- Email: [email protected]
Simulated Donor Family Encounters at Organ Transplantation Coordinators In-Service Training Course: Process and Impact Evaluation
Simulated Donor Family Encounters at Organ Transplantation Coordinators In-Service Training Course: Process and Impact Evaluation b, S.A. Çalıs¸kana, C.A. Bozoklarc, H._I. Duraka, and N. Demiral Yılmaza,* Ö.S. Karabilgina, N. Altug a Ege University Faculty of Medicine, Department of Medical Education, Izmir, Turkey; bEge University Faculty of Medicine, Organ Transplantation Application and Research Center, Izmir, Turkey; and cIstanbul Bilim University Faculty of Medicine, Department of General Surgery, Istanbul, Turkey
ABSTRACT Objective. This study introduced the modified version of the Organ Transplantation Coordinator course including simulated donor family encounters (SDFEs) and communication skills. It also evaluated participants’ opinions and achievement levels, and how they implemented what they learned in the course in their work settings. Methods. The course used the modified Analysis, Design, Development, Implementation, and Evaluation model and was evaluated in 3 steps. The participants’ views were obtained using the course overall evaluation form and communication skills evaluation form, their success was assessed with the posttest and SDFEs evaluation form, and the effects of what they learned during the course on their work settings were assessed through telephone interviews. At this step, the participants were asked to write letters about the targets they intended to achieve in their work settings. The letters were analyzed with the content analysis method, and a questionnaire consisting of 105 targets was developed. A year later the participants were telephoned and asked to what extent they achieved their targets. Results. The participants’ satisfaction from the whole course was high (x: 8.65 1.06). In the communication skills evaluation form, the participants stated that they would mainly utilize their communication and empathy skills during donor family encounters. The participants’ mean posttest score was high (x: 96.0 3.8). During the SDFEs, 70% of the respondents’ performance was considered sufficient. Telephone interviews conducted with the questionnaire revealed that 77.6% of the targets were fulfilled. Conclusions. It can be said that the course affected the participants in terms of implementing their knowledge and communication skills related to family encounters.
A
CCORDING to European Consensus Document 2003, “over 1 million people world-wide have received an organ transplant and some have already survived more than 25 years” [1]. Nonetheless, the chronic shortage of donor organs is a worldwide, continuing serious problem because of prolonged waiting times, deaths on the waiting list, acceptance of lowerquality organs, increased numbers of living donors, and commercialization of organ transplantation in many countries [2]. In 2012, 114,690 solid organs were reported to be transplanted, constituting <10% of global needs [3]. In Turkey, the number of transplantations performed in 2012 for kidney, liver, heart, heart/lung, lung, pancreas, and small bowel was 3999, whereas the number of patients on
the waiting list was 20,833. The rate of deceased organ donation is substantially lower than that in several countries. In 2012, actual deceased organ donation rates for per Part of this work was previously presented at AMEE 2012 and , S.A. was published in abstract only: Ö.S. Karabilgin, N. Altug Çalıs¸kan, C.A. Bozoklar, H._I. Durak, N. Demiral Yılmaz (2012). Simulated Donor Family Encounters at Organ Transplantation Coordinators in-Service Training Course: Process and Impact Evaluation, AMEE Lyon, France. *Address correspondence to Nılufer Demiral Yilmaz, PhD, Ege University Faculty of Medicine, Department of Medical Education, 35100 Bornova, Izmir, Turkey. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.022
Transplantation Proceedings, 47, 1249e1256 (2015)
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million population in Spain, the United States, and Turkey are 35.1, 25.8, and 4.6, respectively [4]. In Spain, which has the highest donor rate, there is a parttime working national network that motivates hospital physicians in the process of organ donation. The Spanish model draws special attention to the transplant coordination network, continuous medical training, and education. There are some factors, such as the public national health system, economic resources, the number of doctors, the number of acute care beds and intensive care unit (ICU) facilities, and age distribution of the population, that influence the use of this model in other countries [5]. In Turkey, after the law related to transplantation procedures was enacted in 1979, the first cadaveric donor kidney and liver transplantations were performed in 1979 and 1988, respectively [6]. The Turkish system was improved like the Spanish model in 2000. The Turkish National Coordination System (NCS) was established by the Ministry of Health (MoH). The NCS consists of the National Coordination Center (NCC), Regional Coordination Center (RCC), and Local Coordination Center (LCC) in hospitals that have ICUs. A coordinator works at each level of the NCS. The basic title for these staff members is Organ Transplantation Coordinator (OTCs), and this is further distinguished by the level of work setting, ie, National Coordination Center Coordinators, Regional Coordinators, and Hospital Coordinators. Among the common tasks and responsibilities of all the coordinators are to organize organ donation campaigns, in-service training for health workers, and public education, and to participate and support every campaign and education prepared by the MoH [7]. With the initiative of a group of volunteers, training programs for coordinators were started in 2002 and repeated in 2003 and 2004. After these courses, the MoH conducted 2-day formal courses and gave certificates to 110 participants in 2005. In 2008, the MoH published a directive for OTC in-service training programs and outlined the rules and regulations of teaching centers, course application procedures, content, methods, durations, and evaluation. Theoretical training is given by recognized training centers or trainers who are appointed by the MoH. It lasts 5 days or 40 hours at least. After the theoretical training, successful participants conduct at least 3 family interviews, organize 2 fact-finding reports of brain death, and submit the donor information from the receiver center to RCC or NCC. Practical training is done at the hospital where the participants work or at the organ transport centers favored by the MoH. These are approved by the ICU, organ transplantation center responsible, or chief of staff. The MoH formal training program consists of training in OTC task definition, brain death diagnosis, donor care, marginal donors, tissue donors, criteria of donor selection, harvesting organ protection transport, patient selection (for heart-lung, liver, kidney, and cornea), religion, ethics, legal aspects of organ donor, NCS and the other country systems, donor selection and organ sharing, visiting ICU, infrastructure
of the coordination office, life after the loss of a loved one, advanced communication skills and presentation techniques, visiting transport services, dialog with the patients, donor family encounters (role playing), and project study. Participants are divided into 3 working groups, and at the end of the training, they present their projects. At a theoretical examination performed after the training, examinees should get 70 points out of 100 points and fulfil the requirements of practical training. At the end of the training, successful participants are entitled to receive a certificate [8]. The training explained in this article was done in Izmir, Ege University Faculty of Medicine (EUFM), in April 2009. The EUFM coordinator asked for help to conduct a formal OTC course at EUFM, we as Department of Medical Education (DME) staff offered to review the formal course and update on several aspects, including teaching methods, reorganization of the content, and impact evaluation. After obtaining the permission of the MoH, we developed the Simulated Donor Family Encounters Enhanced Training Course for Organ Transplantation Coordinators. Focusing on the OTCs’ tasks, required competencies, and national syllabus, the course was modified by the representative from the MoH, Turkish Transplant Coordinators Society, EUFM Department of Medical Education (EUFMDME). This article introduces the modified version of the Simulated Donor Family Encounters Enhanced Training Course for Organ Transplantation Coordinators and evaluates participants’ opinions and achievement levels, and how they implemented what they learned during the course in their work places. METHODS To modify the national OTC course curriculum, this descriptive study adopted one of the most-used prescriptive instructional design models, the Analysis, Design, Development, Implementation, Evaluation (ADDIE) model. A mixed-evaluation approach including quantitative and qualitative evaluation methods was applied.
