Organ procurement and transplant improve health outcomes among patients with organ failure. Although many strategies have been developed to overcome the organ shortage, the worldwide rates of organ donation remain suboptimal. The lack of commitment to the health care mission of organ donation and the limited expertise of health care professionals reflect 2 major barriers to organ procurement and raise the need to teach organ procurement to health care professionals early during their undergraduate education. To accommodate the various available curricular models and to develop a homogeneous and equitable teaching methodology irrespective of the adopted design, an early step is to set clear goals and objectives for an organ procurement program. Outcomes should be matched to different academic levels and tailored to the duration of each medical and nursing curriculum. In all cases, hands-on experience leads to a better understanding of the topic, especially with the advent of simulation techniques that may be useful for training as well as testing purposes. An effective program finally requires that attainment of objectives and outcomes are systematically tested using proper evaluation tools that adequately pair with the curricular design. In conclusion, organ procurement teaching should adopt a systematic evidence-based approach that simultaneously contributes to medical and nursing education and improves organ donation rates.

Key words : Medical education, Curriculum, Organ procurement program, Organ donation, Evidence-based strategy

Introduction

Organ transplant has rapidly evolved into a success story of modern medicine and is a life-saving therapeutic option for patients with end-stage organ failure. Nonetheless, organ availability is limited. According to the International Registry in Organ Donation and Transplantation (IRODaT), the rates of deceased and living organ donors are globally suboptimal but vary from 1 to 35 per million population among different countries.¹

Despite an increase in the organ donation rate with the expansion of donor criteria and advances in surgical and organ preservation techniques, there remains a substantial worldwide gap between the number of individuals on the transplant waiting list and the number of available donors.² Unfortunately, there is verincreasing demand, with more than 120 000 transplant candidates currently wait-listed; each day, 106 individuals are added and 18 patients die before receiving a transplant.³

The role of health care professionals
A systematic approach to understand the determinants of organ donation has been implemented since donation was first made available. Initially, bservational evidence demonstrated that public awareness might influence individuals and subsequently increase organ donor rates.^4-9 So too might interventions that address governmental systems and formalize the donation process and organize activity on the provider end. Such interventions include presumed consent legislations, organ conscription, financial incentives, organ exchange mechanisms, and organizational structure development.¹⁰

Beyond efforts that target donors, emerging evidence has recently demonstrated that donation does not always depend on donors’ choices. In fact, family refusal is considered a major liming factor that significantly impedes organ donation.^11,12 Accordingly, health care professionals (HCPs) who received no organ procurement education were initially required to build optimal family-oriented hospital environments that facilitate organ donation.^13-18 However, HCPs frequently lack the basic knowledge of organ procurement; are sometimes unable to answer questions correctly; and often raise ethical and psychological concerns associated with donation, brain death, and circulatory death.¹⁹ In addition, HCPs are likely to be uncomfortable discussing organ donation or obtaining consent from family members.^16,17 Thus, a novel strategy to shift the responsibility from individual HCPs to expert organizations was deemed necessary.^15,16 The majority of countries currently implement organ procurement organization channeling systems where expert nonprofit organizations coordinate local or regional organ donation processes. Despite their expertise, organ procurement organizations cannot truly function without the combined role of in-hospital HCPs. The need for complementary efforts highlighted the requirement to educate and train HCPs in organ procurement. While HCP education within an organ procurement organization does not necessarily translate into better professional practice, training is necessary for priming, which makes the belief of organ donation salient among HCPs and stimulates the association between professional behavioral changes and organ donation.²⁰ Equally important, trained HCPs are needed to assess medical and environmental elements that might facilitate or hinder donation and execute proper and timely hospital collaborations with organ procurement organizations to help maintain donated organs viable for transplant.¹³

The approach to developing organ procurement programs in medical and nursing education
The cornerstones of any educational strategy are to identify the problems at hand and devise an optimal approaches and to assess the needs of the targeted learners.²¹ In the domain of organ donation, the increasing gap between organ supply and demand drives the need for strategies to increase donor identification and organ procurement. Evidence to support the implementation of educational and organizational strategies for HCPs to improve organ donation has previously been presented. Douville and associates conducted a systematic review to assess the efficacy of interventions aimed at HCPs that promote organ and tissue donation. Although they lacked robust methodologies, 5 studies demonstrated that interventions have a significant effect on HCP behaviors, namely in terms of referring potential donors, approaching donors’ families, and securing a donated organ.²² Another study by McGlade and associates demonstrated that a 33-hour integrated course on organ procurement and clinical care of potential organ donors improved nursing students’ knowledge of organ suitability after death, their ability to obtain consent, and their understanding of organ donation legislation and the definition of death.²³ Accordingly, there is a need to consolidate organ transplant teachings into health care education and to educate HCPs about the intricate nuances of donor identification, approaching the family, and respecting the ethical and legal considerations of donation. In addition to being an educational concern, the positive ramifications of such strategies on public health should also be considered.

