Following the development of science and technology and the increasing incidence of end-stage failure of vital organs such as the kidney, liver, heart, and lungs, the need for organ transplantation is rapidly increasing (1), such that the need for organ donations has increased (200%) over the past two decades (2).

According to the Ministry of Health, the average statistics of brain death in the country is 5-6 thousand people a year. Furthermore, (16%) of the deaths that occur in the Intensive Care Unit (ICU) and (1-4%) of hospital deaths are primarily associated with brain death. Iran has the highest rate of brain death mortality compared to other countries (3). Brain dead patients worldwide are considered potential organ donors, and after the organ donation act of 1999 in Iran, organ donation statistics rose from (1.7) out of a million people in 2008 to 5.7 out a million in 2011. While this figure shows only a slight increase, it suggests a growing trend of organ donation in Iran (4).

Numerous studies have documented evidence of the significant role of nurses, new and transparent rules and regulations, and requirements of the communities. The rate of increasing organ donation throughout the world and in our country has expanded the role of nurses (5-11) such that nowadays, the focus of nursing has shifted from special care nursing to nursing in the organ donation process (5). According to the results of a study by Polletier, Coyle, and Sque, involvement in the organ donation process is the most positive and valuable part of the nursing profession and nurses play a vital role in this process (6, 10, 12). Sque and Coyle's study showed that brain dead patients' families considered nurses the most effective contributor of the health care teamin providing emotional support during the organ donation process (10,12). In addition, Watkinson, Kim, and Collins' study showed that nurses play several roles such as identifying potential organ donors, effectively following-up on the needs of brain dead patients' families', public education, and nursing of patients with multiple organ donors (13-15). In Iran based on the model of nursing in the organ donation process (dynamism and continuous improvement in seeking assurance and getting approve nursing model) in the Organ Transplant Center of Mashhad University of Medical Sciences, two important contributing roles and nurse advocacy in the donation process are discussed (16). The role of nurse contribution refers to nurses informing the family of brain death and asking for organ donations as well as their role as coordinators in the process of organ donation (16). The results of Garland's study showed that although doctors are accountable for diagnosis and prognosis, nurses are best for reiterating the doctor's points; therefore nurses should be present when doctors give information to the patients' families (17). If nurses can manage to appropriately request organ donations when they inform families of brain death, the families can more easily accept their patients' condition and are more likely to consent to donating (8). Nurses can act as coordinators between the treatment team, requesting team, patients and their families, and organ recipients (12, 16, 17). Another role of the nurse is to be the patient's advocate in the organ donation process, which plays a role in the two areas of support and protection.

Support includes two components related to "patient care" and "family care".

One of the most important factors in gaining the trust of families seems to be nurse advocacy in the organ donation process, and this can be achieved by witnessing adequate patient care. Before nurse intervention, the care and treatment team should establish family trust that they will do all they can to ensure the safety and improvement of their patient, and their patient will receive enough care and treatment.

The nurse's role also includes informational support (counseling), emotional support, and bereavement support (16).

Despite the brief description above about nurses' roles and their importance in the organ donation process, various studies show that ICU staff members, such as doctors and nurses, are not prepared to successfully manage the process of organ donation (18, 19).The results of a study by Lin showed that the ability of nurses to spend time with families, answer their questions, and keep a positive attitude toward organ donation during the organ donation process is vital and required (11).

Mattan and Sque's study emphasized the important role of nurses in this process and suggested that its success is closely linked to their practice in organ donation and transplantation (12, 18).

Finally, according to the aforementioned studies and a comparison between studies conducted both domestically and abroad, it is important to consider the role of nurses in the organ donation process. Studies show that nowadays, ICU nurses play a significant and key role in the care of brain dead patients and their families, therefore their practice extremely important to the success of organ donation. Hence, the researcher aimed to assess ICU nurse's practice in relation to nurse's role in the organ donation process from brain dead patients and factors influencing it in Iran.

Materials and Methods

This cross-sectional analytical study was conducted in 2014 with ICU nurses in Ghaem and Imam Reza Hospitals in Mashhad. The sample size was based on the results of a pilot study, and 90 nurses were selected using a stratified random sampling. Inclusion criteria included having at least one encounter with a brain dead patient, no previous training in this field, and interest in participating in the study. Exclusion criteria included withdrawal from the study and failure to complete research. This study was a student thesis, and approval was obtained from the Ethics Committee of Mashhad University of Medical Sciences. Informed consent from subjects and the right to withdraw from the study at any time were considered. Data collection tools included a questionnaire on demographic information, a questionnaire on factors influencing nurse's practice during the organ donation process, and a questionnaire surveying "nurses' practice in relation to their roles in the organ donation process." The nine-question form studied factors influencing nurses' practice in the organ donation process along with questions regarding having an organ donation card, caring for brain dead patients, speaking with families about organ donation, etc. The questionnaire "Nurse practice in relation to their role in the organ donation process" was based and designed on dynamism and continuous improvement in seeking assurance and getting approve nursing model which introduced nurse roles in the organ donation process in Iran (16).

Questionnaire was designed to evaluate nurse practice in relation to their role in the organ donation process, included two factual scenarios of brain dead patients in Shahid Kamyab Hospital in Mashhad written by the researcher. The first scenario related to the role of nurse advocacy in the organ donation process, and the second scenario related to nurses 'participatory roles in this process. Each scenario was followed by five descriptive questions. The minimum score was zero (the lowest nurse practice in the organ donation process), and the maximum score was 10 (the highest nurse practice). Validity of study tools was confirmed by content validity. A test-retest method was used for reliability of the survey factors influencing nurse's practice during the organ donation process questionnaire(r=0.86). Inter-rater agreement was used to assess the reliability of the practice questionnaire (Kappa=0.87). The questionnaires were completed by participating subjects in the ICU of Ghaem and Imam Reza Hospitals in the presence of the researcher. SPSS software Version _11.5 was used to analyze the data. To describe the characteristics of the sample, descriptive statistics including mean, standard deviation, and frequency distribution. To examine the relationship between variables, an independent T-test, Chi-square and one-way ANOVA were used, and Pearson correlation coefficient was used to evaluate practice. Practice scores were calculated on a scale of 100. The results for practice were divided into 5 sections: very high, high, medium, low, very low. Also Normal distribution was determined using a Kolmogorov-Smirnov and Shapiro-Wilk test and based on the result; score of practice had normal distribution.

 (95%) confidence and (80%) power of all tests were considered.

Results

90 nurses participated in this study. (76.7%) of subjects were married, and 23.3% were single. (82.2%) were female, and 18.8% were male. The age range was 24-56 years old, and the average age was (5.8±33.2).

 (50.0%) of the nurses were contract-based, and (97.3%) held a bachelor's degree in nursing. The majority (93.3%) was clinical nurses, and (6.7%) were head nurses table1.