Development of the Enhanced OTCs Course Through the ADDIE Model The ADDIE model describes a systematic process. This model requires determination of training needs, design and development of the program and materials, and evaluation of the effectiveness of the training [9]. The steps in developing the OTCs Course according to the ADDIE model are as follows. Step 1: Analysis. In this step, needs analysis is conducted. Organ donation and transplantation process, the NCS, OTCs’ jobs, and national syllabus were examined and previous training was reviewed. OTC tasks were compared with the expected minimum knowledge and skills. Some skills that are not included in the national curriculum are encountered frequently in practice, such as allaying the family’s religion-related concerns about organ donation and conveying bad news such as brain death to the family. Step 2: Design. In this step, learning objectives, learning strategies, and methods were determined. Among the learning issues are organ donation, brain death, transplantation, mourning, presentation and communication skills, how to break bad news, and other skills regarding family encounters. Understanding of how the
SDFE AT TRANSPLANTATION COORDINATORS COURSE NCS works, basic knowledge of brain death, and ethical and medical perspectives were covered by lectures, panels, group discussions, exercises, role playing, skills training, and simulated donor family encounter (SDFE) learning sessions. Simulations with standardized patients, who are recruited and trained according to nationally established criteria, have more recently been expanded to include standardized families, in which individuals portray various members of a patient’s family around specific subject matter [10]. At this step, existing instructional materials such as slides, videotapes, and posttest questions were reviewed. Step 3: Development. Educational materials were prepared at this step. The new slide sets for ethics, health promotion policy, life after the loss of a beloved one, communication skills, and presentation skills were prepared. SDFEs and the evaluation materials were developed. SDFEs were created. Using true events written by experienced OTCs, EUFM-DME staff generated 5 scenarios. The learning objectives of the scenarios were to establish good communication with the family, to gain an understanding of the emotional state of the family with the loss of a beloved one, to give information about organ transplantation and organ donation, to develop empathy, to persuade a religious family about organ donation, to take informed consent on organ donation, and to conduct a family interview with respect and understanding. Instructions were written for simulated donor family members to take part in scenarios. Simulated donor family members were trained by EUFM-DME instructors. In addition, instructions about the tasks expected of participants were prepared. An SDFE observation rating scale was developed. The observer training and pilot observation study were realized. After pilot study scenarios, instructions and rating scale were reviewed and necessary revisions were made. Trained senior OTCs observed and rated SDFEs.
Step 4: Implementation. Thirty health professionals from different provinces of Turkey participated in the course. The MoH representatives, senior certified OTCs, and EUFM-DME staff members were trainers. At the very beginning of the course, all of the participants presented their posters and introduced themselves and their institutions. The knowledge domains of basic and advanced communication skills and donor family encounters were covered by interactive seminars and work groups. While the participants interviewed 5 simulated families, they were observed by experienced OTCs. Observers filled in the observation rating scales. After each simulated family encounter, feedback was given to the participants by the observers and simulated family members. Video records of the volunteer participants were watched and discussed at the seminar by all participants. Step 5: Evaluation. To evaluate our experience, we chose a mixed approach that focused on the following 3 distinguishable outputs: (1) the participants’ views, (2) the participants’ achievements, (3) the impact of the course on the participants’ applications at their work settings. We aimed to use the evaluation results to improve the national course and to prove its effectiveness. Evaluation Based on the Participants’ Views. We used 2 structured evaluation forms to get the participant feedback. To get the participants’ general opinions, the course evaluation form and the 1-minute paper specifically developed for communication skills training were used. The course evaluation form consisted of 3 sections and 22 items: descriptive information (5 items), opinions about general aspects of the course (9 items) and SDFEs (7 items), and a write-in item for suggestions (1 item). It used a 9-point Likert-type scale (1, strongly
1251 Table 1. Demographic Characteristics of the Participants
Sex Female Male Profession Doctor Nurse Midwife Medical health officer Medical technician Biologist Institution State hospital University hospital Private hospital Provincial health office Organ transplantation coordination center Experience Unexperienced 1 y >1 y No response Previous Organ Transplantation Coordinator training No Yes No response
N ¼ 30
%
15 15
50.0 50.0
16 8 2 2 1 1
53.3 26.7 6.7 6.7 3.3 3.3
19 5 2 2 2
63.3 16.7 6.7 6.7 6.7
6 12 10 2
20.0 40.0 33.3 6.7
25 3 2
83.4 10.0 6.7
disagree; 9, strongly agree). In addition, we asked the participants to rate the overall quality of the whole course and SDFE sessions separately (1, very bad; 10, excellent) and explain the reason for their overall quality score. The 1-minute papers form was completed by participants after the communication skills training. We asked 3 questions, “What is the most significant or the most useful thing you learned at this session?”, “What question or questions did you have at the end of this session?”, and “What knowledge or skills did you gain during the session, and please write their application areas.” A qualitative content analysis method was applied. All responses were transferred to an electronic medium and made into a single text. Content analysis was performed by 2 EUFM-DME researchers. They read the text separately and determined codes. Then, a single code list was created by evaluating coding consistency. At the final stage, 8 themes were defined. Participants’ Achievements. The participants were administered a posttest to evaluate their knowledge and a practice examination to assess their family encounter skills and communication skills. A SDFEs observation rating was used to grade the practice examination. The posttest consisted of a paper-and-pencil test and was administered to the participants at the end of the course to assess their achievement level in the knowledge domain of the course. Forty multiple-choice (5 options with 1 best answer) questions were asked in the test. A numeric marking system was used on a 0-to-100 scale with equal marks (2.5 points) for each correct answer. Only the correct answers were taken into account when the examination results were calculated, and the minimum score to pass the test was 70 (28 correct answers). For the SDFE observation ratings, we used a rating scale that was compiled and pilot tested by EUFM-DME staff. The scale mainly
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Table 2. Revealed Themes and Areas of Application From the Qualitative Analysis Themes
n*
Areas of Application
Communication skills
68
Empathy
57
Coping with difficult situations
22
Donor family encounters
17
Eligibility to work
13
Breaking bad news Communication skills training techniques Presentation skills
11 5 4
Interpersonal skills _Identification of the problem Physician-patient communication Communication with patients’ relatives Donor family encounters Communication among the coordinators Training for social and medical developers about organ donation Interpersonal skills Communication with patients, patients’ relatives, and colleagues Donor family encounters Not to be burned out All types of interviews Polyclinic, clinic environment While working as the Organ Transplant Coordinator In daily life, all spheres of life Communication with director and public To give the information to patient Interviewing the family objectively Coordinator training Donor family encounters Communication with the patient in any setting Business environment Donor family encounters Donor family encounters Donor family encounters Communication with the patient
*Number of times cited by the participants.
measures the following 3 skills and 1 general domain: how an OTC gives information to a donor’s family regarding candidate donor medical status; how an OTC explains and negotiates the issues related to organ donation (explaining the idea, importance, and legal and ethical issues of the donation procedure, as well as respecting and understanding the family’s viewpoint); communication skills (initiating the interview, verbal and nonverbal communication skills, course of interview, termination of the interview); and the overall quality of the encounter. Each item was evaluated on a 10-point scale (1e3, inadequate/ weak; 4e6, adequate/moderate; 7e9, good; 10, excellent). The observation scale was rated by the experienced and trained coordinators. The Cronbach alpha coefficient was measured for internal consistency of observers’ ratings.
