Analysis of the incident factors among the population towards the opposition to organ donation: a literature integrative review
10.54103/dn/20223
BACKGROUND: Fonti istituzionali mostrano ad oggi un cospicuo numero di opposizioni alla donazione, una lenta crescita di iscrizioni al registro dei donatori e un gap tra donatori disponibili e riceventi in lista di attesa.
OBIETTIVI: Valutare i fattori che portano la popolazione nazionale ed internazionale a non acconsentire alla donazione degli organi.
METODI: È stata condotta una revisione integrativa secondo la metodologia Whittemore &amp; Knafl durante il mese di Agosto 2022  presso PubMed. Gli articoli sono stati successivamente selezionati secondo criteri di inclusione ed esclusione precedentemente stabiliti.
RISULTATI: Al termine del processo di selezione sono stati inclusi 16 studi. Alla base della decisione di acconsentire alla donazione degli organi sia in vita sia in caso di morte di un familiare vi è l’influenza di diversi fattori, in particolare il sistema di consenso, la cultura, la religione, l’attività dei professionisti sanitari in particolare l’infermiere e la conoscenza del singolo in materia di trapianto e donazione.
CONCLUSIONI: Per acquisire consenso nei confronti della donazione d’organo dovrebbe essere previsto un intervento olistico rivolto sia alla popolazione generale che ai professionisti sanitari, pianificando interventi educativi centrati sul target preso in considerazione. 
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Rita Fiorentini 
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Dissertation Nursing
Infermieri
Analisi dei fattori incidenti sull’opposizione della popolazione alla donazione d’organo: una revisione integrativa della letteratura 
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Rita Fiorentini 
2024/01/31
10.54103/dn/20223
Corso di Laurea in Infermieristica, Università Politecnica delle Marche, Sede di Macerata
2785-7263
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Hirai K., Ohtake F., Kudo T., Ito T., Sasaki S., Yamazaki G., Eguchi Y. Effect of different types of messages on readiness to indicate willingness to register for organ donation during driver’s license renewal in Japan. Transplantation [Internet]. December 2020 [consulted on the 23rd August 2022]; 104(12): 2591-2598. Available at: https://doi.org/10.1097/TP.0000000000003181.
Analisi dei fattori incidenti sull’opposizione della popolazione alla donazione d’organo: una revisione integrativa della letteratura 
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           ISSN: 2785-7263                                                                                                  DOI: 10.54103/dn/20223




               DISSERTATION NURSING®
               Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

 Integrative Review

Analysis of the incident factors among the population towards the
  opposition to organ donation: a literature integrative review
  Cartechini Valentina1, Gatti Chiara2, Bacaloni Simona3, Carpano Sabrina3, Grillo Claudio3, Rita Fiorentini3
  1 Student,Università Politecnica delle Marche, Macerata campus, Italy
  2 AOU delle Marche, Ancona site, Italy
  3 Bachelor School of Nursing, Università Politecnica delle Marche, Macerata campus, Italy




  Findings:                                                ABSTRACT
  Donation requires a holistic, informational,             BACKGROUND:
  communicative and relational intervention                To date, institutional sources show a conspicuous number of objections to
  geared toward increasing donation rates but
  still respectful and aware of different cultures.
                                                           donation, slow growth in donor registry enrolment, and a gap between
                                                           available donors and wait-listed recipients.

                                                           AIM:
                                                           To assess the factors that lead the national and international population to
                                                           not consent to organ donation.

                                                           METHODS:
                                                           An integrative review was conducted during August 2022 in PubMed
                                                           according to the methodology developed by Whittemore & Knafl. Articles
                                                           were subsequently selected according to previously established inclusion and
                                                           exclusion criteria.

                                                           RESULTS:
                                                           At the end of the selection process, 16 studies were included. The decision to
                                                           consent to organ donation during the course of life or in case of the death of
                                                           a family member is mediated by the influence of several factors, particularly
                                                           the consent system, culture, religion, the activities of health professionals
                                                           particularly the nurse, and the individual's knowledge of transplantation and
                                                           donation.

                                                           CONCLUSION:
                                                           In order to gain consent toward organ donation, there should be a holistic
                                                           intervention targeting both the general population and health professionals
                                                           by planning educational interventions focused on the target audience
                                                           considered.



