FP905 : Impact of an educational module on the knowledge & attitude of nursing students towards eye donation

Dr. Swathi Nagarajan, N11302, Dr. Veni Priya Sigamani, Dr. K. Srikanth

Abstract:

Background: The only source of cornea for corneal transplantation is from timely harvested safe eyes of deceased donors. Nurses attending on terminally ill patients can, if trained, motivate the relatives for eye donation.

Aims: To determine impact of an educational lecture on knowledge & attitude of nursing students towards eye donation.

Settings and Design: Interventional study

Materials and Methods: Nursing students in their 1^st year and 4^th year of training were administered a pre structured questionnaire. A 30 minutes interactive session was conducted for them regarding eye donation and transplantation. After 4 months, the same questionnaire was re administered and changes in their responses were analysed. Statistical analysis used: MedCalc for Windows, version 13.3.1 (MedCalc Software, Ostend, Belgium).Student t test was used to analyse change in knowledge and attitude. P value less than 0.05 was considered significant.

Results: The difference in the level of knowledge and attitude between first year and final year students prior to the exposure to educational awareness video was not statistically significant (p value=0.2 and p value=0.9 respectively). Following the interactive video, change in knowledge levels was significant for both groups

(p value=0.01-1^st Year and p value=0.006- Final year) but there was no significant change in their attitude towards eye donation.

Conclusion: Education module has been effective in imparting knowledge regarding eye donation to nursing students. “The proof of the pudding lies in the eating” and whether this translates to action by actual increase in registration as donors and corneal harvests remains to be seen.

Key-words: Eye banking, corneal transplantation, corneal blindness, eye donation, nursing education.

Introduction:

India holds the dubious distinction of the world’s largest corneal blind population^[1].Causes of corneal blindness include trachoma, ocular trauma, childhood corneal blindness, ulcerations, abuse of steroid eye drops and use of traditional eye medications ^[2]. A corneal transplant is the only option available for visual rehabilitation of those afflicted with vision impairing corneal scarring. Even though, corneal transplants continue to be the most common type of human transplant surgery, the eye donation trends are quite poor for a country the size of India^[3].According to the Eye Bank Association of India (EBAI), the huge gap of demand and supply of corneal grafts is further worsened by a significant proportion of donor corneas being unsuitable for corneal transplantation. A positive attitude of healthcare workers can significantly influence public opinion andNursing staff in lieu of proximity to patient and relatives have an excellent opportunity to motivate them to donate eyes^[4].

The objective of this study was to assess the knowledge and attitude towards eye donation among a group of nursing students and observe whether the clinical exposure of such students, which gradually increases in the four years of nursing school has any influence on it. Further the impact of an educational module on eye donation and corneal transplantation towards any change in knowledge and attitude among these nursing students was also assessed.

Subjects and Methods:

Nursing students (BSc) of the 1^st and final year in a large medical school in Southern India were requested to complete a previously validated anonymous questionnaire modified according to local circumstances ^[5] .Permission to administer this questionnaire was obtained from the Institute Research and Ethics Committee. This study was performed as part of the National Eye Donation Fortnight in 2014. An introductory note was provided at the beginning of the questionnaire that informed participants about the nature of the study and the behaviour under investigation. Participation was voluntary, without any form of compensation and all completed questionnaires were collected on the same day.

The questionnaire consisted largely of a range of self explanatory closed questions that required the participant to respond using a dichotomous (yes/no) or polytomous response. The participants were also given the opportunity to write a free-text response where appropriate. Questions 1, 4-14 and 16 assessed knowledge and questions 2, 3, 15, 17 and 18 assessed their attitude. (Table 1) The students were then exposed to an interactive educational video/PowerPoint presentation by one of the authors (SN). This presentation over a 30 minute period covered all relevant information on eye donation, corneal transplantation and the Standard Operating Procedure (SOP) to be followed during the harvesting of a deceased donor cornea. After a period of 4 months, the students were readministered the same questionnaire. Those students who did not participate the first time were requested to indicate this and were excluded from the final analysis.

Statistical analyses were performed using MedCalc for Windows, version 13.3.1 (MedCalc Software, Ostend, Belgium).Student t test was performed to analyse for change in knowledge and attitude following exposure to the educational program. P value less than 0.05 was considered as significant.