The Impact of the Course at the Participants’ Work Settings. We asked the participants to write a letter of intention and include what kinds of activities they would perform in 1 year at their work settings and to give them to us. In 2010, we conducted a follow-up telephone survey and asked them what activities they had performed. We used a questionnaire derived from the thematic content analysis of the participants’ intention letters. All letters were transferred to an electronic medium as they were and then transferred into a single text. Codes were determined from this text by 2 researchers. Consistency was achieved by comparing the code lists, and a single list of codes of 105 targets was created. The codes were categorized under 10 headings (informing, infrastructure works, cooperation, organization of the health care workers, education, health promotion, service delivery, practice, research planning, motivation).
The telephone survey interviews were performed by a researcher who had not previously contacted the course participants. During the telephone calls, interviewers read the individual intention letters to the participants, and asked about the current status of 105 targets. For each target, participants were asked whether they had achieved it or not.
Data Analysis We used descriptive statistics for quantitative data. The statistical analysis was performed using PASW Statistics 18.0 (IBM SPSS Statistics). Qualitative data were analyzed by content analysis. Cronbach alpha coefficient was measured for internal consistency of observers’ ratings.
RESULTS
Thirty OTCs attended the course. There was equal sex distribution. Sixteen (53.3%) of the participants were doctors, 8 were (26.7%) nurses, and 6 were (20.0%) from various professions (Table 1). The majority (n ¼ 19, 63.3%) of the participants were employed in state hospitals, 5 (16.7%) in university hospitals and the other 6 (20.0%) in various institutions (private hospital, provincial health office, OTC center). Twelve (40.0%) of the participants declared 1 year or less experience in organ transplantation coordination, 33.3% had more than 1 year, and 20.0% had no experience. Only 3 participants declared (10.0%) previous participation in an OTC training program (Table 1).
SDFE AT TRANSPLANTATION COORDINATORS COURSE
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Table 3. Frequencies of the Responses for Course Evaluation Items Unsatisfied (1e4) n* (%)
General aspects of the course Course duration was adequate Course was well organized Course content fulfilled my expectations Instructional methods facilitated my learning Instructors were competent I have gained applicable knowledge and skills Posttest covered the course content SDFEs SDFEs case scenario was realistic SDFE role play was realistic SDFEs were instructional I have learned while observing other SDFEs Instructors’ feedback was useful Discussion after SDFEs was useful
6 3 3 1 1 1 4
(22.2) (10.7) (10.7) (3.6) (3.6) (3.6) (18.2)
1 1 1 2 2 2
(3.6) (3.7) (3.7) (7.4) (7.4) (7.4)
Neutral/Appropriate (5) n* (%)
17 2 1 2 3 2 4
Satisfied (6e9) n* (%)
Median
(63.0) (7.1) (3.6) (7.1) (10.7) (7.1) (18.2)
4 23 24 25 24 25 14
(14.8) (82.1) (85.7) (89.3) (85.7) (89.3) (63.6)
5 8 8.5 9 9 9 7
1 (3.6) 1 (3.7) e 4 (14.8) 1 (3.7) e
26 25 26 21 24 25
(92.9) (92.6) (96.3) (77.8) (88.9) (92.6)
9 9 9 7 8 9
Abbreviation: SDFE, simulated donor family encounter. *Some participants did not respond to some items on the evaluation form.
Evaluation of the Communication Skills Sessions
Twelve (40.0%) of the participants declared previous participation in a communication skills training program. The duration of these programs varied from 1 hour to 1 year in their postgraduate education period. The qualitative content analysis revealed 8 themes that reflected the participants’ opinions on communication skills sessions: communication skills, empathy, coping with difficult situations, family encounters, eligibility to work, breaking bad news, communication skills training techniques, and presentation skills. Communication skills and empathy were the most frequent themes expressed by the participants. Twenty-six application areas were mentioned by the participants for the revealed themes. In all of these 8 themes, participants stated that acquired knowledge and the awareness gathered from the communication skills training program would be useful for conducting donor family encounters and/ or interviews (Table 2).
respectively for general aspects of the course and SDFEs (Table 3). Posttest
The participants’ posttest scores were very high (minimum 85 points), and all passed the test (mean 96.0, SD 3.8). SDFEs Observation Ratings
The Cronbach’s alpha coefficient calculated for interobserver internal consistency was 0.69. The majority of participants showed an adequate or higher level of performance in SDFE observations. Almost all participants (n ¼ 29; 96.7%) showed competency in verbal communication skills. Explaining additional costs for organ donation (13.4%) and explaining legal and religious dimensions of the organ donation/transplantation (43.3%) were revealed as the weakest performance areas of the participants. In the overall evaluation of the encounter, 21 (70.0%) participants showed an adequate or higher level of performance in SDFEs (Table 4).
Evaluation of the Course
Telephone Survey
On the course evaluation form, the majority of the participants stated that they were highly satisfied with general aspects of the course and SDFEs. Cronbach’s alpha coefficient was 0.77. Of the general aspects of the course, whereas instructional methods (89.3%) and applicable knowledge and skills (89.3%) received the highest satisfaction scores, the examination content coverage (63.3%) received the lowest satisfaction scores. Seventeen respondents stated that the course duration was appropriate (63.0%, median 5). Evaluations of SDFEs also received high satisfaction; the lowest-scored item was observing the other SDFEs (77.8%) and the highest-scored items were realistic case scenarios (92.9%) and role plays (92.9%) (Table 3). Overall evaluation mean values were 8.65 1.06 and 8.68 0.73
Twenty three (76.7%) OTC course participants responded to the follow-up telephone survey. One declined to respond and 6 could not participate due to transfer to another position. Targets mostly intended by the participants were education, health promotion, and motivation. Participants achieved 149 (77.6%) targets out of 192 mentioned in their letters of intension, and 43 (22.4%) were not achieved. Of the 192 targets mentioned, the ones achieved most were as follows: giving information, practice, service delivery, and health promotion (Table 5). DISCUSSION
In this interventional study, we modified the national course designed to improve knowledge and skills of OTCs, and
ÇALıS¸KAN ET AL KARABILGIN, ALTUG,
1254 Table 4. Participants’ Performance in SDFEs Not Observed n (%)
Giving information about the donor candidate’s state Explaining the brain death Explaining organ donation concept Showing respect/understanding families’ point of view Explaining the importance of organ transplantation Explaining that the organ donation will not harm body integrity Explaining the possible delay of the funeral Explaining that organ transplantation does not have additional costs Explaining legal and religious dimensions of organ donation/transplantation Initiating the interview Verbal communication skills Nonverbal communication skills Maintaining appropriate flow of the interview Closing the interview Overall evaluation of the encounter
1 4 2 4 4 4 7 12
Inadequate/Weak (1e3) n (%)
(3.3) (13.3) (6.7) (13.3) (13.3) (13.3) (23.3) (40.0)
13 (43.3) 7 (23.3) 1 (3.3) e 2 (6.7) 3 (10.0) 12 (40.0) 14 (46.7)
5 (16.7)
12 (40.0)
e e 2 (6.7) e 2 (6.7) e
5 1 4 4 2 9
(16.7) (3.3) (13.3) (13.3) (6.7) (30.0)
Adequate/Moderate (4e6) n (%)
5 5 13 10 10 8 5 2
(16.7) (16.7) (43.3) (33.3) (33.3) (26.7) (16.7) (6.7)
11 14 14 15 13 15 6 2
6 (20.0) 11 11 11 12 9 10
Good (7e9) n (%)
Excellent (10) n (%)
(36.7) (46.7) (46.7) (50.0) (43.3) (50.0) (20.0) (6.7)
7 (23.3)
(36.7) (36.7) (36.7) (40.0) (30.0) (33.3)
10 17 12 14 15 11
(33.3) (56.7) (40.0) (46.7) (50.0) (36.7)
e e e 1 (3.3) 1 (3.3) e e e e 4 (13.3) 1 (3.3) 1 (3.3) e 2 (6.7) e
Abbreviation: SDFE, simulated donor family encounter.