                      KEYWORDS: Tissue and Organ Procurement, Health Literacy, Attitude of Health Personnel, Nurses


          Corresponding author:                                              58                                    Submission received: 30/05/2023
          Valentina Cartechini: valentina_cartechini@libero.it                                              End of Peer Review process: 08/09/2023
          Università Politecnica delle Marche (Laurea in                                                                     Accepted: 08/09/2023
          Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                                         This work is licensed under a Creative Commons
               Dissertation Nursing V3, N.1 (01/2024)                                    Attribution-NonCommercial-NoDerivatives 4.0 nternational
         ISSN: 2785-7263                                                                                                    DOI: 10.54103/dn/20223




            DISSERTATION NURSING®
             Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing

Revisione Integrativa
    Analisi dei fattori incidenti sull’opposizione della popolazione alla
     donazione d’organo: una revisione integrativa della letteratura
Cartechini Valentina1, Gatti Chiara2, Bacaloni Simona3, Carpano Sabrina3, Grillo Claudio3, Rita Fiorentini3
1 StudentessaUniversità Politecnica delle Marche, sede di Macerata
2 AOU delle Marche, sede di Ancona
3 Corso di Laurea in Infermieristica, Università Politecnica delle Marche, sede di Macerata




Riscontri:                                               ABSTRACT
La donazione richiede un intervento olistico,            INTRODUZIONE:
informativo, comunicativo e relazionale                  Fonti istituzionali mostrano ad oggi un cospicuo numero di opposizioni alla
orientato ad aumentare i tassi di donazione,
ma sempre rispettoso e consapevole delle diverse
                                                         donazione, una lenta crescita di iscrizioni al registro dei donatori e un gap tra
culture.                                                 donatori disponibili e riceventi in lista di attesa.

                                                         OBIETTIVI:
                                                         Valutare i fattori che portano la popolazione nazionale ed internazionale a non
                                                         acconsentire alla donazione degli organi.

                                                         MATERIALI E METODI:
                                                         È stata condotta una revisione integrativa secondo la metodologia Whittemore
                                                         & Knafl durante il mese di Agosto 2022 presso PubMed. Gli articoli sono
                                                         stati successivamente selezionati secondo criteri di inclusione ed esclusione
                                                         precedentemente stabiliti.

                                                         RISULTATI:
                                                         Al termine del processo di selezione sono stati inclusi 16 studi. Alla base della
                                                         decisione di acconsentire alla donazione degli organi sia in vita sia in caso di
                                                         morte di un familiare vi è l’influenza di diversi fattori, in particolare il sistema
                                                         di consenso, la cultura, la religione, l’attività dei professionisti sanitari in
                                                         particolare l’infermiere e la conoscenza del singolo in materia di trapianto e
                                                         donazione.

                                                         CONCLUSIONI:
                                                         Per acquisire consenso nei confronti della donazione d’organo dovrebbe
                                                         essere previsto un intervento olistico rivolto sia alla popolazione generale che
                                                         ai professionisti sanitari, pianificando interventi educativi centrati sul target
                                                         preso in considerazione.




     KEYWORDS: Approvvigionamento di tessuti e organi, Alfabetizzazione sanitaria, Attitudine del personale sanitario, Infermieri,


        Corresponding author:                                                59                                    Submission received: 30/05/2023
        Valentina Cartechini: valentina_cartechini@libero.it                                                End of Peer Review process: 08/09/2023
        Università Politecnica delle Marche (Laurea in                                                                       Accepted: 08/09/2023
        Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                                         This work is licensed under a Creative Commons
            Dissertation Nursing V3, N.1 (01/2024)                                       Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