Results:

A total of ninety and ninety seven students from the 1^st year Nursing participated in the two questionnaires respectively. The seven students who had not participated in the 1^st session were excluded from the final analysis. With regards to the Final year Nursing, eighty five and eight three students participated in the 1^st and 2^nd session respectively. The level of awareness was better in the final year students in both stages. A good percent of students of both years were aware that a hospital/eye bank could be approached for eye donation. Attitudes towards eye donation were positive among all students and a high percentage of students expressed willingness to be donors themselves. There was an improvement in awareness with almost all questions following the exposure to the interactive educational video/powerpoint presentation. However, it was surprising that a vast majority of students of both years continued to remain unaware that the cornea is the tissue being harvested. While knowledge with regards to the non influence of donor disease state had marginally improved, it still continued to be much below other parameters. The difference in the level of knowledge between first year and final year students ( prior to the exposure to educational awareness video) was not statistically significant (p value=0.2 , t test; 2 tailed). Similarly no statistical difference was seen with regards to attitude towards eye donation among the two groups prior to the exposure to the interactive video (p value=0.9, t test; 2 tailed). Following exposure to the interactive video, the change in knowledge levels was significant for both group of students (p value=0.01-1^st Year and p value=0.006- Final year, t test; 2 tailed) but the attitude changes towards eye donation among both groups were not statistically significant.  (Tables 2, 3)

Discussion:

Earlier studies in the Indian subcontinent region reveal relatively high figures of both awareness and willingness to donate eyes ^[6,7,8].Despite realising nearly two decades earlier that a threefold increase in procurement would be required to meet the country’s then requirement of donor corneas, the gap between the procurement and requirement of corneas continues to huge ^[9].

Specific reluctance has been noted towards eye donation when compared to other organ donations with reasons such as eyes “having distinctive characteristics”, being “window to the soul”, “physically seen on another person”, being offered as reasons to explain the averseness to eye donation ^[10,11].Dispelling the myths regarding eye donation is essential to overcome this barrier. The mass media campaign by the Eye Bank Association of India continues to be the most common source of information among medical & paramedical professionals, students & public alike. Statistics indicate an improvement of annual corneal procurement over the years proving the merit of this campaign ^[12]. However the existing corneal procurement – requirement gap exposes the inadequacy of these promotional advertisements in isolation.

India’s Transplantation of Human Organs Act is a voluntary consent system depending on the surviving members to donate the eyes of their dead or dying relative. In the absence of consent from the person concerned, the relatives are unlikely to volunteer eye donation despite awareness regarding the same. Often the ceremonies surrounding death take precedence during the crucial narrow window of 6 hours when the eyes can be harvested. A “catalyst” who solicits eye donation, in such situations, has been found to improve the yield ^[13].This is of special relevance in Hospital Corneal Retrieval Programme (HCRP) initiative. Unlike in the developed world, grief counsellors are available in a very few hospitals in India. It is the nurse who is in close contact with the patient’s relatives from admission and is most suitably positioned to suggest a corneal donation to the grieving relatives ^[14,15].Having gained their trust and respect, the suggestion for a corneal donation is likely to be met more positively.

To be effective, these nurses should be armed with adequate knowledge regarding eye donation. In countries where nurses handle various aspects of organ donation including counselling & procurement, it has been found that they consider themselves lacking in adequate knowledge to counsel for eye donation ^[16].Our study did not find a statistically significant difference in the knowledge of 1^st& final year nursing students, reflecting the not very high priority given to organ donation in nurses’ core curriculum. Following the education module, there was significant increase in the knowledge of nursing students of both groups, more so in the 4^th year group. A strong case may therefore be made to include the teaching of organ and tissue donation in the nursing education curriculum syllabus which could enable nurses to motivate the bereaved families for eye donation.

It is important to realise that merely providing knowledge is a very simplistic approach which is unlikely to yield expected results. Dhaliwal who recorded 80% willingness to donate eyes finally observed that only 2 students had actually registered for the same ^[5] .Radunz et al recorded 42% of participants as being positively influenced by the lecture, but observed no significant increase in actual number of voluntary donors ^[17].

A similar trend is also seen in this study, where, despite noting a significant change in the knowledge of nursing students, there had been no additional registration in the intervening four months. Strangely in our study, following the educational module, more number of students gave “lack of awareness” as their reason for not registering for eye donation than before the interactive video. We speculate that “lack of awareness” is often used as a convenient excuse to explain away the reluctance to register oneself as a corneal donor. Studies show that those nurses who have registered for organ donation were more confident in counselling prospective donor family for the same and are likely to exert a positive influence on the relatives.