added SDFEs and communication skills training. We evaluated and analyzed the enhanced course based on the participants’ views, their achievements, and the impact of the course on their work. Our course evaluation form results show that participants were highly satisfied and the course was successful. A high proportion of skill-related training increased the satisfaction level of the participants. In addition to simulation, several effective instructional methods for organ donation training such as lecture, video, and role play were included in our course and were reported [11]. However, standardized family encounters were used for in-service training of general practitioners, specialists, medical students, and intensive care staff [12e16]. Regarding the instructional format of similar programs, there is a scarcity in the literature of simulation use in organ donation training [10,17]. A study concluded that participants’ knowledge of ethics and law as well as communication skills were improved by standardized family members encounters [12]. The participants described SDFEs, feedback, and discussion sessions as highly instructive methods. In a few studies that evaluated the effectiveness of standardized patient and standardized family encounters, the simulation method was proven to be effective [16,18]. Also it was suggested that the use of an experiential learning model in standardized family encounters might improve organ donation [19]. The participants stated that they would mostly use the knowledge and skills they gained during the communication skills training while interviewing donor families and demonstrating empathy after the training. In the study by Siminoff et al. [17], OTCs stated that they felt more comfortable when they talked to family members and answered questions about organ donation after the communication skills training [17]. In the literature, based
on donor families’ statements, it is reported that communication skills of OTCs affected their decision-making process related to organ donation [20]. Communication skills training is important because it makes coordinators feel more relaxed during family encounters and has a positive effect on a family’s decision-making process; therefore, it must be included in the training of OTCs. Posttest scores of the participants in our course were very high. In the study by Milanes et al. [21], the participants’ knowledge level increased after the course. Knowledge, attitudes, skills, and perceptions are effective on organ and tissue donation rates. It has been reported that there is a positive correlation between the OTCs knowledge level and families’ attitudes toward organ donation [11]. It has been found that donor families could make informed decisions when they are informed by OTCs sufficiently [20]. That the
Table 5. Participants’ Intended Targets and Status of Achievements Achievement n (%) Themes
Targets
Giving information Infrastructural works Cooperation Organization of the health workers Education Health promotion Service delivery Practice Planning research Motivation Total
17 8 14 4 46 37 19 15 2 30 192
(þ)
16 5 11 3 34 22 16 14 1 27 149
(94.1) (62.5) (78.6) (75.0) (73.9) (59.5) (84.2) (93.3) (50.0) (90.0) (77.6)
()
1 3 3 1 12 15 3 1 1 3 43
(5.9) (37.5) (21.4) (25.0) (26.1) (40.5) (15.8) (6.7) (50.0) (10.0) (22.4)
SDFE AT TRANSPLANTATION COORDINATORS COURSE
participants’ knowledge and understanding related to all the learning objectives were determined to be high at the end of the course suggests that it would contribute to the families’ decision-making process positively. At SDFEs, most of the participants’ performance was considered to be satisfactory by the observers. That their performance regarding the donor candidates and provision of information about organ donation was relatively low can be explained by the fact that they were not accustomed to the method and that they suffered anxiety about examination performance. One of the most crucial steps in organ donation is donor family encounters. At the hospital, it was found that about 25% of the families did not take an interest in the donation option, and that the families did not take an appropriate approach to organ donation, and therefore, more than half of them refused donation [19]. Whereas the donation refusal rate was 15.6% in Spain in 2012, it was 76.6% in Turkey [4]. Given the importance of family encounters on donation refusals, inclusion of application methods such as simulated family encounters in training can contribute to the development of coordinators’ skills. The participants achieved most of their targets written in their letters of intention. The most frequently mentioned targets were about giving information, practice, service delivery, and health promotion. The fulfillment of these targets is of importance in nondonor families’ being informed about brain death. Many families are confused about brain death [11]. That discussions related to brain death and organ donation requests are carried out by specially trained persons at different times, and are supported and organized by regional coordinators and intensive care unit staff, increases the rate of organ donation [19e23]. That the targets to protect and improve health were achieved suggests that the participants understood the importance of activities aimed at the public. Campaigns aiming to enlighten the public are indicated to successfully raise the public’s awareness of organ and tissue donation [22]. That the participants attained the organizational and collaborative goals of health professionals is critical because it indicates that they embraced the importance of an interdisciplinary approach in organ donation. Interdisciplinary trainings involving physicians, nurses, and chaplains/imams in addition to organ transplant coordinators have been shown to increase organ donation rates significantly [19]. If interdisciplinary approaches are to be extended, health care workers should be informed about organ and tissue transplantation during their professional training process, and their attitudes toward the issue should be developed. CONCLUSIONS
SDFEs can be used as an effective method in the training of OTCs. It can be said that the course affected the participants in terms of implementing their knowledge and communication skills related to family encounters.
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Our limitations are (1) there is a scarcity of evaluation studies in this area; therefore, we were not able to compare our results, and (2) because the participants were administered only the posttest, we were not able to compare the participants’ knowledge and performance before and after the course. More studies are needed for detailed analysis of the effects simulation method on this area.
REFERENCES [1] Organ shortage: current status and strategies for the improvement of organ donationda European consensus document 2003. Available at: http://www.edqm.eu/medias/fichiers/ Organ_shortagecurrent_status_and_strategies_for_improvement_of_ organ_donation_A_European_consensus_document.pdf. Accessed August 25, 2014. [2] Höckerstedt K, Heikkiläl ML, Holmberg C. Substantial increase in cadaveric organ donors in hospitals implementing the donor action program in Finland. Transplant Proc 2005;37: 3253e5. [3] Organ donation and transplantation activities 2012. Global Observatory on Donation and Transplantation (GODT), World Health Organization. Available at: http://www.transplant-observatory. org/Pages/Data-Reports.aspx. Accessed September 11, 2014. [4] Council of Europe. International figures on donation and transplantation 2012. Newsletter: Transplant 2013;18. [5] Matesanz R. Factors that influence the development of an organ donation program. Transplant Proc 2004;36:739e41. [6] Haberal M. Development of transplantation in Turkey. Transplant Proc 2001;33:3027e9. [7] Saglik.gov.tr [Internet]. Ulusal organ ve doku nakli koordinasyon sistemi yönergesi 2008. Available at: http://www.saglik.gov.tr/ TR/belge/1-6882/ulusal-organ-ve-doku-nakli-koordinasyon-sistemiyonerge-.html. Accessed July 9, 2014. [8] Saglik.gov.tr [Internet]. Organ ve Doku Nakli Koordinatörlügü Egitim Yönergesi. Available at: http://www.saglik.gov.tr/TR/belge/16884/organ-ve-doku-nakli-koordinatorlugu-egitim-yonergesi.html. Accessed July 2, 2014. [9] Allen WC. Overview and evolution of the ADDIE training system. Adv Dev Hum Resour 2006;8:430. [10] Jacoby L, Crosier V, Pohl H. Providing support to families considering the option of organ donation: an innovative training method. Prog Transplant 2006;16:3. [11] Rykhoff ME, Coupland C, Dionne J, Fudge B, Gayle C. A clinical group’s attempt to raise awareness of organ and tissue donation. Prog Transplant 2010;20:33e9. [12] Downar J, Knickle K, Granton JT, Hawryluck L. Using standardized family members to teach communication skills and ethical principles to critical care trainees. Crit Care Med 2012;40: 1814e9. [13] Wu X, Wang Z, Hong B, Shen S, Guo Y, Huang Q, et al. Evaluation and improvement of doctor-patient communication competence for emergency neurosurgeons: a standardized family model. Patient Prefer Adherence 2014;8:883e91. [14] Lorin S, Rho L, Wisnivesky JP, Nierman DM. Improving medical student intensive care unit communication skills: a novel educational initiative using standardized family members. Crit Care Med 2006;34:2386e91. [15] Yuen JK, Mehta SS, Roberts JE, Cooke JT, Reid MC. A brief educational intervention to teach residents shared decision making in the intensive care unit. J Palliat Med 2013;16:531e6. [16] de Montbrun SL, MacRae H. Simulation in surgical education. Clin Colon Rectal Surg 2012;25:156e65. [17] Siminoff LA, Marshall HM, Dumenci L, Bowen G, Swaminathan A. Communicating effectively about donation: an educational intervention to increase consent to donation. Prog Transplant 2009;19:35e43.
