Training; a golden ring for removing nurse's challenges in caring process of the brain death patients

Statistics show that brain death constitutes 1-4% of hospital deaths and 10% of the deaths occurred at the intensive care units (1). In the United States, brain death accounts for less than 1% of all deaths (about 15000 to 20000) (2). According to Iranian statistics, more than 15000 brain deaths occur every year in Iran, and driving accidents are one of its main causes (3-6). Then, these patients are taken to the ICUs to be cared for by nurses (7).
Considering the great number of brain deaths in Iran, and also the great number of patients needing transplant who die due to lack of obtaining an appropriate transplant organ, the Ministry of Health has notified to the universities of medical sciences the regulation number 54/100 dated 23.01.1394. In the 4th clause of this regulation, accurate and specialized medical care in accordance with the instructions, preserving the vital organs of brain death patient (maintaining electrolytes, kidneys, liver, heart, lungs, and stabilizing vital signs) are emphasized which shows the necessity and importance of accurate training for all staffs specially nurses involved in caring for the brain death patients.
Given the high rate of brain death, most patients that ICU nurses face are the brain death patients (8). The caring process of brain death patients has different challenging and undiscovered dimensions due to its difficult and complicated nature which has attracted attention of researchers from all over the world to study its different dimensions. Some of the most important challenges which ICU nurses referred to in the caring process of brain death patients in studies are as follows: understanding the concept of brain death by the ICU nurses is one of the most challenging dimensions of this process (9). Although the meaning of brain death and caring for these patients is one of the vital components of nursing practice at the ICUs (10), understanding the concept of brain death is very difficult for most nurses and challenges all their previous beliefs about death and dying (11) because the concepts and implications for understanding brain death are beyond the understanding of the normal death of a person. This phrase is translated as actual death which means there is no hope for improvement, while the physical appearance of brain death patients, the presence of family members and nurses’ caring activities at the bedside of patients give the impression that they are alive, and all of these contribute to this ambiguity. But this conflict is naturally emotional and experimental for nurses (12). Ronayne in their study found that despite the knowledge about the physiology of brain death, its experience is stressful for nurses even long after facing these patients (8).
One of the other challenges is the announcement of brain death to the patient’s family. Although this is one of the physician’s responsibilities, nurses are also involved in because of their constant presence at the hospital and easy access of patients’ family members to them. This announcement is very stressful and challenging for nurses and is one of the most important parts of caring process (13) because nursing care is not only limited to the patient but also includes facing the specific needs of patient’s family members who are in crisis and experiencing an acute, complex and stressful clinical situation (14). Other nurses’ challenges in the caring process of brain death patients are ethical and legal aspects especially in the field of brain death and organ donation (4). Studies in Iran show that only half of physicians and medical staffs have sufficient awareness about organ donation and its laws, but they do not attempt to encourage organ donation for the fear of increasing mental pressure on patient’s family members (4). However, training is considered an effective factor in facilitating organ donation process (15).
Caring for a brain death patient and possible potential members to donate is another nurses’ challenge in caring process. Caring for a brain dead patient has been always a big challenge for the ICU nurses (14). According to different studies, most nurses believe that they are not ready enough to care for a patient who is a candidate for organ donation (16). So, one of the most difficult responsibilities of ICU nurses is caring for a brain dead patient who is a candidate for organ donation after her/his family’s consent (12). Studies showed that nurses feel hopelessness, inadequacy and depression after caring for a brain dead patient. These feelings may interfere in the quality of patient care and lead the nurse to be burnout (17). Ronayne found that because of the stress of caring for the brain dead patients, some nurses experience cognitive dissonance (8). One of the most important and controversial aspects of caring process is to give the request form of organ donation to the patient’s family. Given that caring process at the ICU involves both the patient and her/his whole family (18), the attitude of staffs especially nurses towards organ donation is very important since their positive attitude leads them to try more to prepare families for organ donation consent (13).
Some research has shown that providing opportunities for training nurses in this area, promotes organ donation and transplant rates since potential donors are timely identified and introduced to the organ bank (19). Nurses found that they need training and support on all aspects of caring for a brain death patient, organ donation and supporting her/his family (15). So, accurate and comprehensive understanding of the caring process of brain death patients especially from the nurses’ perspectives is very important for high quality and comprehensive caring. Due to the shortage of organ donation and the importance of organ health for transplantation, accurate and high quality caring for patient is necessary to make sure that organs remain healthy. Therefore, it is necessary to consider the caring process of the brain dead patient in order to develop an appropriate caring program for these patients.
Thus, considering that nurses are responsible for one of the most stressful caring processes including both caring for a brain dead patient and facing her/his family members (who may not be able to accept their patient’s brain death), and given the necessity of increasing the organ donation rate, and as well as the lack of targeted education on caring for the brain dead patients and insufficient nurses’ knowledge in this area, there is a need for accurate training on this caring process more than before.