In reality, many graduating HCPs lack concrete knowledge regarding organ donation. A needs-assessment study by Anker and associates demonstrated that a significant number of medical schools in the United States and nursing schools in the state of New York provide information on organ donation in short lectures with little emphasis on discussion groups and patient interactions.²⁴ The study also demonstrated that many students are not taught how to discuss donation at a routine health care visit or how to be organ donors themselves. Additionally, 20% of medical schools fail to teach students about the process of obtaining consent for donation, and approximately 12% of nursing programs fail to teach students the definitions of brain and cardiac death.²⁴ Furthermore, results of a pilot study by Bardell and associates demonstrated that medical students at Queen’s University in Ontario, Canada, exhibit little knowledge of scientific and social issues related to organ donation.²⁵ Medical students lack superior knowledge of organ donation over their nonmedical undergraduate colleagues, which may reflect the minimal time allotted to organ donation issues in medical curricula.²⁵ The findings of these studies demonstrate the need to devise effective educational strategies to teach medical and nursing students important knowledge and competencies before they enter the health care workforce.

As a third step in establishing an organ procurement educational strategy, the development of goals and objectives is essential to guide curricular advancing, equalize various teaching methods, and compare pre- and postintervention measures of efficacy.²¹ Learner-specific objectives in organ procurement education include proper identification of donors, knowledge of the ethics of living and deceased organ donation, and demonstration of a skillful approach to proposing donation. Once a set of objectives is described, educational strategies come into play. The most effective educational method provides congruence among cognitive, affective, and psychomotor objectives.²¹ Although cognitive objectives are more elementary with standard classroom teaching, affective and psychomotor objectives often require clinical experience, patient exposure, and simulations. For that reason, the most effective strategies for organ procurement education include a combination of basic lectures and tutorials with more interactive teaching methods. Irrespective of the adopted implementation technique, hands-on experience is crucial to secure a better grasp of the subtleties of organ procurement. The development of robust communication skills and group-based approaches to organ procurement is essential to outline real-life scenarios of interprofessional interplay. Subsequently, interprofessional education and practice should be central to teaching organ procurement and include simulated or live-situation workshops for training and testing.

Given the heterogeneity of curricula and the varied educational models such as discipline-, organ problem-, or competency-based models, the implementation of a universal integrated course on organ procurement and transplant may seem challenging. However, it is possible to ensure the achievement of all major objectives by devising proper assessment methods and tailoring an integrated course to the educational model. Individual institutional committees are essential to adapt organ procurement programs and develop teaching strategies aligned with individual curricular designs. Although a condensed course approach has previously been reported, the longevity of the gained knowledge and competencies have not been studied.²⁶ Organ procurement program can also be taught progressively, whether embedded within other courses or clerkships (eg, ethics, surgery, or public health) or as a separate topic that parallels other disciplines. For instance, introducing the concept of organ donation and procurement in an organ-based model of medical education may be accomplished gradually during modules that include different donated organs, such as hepatology, nephrology, ophthalmology, and pulmonology.

Standardized methods to assess student learning should be used to ensure that all objectives have been met. Multiple-choice questions may be effective for assessing students’ basic knowledge of organ donation and procurement, although testing understanding of ethical dilemmas and cultural ambiguities often require structured essay questions. Another approach to assessment is the use of objective structured clinical examinations that include simulation scenarios and standardized patients (actors trained to depict a clinical situation).²⁷ Objective structured clinical exam­inations have been successfully applied in several domains of medical and nursing education and may be useful in tackling the social, ethical, and legal aspects of donation and transplant, as well as in testing student competencies that pertain to patient and family approaches.

Furthermore, long-term evaluation of organ procurement educational strategies is required to determine the efficacies of interventions and identify areas for improvement.²¹ Ideally, approaches should lead to improved rates of donor identification, donor referrals, and donor and family consent. This in turn should lead to higher rates of organ donors and successful transplants. Although this may be difficult to assess given the probable heterogeneity of implementation and the small short-term effects, intra-institutional evaluation of these measures may help guide organ procurement curricular develop­ment. Feedback assessment and evaluation create a closed loop that circulates back to the original unmet public need of effective organ procurement. In summary, the evaluation of an educational approach should answer the question: how effective was this particular strategy in improving organ procurement?

Conclusion

Organ donation is an important public need that requires worldwide efforts. Health care professional play a major role in the determination of organ donation rates. Despite the association between training of HCPs and the increased rate of organ donation, HCPs often lack an understanding of their role in organ procurement. Thus, the integration of organ procurement programs into undergraduate medical and nursing curricula is necessary. Programs should include well-defined objectives and follow an evidence-based systematic approach that yields educational benefits and ultimately increases organ donation rates.

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