1256 [18] Bramstedt AK, Moolla A, Rehfield P, Do L. Use of standardized patients to teach medical students about living organ donation. Prog Transplant 2012;22:86e90. [19] Williams MA, Lipsett CH, Rushton RN, Eugene C, Grochowski ID, Berkowitz SL, et al. The physician’s role in discussing organ donation with families. Crit Care Med 2003;315: 1568e73. [20] Simpkin AL, Robertson LC, Barber VS, Young JD. Modifiable factors influencing relatives’ decision to offer organ donation: systematic review. BMJ 2009;339:b991.
ÇALıS¸KAN ET AL KARABILGIN, ALTUG, [21] Milanes CL, Gonzalez L, Hernandez E, Arminio A. Transplant coordination program: a useful tool to improve organ donation in Venezuela. Prog Transplant 2003;13:296e8. [22] Quinn MT, Alexander GC, Hollingsworth D, O’Connor KG, Meltzer D. Design and evaluation of a workplace intervention to promote organ donation. Prog Transplant 2006;16:253e9. [23] Ralp A, Chapman JR, Gillis J, Craig JC, Butow P, Howard K, et al. Family perspective on deceased organ donation: thematic synthesis of qualitative studies. Am J Transplant 2014;14: 923e35.
ABSTRACT Objective. This study introduced the modified version of the Organ Transplantation Coordinator course including simulated donor family encounters (SDFEs) and communication skills. It also evaluated participants’ opinions and achievement levels, and how they implemented what they learned in the course in their work settings. Methods. The course used the modified Analysis, Design, Development, Implementation, and Evaluation model and was evaluated in 3 steps. The participants’ views were obtained using the course overall evaluation form and communication skills evaluation form, their success was assessed with the posttest and SDFEs evaluation form, and the effects of what they learned during the course on their work settings were assessed through telephone interviews. At this step, the participants were asked to write letters about the targets they intended to achieve in their work settings. The letters were analyzed with the content analysis method, and a questionnaire consisting of 105 targets was developed. A year later the participants were telephoned and asked to what extent they achieved their targets. Results. The participants’ satisfaction from the whole course was high (x: 8.65 1.06). In the communication skills evaluation form, the participants stated that they would mainly utilize their communication and empathy skills during donor family encounters. The participants’ mean posttest score was high (x: 96.0 3.8). During the SDFEs, 70% of the respondents’ performance was considered sufficient. Telephone interviews conducted with the questionnaire revealed that 77.6% of the targets were fulfilled. Conclusions. It can be said that the course affected the participants in terms of implementing their knowledge and communication skills related to family encounters.
A
CCORDING to European Consensus Document 2003, “over 1 million people world-wide have received an organ transplant and some have already survived more than 25 years” [1]. Nonetheless, the chronic shortage of donor organs is a worldwide, continuing serious problem because of prolonged waiting times, deaths on the waiting list, acceptance of lowerquality organs, increased numbers of living donors, and commercialization of organ transplantation in many countries [2]. In 2012, 114,690 solid organs were reported to be transplanted, constituting <10% of global needs [3]. In Turkey, the number of transplantations performed in 2012 for kidney, liver, heart, heart/lung, lung, pancreas, and small bowel was 3999, whereas the number of patients on
the waiting list was 20,833. The rate of deceased organ donation is substantially lower than that in several countries. In 2012, actual deceased organ donation rates for per Part of this work was previously presented at AMEE 2012 and , S.A. was published in abstract only: Ö.S. Karabilgin, N. Altug Çalıs¸kan, C.A. Bozoklar, H._I. Durak, N. Demiral Yılmaz (2012). Simulated Donor Family Encounters at Organ Transplantation Coordinators in-Service Training Course: Process and Impact Evaluation, AMEE Lyon, France. *Address correspondence to Nılufer Demiral Yilmaz, PhD, Ege University Faculty of Medicine, Department of Medical Education, 35100 Bornova, Izmir, Turkey. E-mail: [email protected]
ª 2015 by Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010-1710
0041-1345/15 http://dx.doi.org/10.1016/j.transproceed.2015.04.022
Transplantation Proceedings, 47, 1249e1256 (2015)
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million population in Spain, the United States, and Turkey are 35.1, 25.8, and 4.6, respectively [4]. In Spain, which has the highest donor rate, there is a parttime working national network that motivates hospital physicians in the process of organ donation. The Spanish model draws special attention to the transplant coordination network, continuous medical training, and education. There are some factors, such as the public national health system, economic resources, the number of doctors, the number of acute care beds and intensive care unit (ICU) facilities, and age distribution of the population, that influence the use of this model in other countries [5]. In Turkey, after the law related to transplantation procedures was enacted in 1979, the first cadaveric donor kidney and liver transplantations were performed in 1979 and 1988, respectively [6]. The Turkish system was improved like the Spanish model in 2000. The Turkish National Coordination System (NCS) was established by the Ministry of Health (MoH). The NCS consists of the National Coordination Center (NCC), Regional Coordination Center (RCC), and Local Coordination Center (LCC) in hospitals that have ICUs. A coordinator works at each level of the NCS. The basic title for these staff members is Organ Transplantation Coordinator (OTCs), and this is further distinguished by the level of work setting, ie, National Coordination Center Coordinators, Regional Coordinators, and Hospital Coordinators. Among the common tasks and responsibilities of all the coordinators are to organize organ donation campaigns, in-service training for health workers, and public education, and to participate and support every campaign and education prepared by the MoH [7]. With the initiative of a group of volunteers, training programs for coordinators were started in 2002 and repeated in 2003 and 2004. After these courses, the MoH conducted 2-day formal courses and gave certificates to 110 participants in 2005. In 2008, the MoH published a directive for OTC in-service training programs and outlined the rules and regulations of teaching centers, course application procedures, content, methods, durations, and evaluation. Theoretical training is given by recognized training centers or trainers who are appointed by the MoH. It lasts 5 days or 40 hours at least. After the theoretical training, successful participants conduct at least 3 family interviews, organize 2 fact-finding reports of brain death, and submit the donor information from the receiver center to RCC or NCC. Practical training is done at the hospital where the participants work or at the organ transport centers favored by the MoH. These are approved by the ICU, organ transplantation center responsible, or chief of staff. The MoH formal training program consists of training in OTC task definition, brain death diagnosis, donor care, marginal donors, tissue donors, criteria of donor selection, harvesting organ protection transport, patient selection (for heart-lung, liver, kidney, and cornea), religion, ethics, legal aspects of organ donor, NCS and the other country systems, donor selection and organ sharing, visiting ICU, infrastructure
of the coordination office, life after the loss of a loved one, advanced communication skills and presentation techniques, visiting transport services, dialog with the patients, donor family encounters (role playing), and project study. Participants are divided into 3 working groups, and at the end of the training, they present their projects. At a theoretical examination performed after the training, examinees should get 70 points out of 100 points and fulfil the requirements of practical training. At the end of the training, successful participants are entitled to receive a certificate [8]. The training explained in this article was done in Izmir, Ege University Faculty of Medicine (EUFM), in April 2009. The EUFM coordinator asked for help to conduct a formal OTC course at EUFM, we as Department of Medical Education (DME) staff offered to review the formal course and update on several aspects, including teaching methods, reorganization of the content, and impact evaluation. After obtaining the permission of the MoH, we developed the Simulated Donor Family Encounters Enhanced Training Course for Organ Transplantation Coordinators. Focusing on the OTCs’ tasks, required competencies, and national syllabus, the course was modified by the representative from the MoH, Turkish Transplant Coordinators Society, EUFM Department of Medical Education (EUFMDME). This article introduces the modified version of the Simulated Donor Family Encounters Enhanced Training Course for Organ Transplantation Coordinators and evaluates participants’ opinions and achievement levels, and how they implemented what they learned during the course in their work places. METHODS To modify the national OTC course curriculum, this descriptive study adopted one of the most-used prescriptive instructional design models, the Analysis, Design, Development, Implementation, Evaluation (ADDIE) model. A mixed-evaluation approach including quantitative and qualitative evaluation methods was applied.