BACKGROUND                                                        of the extreme sensitivity of the topic and the
                                                                  variability of influencing factors, it has been
Organ donation is a complex issue, regulated by laws              conducted an analysis of the different factors
with the purpose of ensuring the safety of the donor              involved in this decision.
and the future recipient, as well as manage roles and
functions of all the health professionals involved.               Aim:
With respect to the latter, special attention should be
                                                                  The primary objective of the research was to analyze
paid to the nurse, who plays a role of high
                                                                  the factors influencing whether or not people choose
responsibility as claimed by the Code of Ethics 2019
                                                                  to become donors. The secondary objective was to
(1): "The nurse promotes information about blood,
                                                                  evaluate the effectiveness of educational pathways
tissue and organ donation as an act of solidarity;
                                                                  incentivizing donation.
educates and supports those involved in donating and
receiving blood, tissues and organs." Therefore,
despite their importance, nurses to date do not
receive sufficient preparation in this area from                  METHODS
university training, and during their work, educational
                                                                  The work was set up according to the integrative
courses are offered at the national and regional levels,
                                                                  review model proposed by Whittemore & Knafl (11),
but these are limited in number (2,3,4,5,6). As a
                                                                  in order to obtain an analysis of heterogeneous
consequence, the previously mentioned elements,
                                                                  literature as rigorous as possible.
combined with the presence of personal, social and
cultural factors that influence the opinion of the "lay"          Identification of the problem
population in terms of health, affect donation rates.
From the analysis of the network of donation and                  First, the research question was defined according to
transplantation activities, institutional sources                 PICO methodology:
reported in 2022 a total of 3083 transplants                      ● P (population): international population;
performed(7), compared to the 8132 patients on the
waiting list (8).                                                 ● I (intervention): understanding the factors affecting
This evidence shows a wide imbalance between                      donation;
availability and demand for organs and therefore the
need to increase access to donation, still challenged by          ● C (comparison): /
objections: in 2022, in fact, of the 2049661 donation             ● O (goal): improving donation rates and decreasing
declaration signed at the Municipalities 68.2% were               objections.
consents and 31.8% oppositions; Local Health
Authorities recorded 1222 declarations, with 48.3%                Literature search process
oppositions, while the Italian Association for Organ,
                                                                  (a) Definition of inclusion and exclusion criteria: were
Tissue and Cell Donation (AIDO) collected a total of
                                                                  designated a priori so that bibliographic citations
12000 declarations (9). Moreover, the same trend was
                                                                  consistent with the topic under consideration could
confirmed within hospital facilities, where the Marche
                                                                  then be obtained. Therefore, studies published
Regional Transplant Center (10) reported that within
                                                                  between January 1, 2002 and August 23, 2022,
resuscitations in 2022 the national average opposition
                                                                  qualitative studies, and quantitative studies such as
rate was 29.6%, while within the Marche Region it
                                                                  randomized controlled trials (RCTs), systematic
was corresponding to 28%. For this reason, in light
      Corresponding author:                                  60                                 Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                               End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                      Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                      This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                      Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                                     DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



reviews (SRs), meta-analyses, and observational                                    2279, then reduced to 66 by applying the search filters
studies were included within the review; on the other                              corresponding to the previously defined inclusion
hand, studies involving subjects under the age of 18                               criteria.
years, studies involving tissue donation, and living
donation were eliminated.                                                          Literature screening

(b) Determination of the search string: the literature                             Final eligibility of the 66 studies was made by a single
was searched through the MEDLINE database on                                       reviewer, based on compliance with the defined
PubMed, through terms that could entail the large                                  exclusion criteria and the relevance of each study to
population sample considered and the various factors                               the objective of the review. The screening of the
involved        (healthcare      professionals/general                             literature was carried out in two steps, with a first
population;      technical    aspects    related    to                             selection of the articles performed reading the title
healthcare/cultural and personal aspects). The search                              and abstract of each study, leading to the exclusion of
string was defined as following:                                                   32 articles. It was then performed an analysis of the
                                                                                   full text of each citation, resulting in the final
(tissue and organ procurement [Mesh Major Topic]) AND                              selection of 16 articles. The entire process of
(organ donation) AND (attitude).                                                   searching and evaluating the literature considered was
                                                                                   summarized in the PRISMA below (Fig.1) (12).
The bibliographic citations obtained at this point were
                                                      Identification of studies via databases and registers
                   Identification




                                                                                        Records removed before screening:
                                         Records identified from*:                       - Duplicate records removed (n = 0)
                                            PubMed (n = 2279)                            - Application of inclusion
                                                                                           criteria/research filters (n=2213)




                                         Records screened                               Records excluded:
                                         (n = 66)                                       (n = 32)
                   Screening




                                         Reports sought for retrieval                   Reports not retrieved:
                                         (n = 34)                                       (n = 10)




                                         Reports assessed for eligibility               Reports excluded:
                                         (n = 24)                                        - Sample Age (n = 8)
                   Include




                                         Studies included in review
                      d




                                         (n = 16)



                                    Figure1:summary and flow-chart of the literature selection process using PRISMA.

      Corresponding author:                                                   61                                  Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                                                 End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                                        Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                                        This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                                        Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                                      DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



Data analysis process                                                              population, the consent model, sociocultural aspects
                                                                                   (opinion towards donation, family, religion and
(a) Data reduction: for each bibliographic reference                               educational interventions) were included; in the case
title, author(s), objective, study design, sample type,                            of health professionals, technical knowledge regarding
main findings and conclusions were extracted,                                      donation, work setting and effectiveness of
defining an initial classification of evidence according                           educational interventions were investigated.
to the type of sample considered and then with
respect to the "lay" population in health care and                                 (c) Data comparison: The data comparison process
health care professionals.                                                         involved the identification of themes and
                                                                                   relationships among different factors considered in
(b) Data visualization: the extracted evidence was                                 the visualization phase. In fact, a concept map was
organized into different subgroups. In the case of the                             developed for this purpose (Fig.2).



