due to lack of preparation.

According to the aforementioned data, the findings of this investigation corroborate that the CIHDOTT nurses entered the CIHDOTT with little or no previous knowledge, which is consistent with the deficiencies during the formal education of this professional. The lack of preparation to assume a role as a nurse of CIHDOTT is pointed out in the reports, having as main cause, the lack of knowledge about the donation of organs and tissues. Research carried out with nurses evidence that they did not have enough information about organ donation, believing and supporting the need to educate health professionals about the process of organ donation and transplantation, since they can positively determine the attitudes towards to the donor powers¹⁵.

A study with nurses¹⁶ shows that those who acted as coordinators of donation and transplantation commissions in the US did not have any formal training to perform their work role. It is also worth noting that educating such professionals can be difficult when there is no formal competence or established standards for such activity.

The theoretical formation was mentioned as something important and, despite the lack of availability of this knowledge, the nurse searches for information about donation and transplantation go through the most varied forms. In this sense, this is emphasized as being a quality of nurses in relation to the search for formal and/or informal knowledge for the development of their role as nurses of CIHDOTT.

Thus, the nurse is constantly instigated to seek knowledge, which enables him to offer care in favor of the patient, perhaps, as a result of which, in some matters pertinent to the profession is not assigned the importance at the moment of preparation of the nurse. In this sense, a highlight can be given to issues related to death, one of the issues that will be present during the professional life of nurses, but which is rarely addressed during training¹⁷.

It was evidenced that there was an increase in confidence and performance in nurses’ work in the process of donating organs and tissues at the end of a specific training. The research also points out that the work satisfaction of all those involved has been improved, emphasizing that training has been extremely effective¹⁶.

The reports also mentioned that nurses are interested in more qualification, which prepares them for any circumstances that may occur during the process of organ and tissue donation. A Brazilian study emphasizes that, although nurses who work in donation and transplantation are recognized by practical experience, the need for research that can improve the care provided may not be ignored, as well as requiring a range of scientific knowledge in the area of ​​organ donation and transplantation⁶. Research has shown low scores among nurses and physicians regarding knowledge about organ donation, suggesting that lack of knowledge has a negative effect on people's attitude toward organ donation¹⁵,¹⁶.

It is known that both the theoretical knowledge coming from formal or informal means, and the domain of practice from experience, will only be performed ideally, if they are interrelated, since, in isolation, it would be difficult for nurses to contemplate the process of donation of organs and transplantation in its fullness. Therefore, the literature demonstrates that knowledge alone does not influence nurses' willingness to become involved in the organ recruitment process, and should also be associated with attitudes towards this process¹⁷.

Generally, in the CIHDOTT survey, the skills of the new nurses are reached with the aid of more experienced nurses in the commission. Research conducted in the US reveals that many new nurses are enabled through on-the-job training, that is, in day-to-day work, often coming to designate the most experienced staff to train the new nurses, and in some cases, simply, the nurse who is most available at CIHDOTT is used for training. The same research suggests as a suggestion, offering courses lasting 4 to 10 months, which would enable the new nurse to participate in the activities of the committee with greater knowledge, improving the satisfaction of the service and reducing the friction between the employees¹⁸,¹⁹.

A study conducted in the US with 184 nursing scholars reports that nurses today may not recognize their important role and the ever-increasing benefits of organ and tissue donation. It is a reflection of weaknesses in the approach adopted by nurses during the phases of the identification, maintenance, donation, capture and organ transplantation²⁰. This demonstrates that discussing organ donation and transplantation at the academy allows the nurse to demonstrate positive attitudes toward this process.

In Brazil, discussions about the relevance of continuous education have taken center stage in health care settings. In this way, this can be a feasible and effective proposition, considering that it is one of the most used tools, as a form of professional qualification. The policy of continuous education in health favors the exchange and promotes the production of knowledge. Pedagogical decentralization enables new educators within health institutions, which positively influence the construction and production of health, thoughts, and desires in professionals encouraging them to be protagonists of the Unified Health System, understanding its principles and guidelines in a strong affirmation policy for life²¹.

In view of the above, it is considered that in both vocational training and in the context of health services, the approach to the organ donation and transplantation process should be emphasized. Also, Decree 2600/2009, points to the need for training and preparation of this professional before joining CIHDOT⁵. The shortcomings in preparing professionals to work in CIHDOTT can put at risk the trust of the whole process, because, in addition to being complex, organ donation involves a series of factors in which nurses must have the skills to do so; otherwise, they may lose the bond with the family when they are placed in unanswered situations, or they cannot coordinate and to assist the care team in the best possible management for the potential organ donor by placing it in check.

Raising awareness and preparing professionals to work in this area requires, at the same time, specialized knowledge and a differentiated professional profile to deal with sensitive situations that involve the process of death and dying. It is necessary, therefore, a more specific attention on the part of institutions and health-care services, regarding this theme. This allows a satisfactory and efficient performance of nurses in these committees, which can bring positive results and a greater impact on the rates of organ transplantation in our country.

CONCLUSIONS

It is considered that CIHDOTTs represent an important scenario for the nurse practitioner, and there should be adequate preparation for this. The inclusion of the approach on the process of organ donation and transplantation in academic training is an effective strategy for the preparation and sensitization of nurses about the subject. Likewise, the development of permanent education actions about the subject, especially in institutions that host CIHDOTT, is also essential, since it can bring positive repercussions, even on the indicators of acceptance of organ donation by relatives of patients with a diagnosis of brain death.

It is considered that, since it is a subject that has recently gained prominence, new investigations must be carried out, aiming the construction of knowledge that subsidizes the practice of nurses in this scenario of performance. This perspective is of particular importance when considering the need to expand the indicators of organ donation and transplantation in Brazil and the important role played by nurses in this process, when working in CIHDOTT.