Development of the Enhanced OTCs Course Through the ADDIE Model The ADDIE model describes a systematic process. This model requires determination of training needs, design and development of the program and materials, and evaluation of the effectiveness of the training [9]. The steps in developing the OTCs Course according to the ADDIE model are as follows. Step 1: Analysis. In this step, needs analysis is conducted. Organ donation and transplantation process, the NCS, OTCs’ jobs, and national syllabus were examined and previous training was reviewed. OTC tasks were compared with the expected minimum knowledge and skills. Some skills that are not included in the national curriculum are encountered frequently in practice, such as allaying the family’s religion-related concerns about organ donation and conveying bad news such as brain death to the family. Step 2: Design. In this step, learning objectives, learning strategies, and methods were determined. Among the learning issues are organ donation, brain death, transplantation, mourning, presentation and communication skills, how to break bad news, and other skills regarding family encounters. Understanding of how the
SDFE AT TRANSPLANTATION COORDINATORS COURSE NCS works, basic knowledge of brain death, and ethical and medical perspectives were covered by lectures, panels, group discussions, exercises, role playing, skills training, and simulated donor family encounter (SDFE) learning sessions. Simulations with standardized patients, who are recruited and trained according to nationally established criteria, have more recently been expanded to include standardized families, in which individuals portray various members of a patient’s family around specific subject matter [10]. At this step, existing instructional materials such as slides, videotapes, and posttest questions were reviewed. Step 3: Development. Educational materials were prepared at this step. The new slide sets for ethics, health promotion policy, life after the loss of a beloved one, communication skills, and presentation skills were prepared. SDFEs and the evaluation materials were developed. SDFEs were created. Using true events written by experienced OTCs, EUFM-DME staff generated 5 scenarios. The learning objectives of the scenarios were to establish good communication with the family, to gain an understanding of the emotional state of the family with the loss of a beloved one, to give information about organ transplantation and organ donation, to develop empathy, to persuade a religious family about organ donation, to take informed consent on organ donation, and to conduct a family interview with respect and understanding. Instructions were written for simulated donor family members to take part in scenarios. Simulated donor family members were trained by EUFM-DME instructors. In addition, instructions about the tasks expected of participants were prepared. An SDFE observation rating scale was developed. The observer training and pilot observation study were realized. After pilot study scenarios, instructions and rating scale were reviewed and necessary revisions were made. Trained senior OTCs observed and rated SDFEs.
Step 4: Implementation. Thirty health professionals from different provinces of Turkey participated in the course. The MoH representatives, senior certified OTCs, and EUFM-DME staff members were trainers. At the very beginning of the course, all of the participants presented their posters and introduced themselves and their institutions. The knowledge domains of basic and advanced communication skills and donor family encounters were covered by interactive seminars and work groups. While the participants interviewed 5 simulated families, they were observed by experienced OTCs. Observers filled in the observation rating scales. After each simulated family encounter, feedback was given to the participants by the observers and simulated family members. Video records of the volunteer participants were watched and discussed at the seminar by all participants. Step 5: Evaluation. To evaluate our experience, we chose a mixed approach that focused on the following 3 distinguishable outputs: (1) the participants’ views, (2) the participants’ achievements, (3) the impact of the course on the participants’ applications at their work settings. We aimed to use the evaluation results to improve the national course and to prove its effectiveness. Evaluation Based on the Participants’ Views. We used 2 structured evaluation forms to get the participant feedback. To get the participants’ general opinions, the course evaluation form and the 1-minute paper specifically developed for communication skills training were used. The course evaluation form consisted of 3 sections and 22 items: descriptive information (5 items), opinions about general aspects of the course (9 items) and SDFEs (7 items), and a write-in item for suggestions (1 item). It used a 9-point Likert-type scale (1, strongly
1251 Table 1. Demographic Characteristics of the Participants
Sex Female Male Profession Doctor Nurse Midwife Medical health officer Medical technician Biologist Institution State hospital University hospital Private hospital Provincial health office Organ transplantation coordination center Experience Unexperienced 1 y >1 y No response Previous Organ Transplantation Coordinator training No Yes No response
N ¼ 30
%
15 15
50.0 50.0
16 8 2 2 1 1
53.3 26.7 6.7 6.7 3.3 3.3
19 5 2 2 2
63.3 16.7 6.7 6.7 6.7
6 12 10 2
20.0 40.0 33.3 6.7
25 3 2
83.4 10.0 6.7
disagree; 9, strongly agree). In addition, we asked the participants to rate the overall quality of the whole course and SDFE sessions separately (1, very bad; 10, excellent) and explain the reason for their overall quality score. The 1-minute papers form was completed by participants after the communication skills training. We asked 3 questions, “What is the most significant or the most useful thing you learned at this session?”, “What question or questions did you have at the end of this session?”, and “What knowledge or skills did you gain during the session, and please write their application areas.” A qualitative content analysis method was applied. All responses were transferred to an electronic medium and made into a single text. Content analysis was performed by 2 EUFM-DME researchers. They read the text separately and determined codes. Then, a single code list was created by evaluating coding consistency. At the final stage, 8 themes were defined. Participants’ Achievements. The participants were administered a posttest to evaluate their knowledge and a practice examination to assess their family encounter skills and communication skills. A SDFEs observation rating was used to grade the practice examination. The posttest consisted of a paper-and-pencil test and was administered to the participants at the end of the course to assess their achievement level in the knowledge domain of the course. Forty multiple-choice (5 options with 1 best answer) questions were asked in the test. A numeric marking system was used on a 0-to-100 scale with equal marks (2.5 points) for each correct answer. Only the correct answers were taken into account when the examination results were calculated, and the minimum score to pass the test was 70 (28 correct answers). For the SDFE observation ratings, we used a rating scale that was compiled and pilot tested by EUFM-DME staff. The scale mainly
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Table 2. Revealed Themes and Areas of Application From the Qualitative Analysis Themes
n*
Areas of Application
Communication skills
68
Empathy
57
Coping with difficult situations
22
Donor family encounters
17
Eligibility to work
13
Breaking bad news Communication skills training techniques Presentation skills
11 5 4
Interpersonal skills _Identification of the problem Physician-patient communication Communication with patients’ relatives Donor family encounters Communication among the coordinators Training for social and medical developers about organ donation Interpersonal skills Communication with patients, patients’ relatives, and colleagues Donor family encounters Not to be burned out All types of interviews Polyclinic, clinic environment While working as the Organ Transplant Coordinator In daily life, all spheres of life Communication with director and public To give the information to patient Interviewing the family objectively Coordinator training Donor family encounters Communication with the patient in any setting Business environment Donor family encounters Donor family encounters Donor family encounters Communication with the patient
*Number of times cited by the participants.