                                                                     ORGAN
                                                                    DONATION
                      LAY                                                                                              HEALTHCARE
                   POPULATION                                                                                         PROFESSIONALS


                                                                        Consent Model

                                                             Opinion on donation

                                                             Family role

                                                             Religion

                                                             Technical characteristics regarding donation

                                                             Work setting
                                                                 Effectiveness of educational
                                                                         interventions

       Figure 2: graphical representation of the data analysis process with definition of groups and subgroups following evidence extraction




RESULTS

The main information about each study included in the review is shown in the table below (Table 1).


      Corresponding author:                                                 62                                     Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                                                  End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                                         Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                                         This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                                         Attribution-NonCommercial-NoDerivatives 4.0 nternational
        ISSN: 2785-7263                                                                                                            DOI: 10.54103/dn/20223




           DISSERTATION NURSING®
            Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



 Authors,
                         Type of
 Journal,
                        study and                             Objective                                   Main results and critical points
 Year of
                          sample
Publication
  Aykas et al.         SR + metanalysis
                                             Assess the opinion regarding the donation
     (2015),              of studies,                                                         Eighty-five percent of the sample analyzed consider organ donation
                                             of Turkey's Muslim religious officers and
 Transplantation        including 2154                                                        appropriate but less than 1 percent demonstrate to have a donor card.
                                                         theology students.
  Proceedings.             subjects.

                                                To assess the attitude of health care
  Bastami et al.                                                                            There is evidence in the emergency department of greater donation in the
                                               personnel and the general population
 (2013), Critical      SR of 20 studies.                                                     case of deaths from neurological causes than in the case of death from
                                             regarding organ donation following death
 Care Medicine.                                                                                           cardiac causes, as well as less awareness of it.
                                                       from cardiac causes.

                          RCT of 3244
                       subjects recruited
                              from a        Determine which, among different types of
Hirai et al. (2020),                                                                        Reciprocity messages show a positive effect in increasing donor registry
                          motorization      messages, is the most effective in promoting
 Transplantation.                                                                               membership, while loss messages counteract refusal to register.
                         office in Japan,                  organ donation.
                       randomized into 6
                             groups.

   Irving et al.
     (2012),           SR of 18 studies     Assess subjects' opinions about donation to     Opinion about donation is influenced by religion, culture, family opinion,
  Nephrology            of qualitative         consider appropriate communication           body issue, trust in the health care system, and the individual's knowledge
     Dialysis              nature.                           strategies.                                                   about donation.
 Transplantation


                                                Assess the impact of the emergency
                                                                                            EMERGENCY DEPARTMENT AS BARRIER: indifference or negative opinion
                           SR of 13         departments toward the donation process,
                                                                                             of the individual leads to lack of knowledge and attitude to search for
  Jawoniyi et al.       publications of       the factors that would make them more
                                                                                                 possible potential donors. Influence of various factors, such as
(2018), Journal of     both qualitative     informed and proactive, highlight their role
                                                                                             professional status, years and context of clinical experience, negative
 Clinical Nursing.     and quantitative          in donation and its promotion, and
                                                                                            emotions. FACTORS TO CONSIDER: the time factor, "conflict of interest,"
                           nature.            highlight interventions that would make
                                                                                                             lack of knowledge of donation criteria.
                                                   them more proactive toward it.



                       RCT of intensive
                                                 To evaluate the effectiveness of an
                           care nurses,
Lin et al. (2014),                           educational intervention in intensive care       Both immediately after and two months later, the experimental group
                       divided into 73 in
Transplantation                             nurses conducted according to the Theory of        showed a greater propensity to promote organ donation. The most
                        the experimental
  Proceedings.                                Planned Behaviors on the propensity to                  influential factor was the educational intervention.
                         group and 65 in
                                                     promote organ donation.
                       the control group.


                                                                                               Immigrants from Western Europe and Latin America show greater
   Lopez et al.                                 Assess the opinion of the immigrant
                         RCT of 1202                                                         inclination to donate, as opposed to those from Africa and Asia. Socio-
 (2011), Clinical                             population in Spain about donation and
                         individuals.                                                       cultural factors play an important role in the decision to become a donor
 Transplantation.                            attest to the different influencing factors.
                                                                                                                              or not.

                       SR of qualitative                                                    There is evidence of greater knowledge of the consent system especially
 Molina Pérez et
                       and quantitative        Evaluate the knowledge and opinion              in countries with an opt - in consent system. Same trend (with the
    al. (2019),
                           literature        regarding different consent models in the         exception of Sweden) is confirmed when knowledge regarding the
 Transplantation
                         regarding 60                        population                      procedures for expressing consent is investigated. Among the different
     reviews.
                            studies.                                                           systems, the preferred one still turns out to be the opt - in system.