The success of an eye donation program relies not only on governmental and infrastructural support, but also on the awareness and favourable attitude of general public to organ donation and the cultural background of the family of potential donor. Public attitude towards eye donation in India has been reported to be less favourable when compared with western data. This may to some extent explain the seeming contradiction of high awareness and low donation rates observed. Existing social customs and religious beliefs influence ones attitude towards organ donation. With religious institutions supporting eye donation as an act of merit/ charity, an important cause of unwillingness to donate organs is gradually being overcome. Till organ donation at death becomes the norm in our society, counsellors who solicit the same will play an important role. Nurses by virtue of their proximity to the near and dear ones of the deceased are best suited to play this critical role.

Conclusion :

Education module has been effective in imparting knowledge regarding eye donation to nursing students. “The proof of the pudding lies in the eating” and whether this translates to action by actual increase in registration as donors and corneal harvests remains to be seen.

References:

1. Oliva MS, Schottman T, Gulati M. Turning the tide of corneal blindness.Indian J Ophthalmol. 2012; 60(5):423-427.
2. Ronanki VR, Sheeladevi S, Ramachandran BP, Jalbert I. Awareness regarding eye donation among stakeholders in Srikakulam district in South India.BMC Ophthalmology. 2014;14:25.
3. Rao GN. Eye banking–Are we really up to it in India? Indian J Ophthalmol. 2004;52 (3):183-184.
4. Goz F, Goz M,Erkan M. Knowledge and attitudes of medical, nursing, dentistry and health technician students towards organ donation: a pilot study. J ClinNurs. 2006;15(11):1371–1375.
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Tables:

Table1:Questionnaire administered to assess knowledge and aptitude of Nursing students.

Sl.No.
1.	How did you come to know about eye donation?
2.	Are you willing to donate your eyes?
3.	Are you willing to donate your close relative’s eyes?
4.	Whom do you approach for eye donation?
5.	Who should remove the eye from the donor?
6.	Name an eye bank in Pondicherry
7.	Can the eye be removed from a living person for donation?
8.	Can you donate one eye to some blind person you know (like kidney donation)?
9.	Within how much time after death should the eyes be removed?
10.	What is removed from the donor eye?
11.	What is transplanted from the donor eye?
12.	How long the donor eye can be kept/stored before transplantation?
13.	Do you know of anybody whose eyes have been donated?
14.	Do you know of anybody whose eyes have been transplanted?
15.	Have you registered to donate your eyes?
16.	In what cases can eyes not be donated?
17.	Why do you wish to donate your eyes?
18.	Why are you hesitant to register for eye donation?

 

Table 2 : Knowledge of nursing students before & after the educational talk.

Sl.No.	Knowledge	1st year (in percentages)		Final year (in percentages)
		Pre talk	Post talk	Pre talk	Post talk
1.	Awareness of eye donation – from media like TV, newspapers, movies etc.	51	–	80	–
2.	Knew that they could approach hospital, eye doctor or eye bank for eye donation.	43	87	96	96
3.	Eye specialist should remove the eye from the donor.	62	–	59	–
4.	Were able to name an eye bank in their town.	35	41	59	68
5.	Knew that eyes cannot be removed from a living person for donation.	64	79	59	66
6.	Knew that one cannot donate eyes to known persons (like kidney donation).	36	40	48	53
7.	Knew that eyes should be removed within 6 hours of death.	33	48	53	63
8.	Either the whole globe or the cornea is removed from the donor eye.	46	71	55	71
9.	Cornea is the tissue transplanted from the donor eye.	17	36	13	34
10.	It is possible to store the donor tissue before transplantation.	22	25	25	25
11.	Were aware of a person whose eyes had been donated.	35	–	30	–
12.	Were aware of somebody who had received corneal transplant.	30	–	26	–
13.	Knew that eye harvesting should not be refused on account of donor’s disease state.	10	7	8	16

 

Table 3 : Attitude of nursing students before and after the educational talk.

Sl.No.	Attitude	1st year (in percentages)		Final year (in percentages)
		Pre talk	Post talk	Pre talk	Post talk
1.	Willingness to donate their own eyes.	88	90	87	90
2.	Willingness to donate a deceased close relative’s eyes.	37	40	46	57
3.	Actually registered for eye donation.	14	14	12	12
4.	Nobility & charity of act as motivating factors for willingness to donate eyes.	97	92	99	81
5.	Lack of awareness given as reason for hesitancy in registering for eye donation.	43	63	31	47