measures the following 3 skills and 1 general domain: how an OTC gives information to a donor’s family regarding candidate donor medical status; how an OTC explains and negotiates the issues related to organ donation (explaining the idea, importance, and legal and ethical issues of the donation procedure, as well as respecting and understanding the family’s viewpoint); communication skills (initiating the interview, verbal and nonverbal communication skills, course of interview, termination of the interview); and the overall quality of the encounter. Each item was evaluated on a 10-point scale (1e3, inadequate/ weak; 4e6, adequate/moderate; 7e9, good; 10, excellent). The observation scale was rated by the experienced and trained coordinators. The Cronbach alpha coefficient was measured for internal consistency of observers’ ratings.
The Impact of the Course at the Participants’ Work Settings. We asked the participants to write a letter of intention and include what kinds of activities they would perform in 1 year at their work settings and to give them to us. In 2010, we conducted a follow-up telephone survey and asked them what activities they had performed. We used a questionnaire derived from the thematic content analysis of the participants’ intention letters. All letters were transferred to an electronic medium as they were and then transferred into a single text. Codes were determined from this text by 2 researchers. Consistency was achieved by comparing the code lists, and a single list of codes of 105 targets was created. The codes were categorized under 10 headings (informing, infrastructure works, cooperation, organization of the health care workers, education, health promotion, service delivery, practice, research planning, motivation).
The telephone survey interviews were performed by a researcher who had not previously contacted the course participants. During the telephone calls, interviewers read the individual intention letters to the participants, and asked about the current status of 105 targets. For each target, participants were asked whether they had achieved it or not.
Data Analysis We used descriptive statistics for quantitative data. The statistical analysis was performed using PASW Statistics 18.0 (IBM SPSS Statistics). Qualitative data were analyzed by content analysis. Cronbach alpha coefficient was measured for internal consistency of observers’ ratings.
RESULTS
Thirty OTCs attended the course. There was equal sex distribution. Sixteen (53.3%) of the participants were doctors, 8 were (26.7%) nurses, and 6 were (20.0%) from various professions (Table 1). The majority (n ¼ 19, 63.3%) of the participants were employed in state hospitals, 5 (16.7%) in university hospitals and the other 6 (20.0%) in various institutions (private hospital, provincial health office, OTC center). Twelve (40.0%) of the participants declared 1 year or less experience in organ transplantation coordination, 33.3% had more than 1 year, and 20.0% had no experience. Only 3 participants declared (10.0%) previous participation in an OTC training program (Table 1).
SDFE AT TRANSPLANTATION COORDINATORS COURSE
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Table 3. Frequencies of the Responses for Course Evaluation Items Unsatisfied (1e4) n* (%)
General aspects of the course Course duration was adequate Course was well organized Course content fulfilled my expectations Instructional methods facilitated my learning Instructors were competent I have gained applicable knowledge and skills Posttest covered the course content SDFEs SDFEs case scenario was realistic SDFE role play was realistic SDFEs were instructional I have learned while observing other SDFEs Instructors’ feedback was useful Discussion after SDFEs was useful
6 3 3 1 1 1 4
(22.2) (10.7) (10.7) (3.6) (3.6) (3.6) (18.2)
1 1 1 2 2 2
(3.6) (3.7) (3.7) (7.4) (7.4) (7.4)
Neutral/Appropriate (5) n* (%)
17 2 1 2 3 2 4
Satisfied (6e9) n* (%)
Median
(63.0) (7.1) (3.6) (7.1) (10.7) (7.1) (18.2)
4 23 24 25 24 25 14
(14.8) (82.1) (85.7) (89.3) (85.7) (89.3) (63.6)
5 8 8.5 9 9 9 7
1 (3.6) 1 (3.7) e 4 (14.8) 1 (3.7) e
26 25 26 21 24 25
(92.9) (92.6) (96.3) (77.8) (88.9) (92.6)
9 9 9 7 8 9
Abbreviation: SDFE, simulated donor family encounter. *Some participants did not respond to some items on the evaluation form.
Evaluation of the Communication Skills Sessions
Twelve (40.0%) of the participants declared previous participation in a communication skills training program. The duration of these programs varied from 1 hour to 1 year in their postgraduate education period. The qualitative content analysis revealed 8 themes that reflected the participants’ opinions on communication skills sessions: communication skills, empathy, coping with difficult situations, family encounters, eligibility to work, breaking bad news, communication skills training techniques, and presentation skills. Communication skills and empathy were the most frequent themes expressed by the participants. Twenty-six application areas were mentioned by the participants for the revealed themes. In all of these 8 themes, participants stated that acquired knowledge and the awareness gathered from the communication skills training program would be useful for conducting donor family encounters and/ or interviews (Table 2).
respectively for general aspects of the course and SDFEs (Table 3). Posttest
The participants’ posttest scores were very high (minimum 85 points), and all passed the test (mean 96.0, SD 3.8). SDFEs Observation Ratings
The Cronbach’s alpha coefficient calculated for interobserver internal consistency was 0.69. The majority of participants showed an adequate or higher level of performance in SDFE observations. Almost all participants (n ¼ 29; 96.7%) showed competency in verbal communication skills. Explaining additional costs for organ donation (13.4%) and explaining legal and religious dimensions of the organ donation/transplantation (43.3%) were revealed as the weakest performance areas of the participants. In the overall evaluation of the encounter, 21 (70.0%) participants showed an adequate or higher level of performance in SDFEs (Table 4).