       Corresponding author:                                                        63                                    Submission received: 30/05/2023
       Valentina Cartechini: valentina_cartechini@libero.it                                                        End of Peer Review process: 08/09/2023
       Università Politecnica delle Marche (Laurea in                                                                               Accepted: 08/09/2023
       Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                                                This work is licensed under a Creative Commons
           Dissertation Nursing V3, N.1 (01/2024)                                               Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                                           DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
           Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



                          SR of 14
                      quantitative and
                       12 qualitative
  Morgan et al.           studies of                                                       Opinion regarding donation tends to be influenced by: knowledge of the
                                          Assess opinion about donation and intention
(2012), Ethnicity          different                                                        donation process and registration methods, family opinion, religious
                                                     to sign a donor card.
   & Health.             immigrant                                                                  belief, body issue, and trust in the health care system.
                       populations in
                      North America
                           and UK.


                      RCT, with 101                                                        Of the 102 in the experimental group, 7 provided consent for donation. In
                     nursing students                                                     the control group, one of the participants provided consent. Of these eight,
Murakami et al.                            Evaluate donor registration following two
                       in the control                                                      only the 4 subjects in the experimental group obtained consent from their
(2016), Clinical                          types of interventions and then promote it to
                     group and 102 in                                                         family members. In the experimental group, 6 mothers, 2 parents, 2
transplantation.                                        family members.
                     the experimental                                                         fathers, an older brother and an older sister provided consent. In the
                           group.                                                                           control group, one mother and one father.


                       Review of a
                      questionnaire
  Padela et al.
                    conducted in 2003     Determine the factors that influence opinion     Christian religion, female sex, college degree and high socio-economic
(2011), Clinical
                      on a sample of            with respect to organ donation.              conditions are factors that positively correlate with organ donation
Transplantation.
                        1016 Arab
                       Americans.

                        RCT with 3                                                         In the two experimental groups, there was an increase in the number of
  Quinn et al.                                  To evaluate the effectiveness of an
                     groups: a control                                                        subjects who signed up for a donor card. Family discussion about
(2006), Progress                           intervention carried out in the workplace to
                      group, a basic                                                       donation increased in all three groups while the rate of family members'
       in                                   increase postmortem donation and family
                       group and an                                                       enrolment in the donor registry increased by 14% in the control group and
Transplantation.                                     communication about it.
                     advanced group.                                                                           17% in the experimental group.


                      RCT, with 340
                    college students in    To evaluate the effectiveness of delivering
 Riccetto et al.                                                                          There are differences in terms of questionnaire response in the two groups
                     the experimental      informational materials regarding donation
(2019), Clinics.                                                                                  regarding knowledge and opinion toward organ donation.
                     group and 380 in           compared with the control group.
                    the control group.


                                                                                              The implementation of a presumed consent system is shown to be
                                          Determine the impact of presumed consent        effective in raising donation rates, although these are also determined by
 Rithalia et al.
                     RS of 26 studies     with respect to donation rates and assess the   other factors for which there is a difficult assessment of the impact. The
 (2009), BMJ.
                                              population's opinion of this system.            latest studies conducted in the United Kingdom show support for
                                                                                                                presumed consent at 64 percent.


                     RCT conducted
                       with college
                                          The first objective was to assess the number
                     students, in two
 Thornton et al.                           of students who logged into the electronic       The video with real testimonies was the one that led to the number of
                       experimental
(2019), Clinical                             donor registry to provide consent; the        visits to the donor registry but was rated lower in quality than the other
                    groups of 755 and
Transplantation.                             second was to assess the quality of the                                   two interventions.
                     753 participants
                                                          interventions.
                       and 753 in a
                      control group.


 Vincent et al.                                                                           Although there is a positive opinion about donation, few subjects declared
                                            To assess the propensity of individuals of
 (2022), BMJ         SR of 89 studies.                                                       their willingness to do so. The influencing factors are geographical
                                                    Indian origin to donate.
    Open.                                                                                             location, family opinion, body issue, and religion.