Evaluation of the Course
Telephone Survey
On the course evaluation form, the majority of the participants stated that they were highly satisfied with general aspects of the course and SDFEs. Cronbach’s alpha coefficient was 0.77. Of the general aspects of the course, whereas instructional methods (89.3%) and applicable knowledge and skills (89.3%) received the highest satisfaction scores, the examination content coverage (63.3%) received the lowest satisfaction scores. Seventeen respondents stated that the course duration was appropriate (63.0%, median 5). Evaluations of SDFEs also received high satisfaction; the lowest-scored item was observing the other SDFEs (77.8%) and the highest-scored items were realistic case scenarios (92.9%) and role plays (92.9%) (Table 3). Overall evaluation mean values were 8.65 1.06 and 8.68 0.73
Twenty three (76.7%) OTC course participants responded to the follow-up telephone survey. One declined to respond and 6 could not participate due to transfer to another position. Targets mostly intended by the participants were education, health promotion, and motivation. Participants achieved 149 (77.6%) targets out of 192 mentioned in their letters of intension, and 43 (22.4%) were not achieved. Of the 192 targets mentioned, the ones achieved most were as follows: giving information, practice, service delivery, and health promotion (Table 5). DISCUSSION
In this interventional study, we modified the national course designed to improve knowledge and skills of OTCs, and
ÇALıS¸KAN ET AL KARABILGIN, ALTUG,
1254 Table 4. Participants’ Performance in SDFEs Not Observed n (%)
Giving information about the donor candidate’s state Explaining the brain death Explaining organ donation concept Showing respect/understanding families’ point of view Explaining the importance of organ transplantation Explaining that the organ donation will not harm body integrity Explaining the possible delay of the funeral Explaining that organ transplantation does not have additional costs Explaining legal and religious dimensions of organ donation/transplantation Initiating the interview Verbal communication skills Nonverbal communication skills Maintaining appropriate flow of the interview Closing the interview Overall evaluation of the encounter
1 4 2 4 4 4 7 12
Inadequate/Weak (1e3) n (%)
(3.3) (13.3) (6.7) (13.3) (13.3) (13.3) (23.3) (40.0)
13 (43.3) 7 (23.3) 1 (3.3) e 2 (6.7) 3 (10.0) 12 (40.0) 14 (46.7)
5 (16.7)
12 (40.0)
e e 2 (6.7) e 2 (6.7) e
5 1 4 4 2 9
(16.7) (3.3) (13.3) (13.3) (6.7) (30.0)
Adequate/Moderate (4e6) n (%)
5 5 13 10 10 8 5 2
(16.7) (16.7) (43.3) (33.3) (33.3) (26.7) (16.7) (6.7)
11 14 14 15 13 15 6 2
6 (20.0) 11 11 11 12 9 10
Good (7e9) n (%)
Excellent (10) n (%)
(36.7) (46.7) (46.7) (50.0) (43.3) (50.0) (20.0) (6.7)
7 (23.3)
(36.7) (36.7) (36.7) (40.0) (30.0) (33.3)
10 17 12 14 15 11
(33.3) (56.7) (40.0) (46.7) (50.0) (36.7)
e e e 1 (3.3) 1 (3.3) e e e e 4 (13.3) 1 (3.3) 1 (3.3) e 2 (6.7) e
Abbreviation: SDFE, simulated donor family encounter.
added SDFEs and communication skills training. We evaluated and analyzed the enhanced course based on the participants’ views, their achievements, and the impact of the course on their work. Our course evaluation form results show that participants were highly satisfied and the course was successful. A high proportion of skill-related training increased the satisfaction level of the participants. In addition to simulation, several effective instructional methods for organ donation training such as lecture, video, and role play were included in our course and were reported [11]. However, standardized family encounters were used for in-service training of general practitioners, specialists, medical students, and intensive care staff [12e16]. Regarding the instructional format of similar programs, there is a scarcity in the literature of simulation use in organ donation training [10,17]. A study concluded that participants’ knowledge of ethics and law as well as communication skills were improved by standardized family members encounters [12]. The participants described SDFEs, feedback, and discussion sessions as highly instructive methods. In a few studies that evaluated the effectiveness of standardized patient and standardized family encounters, the simulation method was proven to be effective [16,18]. Also it was suggested that the use of an experiential learning model in standardized family encounters might improve organ donation [19]. The participants stated that they would mostly use the knowledge and skills they gained during the communication skills training while interviewing donor families and demonstrating empathy after the training. In the study by Siminoff et al. [17], OTCs stated that they felt more comfortable when they talked to family members and answered questions about organ donation after the communication skills training [17]. In the literature, based
on donor families’ statements, it is reported that communication skills of OTCs affected their decision-making process related to organ donation [20]. Communication skills training is important because it makes coordinators feel more relaxed during family encounters and has a positive effect on a family’s decision-making process; therefore, it must be included in the training of OTCs. Posttest scores of the participants in our course were very high. In the study by Milanes et al. [21], the participants’ knowledge level increased after the course. Knowledge, attitudes, skills, and perceptions are effective on organ and tissue donation rates. It has been reported that there is a positive correlation between the OTCs knowledge level and families’ attitudes toward organ donation [11]. It has been found that donor families could make informed decisions when they are informed by OTCs sufficiently [20]. That the
Table 5. Participants’ Intended Targets and Status of Achievements Achievement n (%) Themes
Targets
Giving information Infrastructural works Cooperation Organization of the health workers Education Health promotion Service delivery Practice Planning research Motivation Total
17 8 14 4 46 37 19 15 2 30 192
(þ)
16 5 11 3 34 22 16 14 1 27 149
(94.1) (62.5) (78.6) (75.0) (73.9) (59.5) (84.2) (93.3) (50.0) (90.0) (77.6)
()
1 3 3 1 12 15 3 1 1 3 43
(5.9) (37.5) (21.4) (25.0) (26.1) (40.5) (15.8) (6.7) (50.0) (10.0) (22.4)
SDFE AT TRANSPLANTATION COORDINATORS COURSE
participants’ knowledge and understanding related to all the learning objectives were determined to be high at the end of the course suggests that it would contribute to the families’ decision-making process positively. At SDFEs, most of the participants’ performance was considered to be satisfactory by the observers. That their performance regarding the donor candidates and provision of information about organ donation was relatively low can be explained by the fact that they were not accustomed to the method and that they suffered anxiety about examination performance. One of the most crucial steps in organ donation is donor family encounters. At the hospital, it was found that about 25% of the families did not take an interest in the donation option, and that the families did not take an appropriate approach to organ donation, and therefore, more than half of them refused donation [19]. Whereas the donation refusal rate was 15.6% in Spain in 2012, it was 76.6% in Turkey [4]. Given the importance of family encounters on donation refusals, inclusion of application methods such as simulated family encounters in training can contribute to the development of coordinators’ skills. The participants achieved most of their targets written in their letters of intention. The most frequently mentioned targets were about giving information, practice, service delivery, and health promotion. The fulfillment of these targets is of importance in nondonor families’ being informed about brain death. Many families are confused about brain death [11]. That discussions related to brain death and organ donation requests are carried out by specially trained persons at different times, and are supported and organized by regional coordinators and intensive care unit staff, increases the rate of organ donation [19e23]. That the targets to protect and improve health were achieved suggests that the participants understood the importance of activities aimed at the public. Campaigns aiming to enlighten the public are indicated to successfully raise the public’s awareness of organ and tissue donation [22]. That the participants attained the organizational and collaborative goals of health professionals is critical because it indicates that they embraced the importance of an interdisciplinary approach in organ donation. Interdisciplinary trainings involving physicians, nurses, and chaplains/imams in addition to organ transplant coordinators have been shown to increase organ donation rates significantly [19]. If interdisciplinary approaches are to be extended, health care workers should be informed about organ and tissue transplantation during their professional training process, and their attitudes toward the issue should be developed. CONCLUSIONS
SDFEs can be used as an effective method in the training of OTCs. It can be said that the course affected the participants in terms of implementing their knowledge and communication skills related to family encounters.
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Our limitations are (1) there is a scarcity of evaluation studies in this area; therefore, we were not able to compare our results, and (2) because the participants were administered only the posttest, we were not able to compare the participants’ knowledge and performance before and after the course. More studies are needed for detailed analysis of the effects simulation method on this area.
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