                                                             Table 1: synoptic table of included studies



      Corresponding author:                                                      64                                     Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                                                       End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                                              Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                                              This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                                              Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



DISCUSSION                                                        France (a country with an opt - out system) where
                                                                  only 39 % of the population showed themselves
Studying the underlying causes of refusal to consent              informed about the process (17). However, the
to organ donation in the general population requires              knowledge rate is not only influenced by the adoption
analyzing the actors involved in the entire process: the          of either model but by the countries' own promotion
population, health professionals, and the medical-legal           of information campaigns: in Sweden, a country with
system regulating the entire process. For these                   an assumed consensus system for example, between
reasons, as reported in the Materials section, the                2001 and 2005 after the implementation of two
literature was discussed and divided according to four            educational interventions, the population's knowledge
basic aspects: the different models of consent, socio -           increased from 18% to 40% (19).
cultural factors, the role of health professionals, and
the interventions implemented to promote donation.                Influence of socio - cultural and religious aspects

Consensus models                                                  Socio - cultural aspects are factors that guide lifestyles
                                                                  of each individual and therefore it was deemed
The systems most widely adopted by different                      appropriate to conduct a thorough search of the
countries to regulate consent to organ donation can               literature also regarding the influence of these
be distinguished into two groups: the presumed (opt-              elements with respect to donation. The results
out) one, currently applied in France and Spain,                  showed that 20% of Arabs believe that donation is
where the individual is considered a donor from birth             never justifiable, 35% always justifiable, and 46% are
and must sign a statement opposing donation, and the              in the middle between the two opinions, while 67.2%
explicit (opt - in) one, practiced, for example, in Italy,        of subjects from Western Europe, 59.8% from
where, on the contrary, individuals must instead sign             Eastern Europe, 40.2% from North Africa, 64.6%
a statement attesting to their willingness to become              from Latin America, and 25% from Asia show
one (13). From these definitions, it is interesting to            positive opinion (20). The analysis of the link between
analyze the population and especially the                         belief and donation shows that Arabs of Christian
repercussions of the different systems towards                    religion are more in favor of donation than those of
donation rates. Despite the fact, therefore, that opt -           Muslim religion (20, 21). In spite of this, other studies
out proves to be the most effective in increasing                 have defined religion as one of the factors influencing
donation rates there emerges the low level of support             to a lesser extent the choice or not to become a
for it, towards which most people in European                     donor, leading to the absence of data that can define
countries are opposed with the exception of Belgium               an actual correlation between the two elements (22,
(13) and Scotland (16). The rejection toward implicit             23, 24, 25, 26). Specifically, we considered in
consent lies in the perception that it is not in line with        particular the Muslim and Sikh religions: in the
ethical principles of respect for human life and also             former case, there is a strong religious faith in some
creates the false perception that health professionals            areas of the United Kingdom, with identification of
do not implement all available life-saving                        religious leaders as true points of reference (although
interventions; the opt - in system, on the other hand,            in objective terms Islam has not pronounced itself
is considered more adequate within several European               unanimously regarding donation) (27, 28); in the latter
countries because it is associated with a greater                 case, on the other hand, there is strong support for
knowledge of the donation and transplantation                     donation as a gesture of extreme altruism although,
system: supporting the latter figure is, for example,             particularly in the elderly, there is a belief that organ

      Corresponding author:                                  65                                 Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                               End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                      Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                      This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                      Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



removal interferes with reincarnation and goes against            factors with Caucasian Americans (38): "I'm sorry to
divine will (29, 30). The same consensus is confirmed             say this, but we think it's for white people and not for
in Spain, where 36.8 percent of Islamists, 50 percent             us, because whenever pictures of people receiving
of Jews and 30 percent of Buddhists define                        transplants are shown on TV, they are always white"
themselves as in favor of donation (20). The analysis             (41). One constant directly implicated in the donation
of the opinion of Turkish religious officers and                  process is the family, both as a factor conditioning the
Muslim religious theology students shows that 85%                 individual's choices during his or her lifetime and as a
of the sample agree that the Islamic religion considers           figure expressing the individual's wishes once he or
donation appropriate but none of the students and                 she is deceased. Indians living in their home country
only 19 of the officers say they hold a donor card                report the family's contrary opinion as one of the
(31). Another concept that deserves attention is                  main hindering factors (45, 46), while those living in
alteration of bodily integrity: some evidence suggests            other countries such as the United Kingdom tend to
that this is not an unfavorable factor for donation (22,          be more open to expressing their wishes with the
23, 32, 33, 34, 35), others report that some individuals          family, as they present a greater awareness of the
particularly of Indian origin, in order not to alter the          process (37, 46, 47); in general, moreover, the
bodily integrity necessary for funeral rites declare              Caribbean, African, and South Asian cultures are less
themselves in favor only of corneal explantation (23,             likely to accept family discussion of donation than the
32, 36, 37,38). On the other hand, looking at the                 Caucasian population. The reasons that limit family
population's knowledge regarding the process of                   discussion regarding the topic of donation are
donation and transplantation (21), generalities with              superstition towards death and the fact that parents
respect to donation are fairly well known, while the              do not want to talk about the possible death of their
concepts of brain death, how to register on the donor             children: this is especially the case in older members
registry, and how to acquire a donor card are lacking:            of families and that the younger ones, although they
in African Americans in particular, knowledge                     have a positive opinion towards donation, tend to
regarding organ donation is higher when there is a                follow the former's lead (30): "I personally have no
need for transplantation in a member of the                       objection but my father does, so I'm still not sure"
community (39, 40), and in different immigrant                    (48).
cultures in the United Kingdom and the United
States, awareness regarding the process is lower than             Role of health professionals
in the Caucasian population, as organ donation is                 Health care teams play a fundamental role throughout
considered a matter for "whites" (41). Failure to                 the donation and transplantation process, having the
convey adequate information can lead within the                   task of identifying potential donors, initiating
population to the creation of false myths and                     communication with family members in order to
distorted information (41), which also fall on the                acquire consent to proceed with the explantation, and
ability and good performance of health professionals,             also representing the “method of connection”
for example, in what concerns the non-                            between donor and recipient (49,50). Within the
implementation of all life-saving treatments in the               process, therefore, each professional plays an essential
case of a patient with a donor card (42, 43): mistrust            role and must possess specific skills related to both
of the health care system and the use of explanted                the technical aspect of transplantation and donation
organs for inappropriate purposes is greater in                   and an emotional component that allows effective
Africans and Caribbeans at parity of socio-cultural               communication while being respectful of the delicate

      Corresponding author:                                  66                                 Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                               End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                      Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                      This work is licensed under a Creative Commons
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       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



moment. Evidence shows that 99% of professionals                  framework and more targeted training to the
are in favour and show a positive attitude toward                 environments in which one’s clinical activity takes
donation (51,52,53), although there is little willingness         place, dependent on the type of healthcare figure,
on their part to consent to it (54). There is                     period and setting of work experience (49, 66, 67, 68,
discordance regarding preference and consent: nurses,             69). To increase knowledge and, consequently, make
for example, are 46% in favour of donating organs                 healthcare professionals more inclined to donation,
following death from cardiac accidents and 78% are                the National Transplant Center offers several training
in favour of donating following death from                        events, which are carried out both within the entire
neurological causes (55%), the reasons for this lack of           Italian territory and at the regional level (7). From this
support lies in the nurses’ belief that they are directly         evidence, considering also the limited number of
responsible for the patient’s death (56).In the                   professionals accepted, the modalities in which they
moment in which the patient becomes a potential                   are carried out, and the presence in any case of a lack
donor, the ambivalence of health professionals comes              of knowledge on the part of health care professionals,
into play, feeling crossed between being the personnel            it is noted that there is a need to investigate additional
who implements all the possible interventions to save             training models that might be more effective and
the patient’s life and be the ones who instead must               more impactful. Several educational strategies have
implement all the necessary procedures to allow organ             thus been tested: studies confirm that an educational
preservation once death has been declared (57). The               intervention in ICU nurses, based on the Theory of
conflict of interest may cause psychological distress in          Planned Behavior, is effective in increasing the
health care professionals who generally take care and             propensity of professionals to promote donation, as it
do no harm to the patient, but it is also generated by a          provides both technical training regarding the process
lack of knowledge regarding the different types of                and at the same time makes them aware of the
donation and distrust of the certainty of the diagnosis           importance of the gesture through real-life
of death (58, 59). For these reasons, there is the need           testimonials, as opposed to simple information
to separate professionals between those who provide               through brochures (71). Other studies, however,
life saving care and those who instead take care of the           confirm that regardless of the type of training any
communication with family members to acquire                      intervention on health care professionals is shown to
consent for donation (55). However, in general, the               be effective in increasing their knowledge and
lack of support from health professionals results in a            readiness to promote donation and especially the
lack of proactive attitude toward donation, failure to            proper use of organs (72). In other studies, the
adequately inform the general population and failure              educational intervention is analyzed according to the
to implement effective communication with the                     Trans - theoretical model (73, 74, 75), which predicts
family members of the donors, resulting in low                    that change towards a given action occurs according
donation rates (3, 60, 61, 62, 63, 64, 65). One of the            to a phase of precontemplation, contemplation,
factors that causes this is the lack of adequate                  preparation, action and maintenance: they therefore
education and training of nurses and all healthcare               applied an experimental intervention, where nursing
personnel involved (2,3), due primarily to inadequate             students were subjected to a testimonial reading, a
training within universities (4,5) and later during the           class discussion and given brochures, proving,
professional career. The evidence suggests as possible            however, to be no more effective than the simple
strategy the increase in knowledge with respect to the            delivery of informational materials. While, therefore,
different modalities of donation, the regulatory                  the intervention in this case may not be effective in

      Corresponding author:                                  67                                 Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                               End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                      Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                      This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                      Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



increasing consent and adherence to donation,                     Prevention (CDC). An intervention therefore based
opposite result emerged in another study (54), which              on the emotional aspect and the need to dispel false
again used the previously described model to design               beliefs associated with donation would tend to be
an experimental intervention based on a two-hour                  more favorable toward donation (78) and also, by
theoretical training on transplantation and donation              being broadcast through the Internet, would allow for
and a group discussion with transplant coordinators,              a large-scale promotional intervention while keeping
donor and recipient family members, proving                       costs low. Nevertheless, the intervention, in order to
effective in terms of knowledge and positive opinion              be effective in terms of increasing donation rates,
regarding donation while not resulting in behavioral              must be carefully calibrated to the age group and
change in the subjects.                                           population cluster, as in another study conducted on
                                                                  a sample recruited by Amazon Mechanical Turk, the
Educational interventions towards the general                     video focused on the emotional aspect, although the
population                                                        most preferred one, in fact did not lead to an increase
The nurse and all health care professionals, in                   in donor registry visits (79). Also with regard to
addition to the technical aspect of donation, play the            university     students,    the    administration    of
fundamental role of educating and informing the                   informational      material     used    in     previous
population, which must be supported by the Health                 communication campaigns, among others, proved to
System (76). The Ministry of Health, through the                  be full of "flaws," in that it led the subjects to less
National Transplant Center, annually launches the                 truthful responses, to greater perplexity regarding
Communication Campaign for the promotion of                       donation especially with regard to the consent model,
organ, tissue and cell donation, which for the current            safety of treatment, and for the lack of attention with
year coincided with the 26th National Day for Organ               respect to the emotional aspect of the material
and Tissue Donation and Transplantation on April                  provided. On the other hand, it was possible to attest
16, 2023. The campaign, titled "Donating is a Natural             that the subjects were more knowledgeable about the
Choice," aims to inform the population about the                  technical aspect of donation and that the age of the
options for expressing consent regarding donation, is             subjects influenced the preferred communication
mainly aimed at the 18- to 35-year-olds and the over-             system (younger people tended to prefer technology
60s, who are the ones who show the least support for              while older people preferred books and television)
donation itself, and is carried out both through the              (80). Other evidence, however, points to the
website www.sceglididonare.it and through social                  effectiveness of administering informational materials
media, with digital content creation by the NTC                   (81). Therefore, in addition to the content of the
throughout the year 2023. Despite this, several                   material provided, the proper communication
authors have posed different hypotheses to                        technique should also be planned when setting up the
incentivize organ donation within the population. In              campaign: in this regard, another study (82) tested the
an initial study with a sample of university students             greater effectiveness in terms of increasing the
(77), the administration of videos with real                      propensity to donate between a message of parity
testimonials and more focused on the emotional                    ("Many people have already consented to donate"), a
aspect was found to be more effective, albeit found to            message of gain ("Your intention could save six
be qualitatively inferior, than one focused on the                people") of loss ("Five people die every week because
technical aspect of donation and information                      there are not enough donors"), of reciprocity ("You
provided by the Centers for Disease Control and                   may someday need organs from a donor"), of

      Corresponding author:                                  68                                 Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                               End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                      Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                      This work is licensed under a Creative Commons
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       ISSN: 2785-7263                                                                                   DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



reciprocity and parity combined used by the Japanese              Nonetheless, although extremely heterogeneous
Organ Transplantation Network ("Many people have                  literature in content and structure was used in the
already expressed their intention to become donors. It            conduct of this review, attention was paid to the topic
may be necessary for you to receive organs.") and                 of donation for future study.
finally a sixth type of message called control,
containing general information about organ donation.
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      Corresponding author:                                  69                                 Submission received: 30/05/2023
      Valentina Cartechini: valentina_cartechini@libero.it                               End of Peer Review process: 08/09/2023
      Università Politecnica delle Marche (Laurea in                                                      Accepted: 08/09/2023
      Infermieristica) Via Pancalducci 2, 62100 Macerata
                                                                      This work is licensed under a Creative Commons
          Dissertation Nursing V3, N.1 (01/2024)                      Attribution-NonCommercial-NoDerivatives 4.0 nternational
       ISSN: 2785-7263                                                                                      DOI: 10.54103/dn/20223




          DISSERTATION NURSING®
          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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          Journal Homepage: https://riviste.unimi.it/index.php/dissertationnursing



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