Attitudes and knowledge about post-mortem organ donation among medical students, trainee nurses and students of health sciences in Germany

Objective In 2018 Germany had the lowest rate of post-mortem organ donation in the Eurotransplant network. Healthcare trainees and students will be important advisors on organ donation for patients in the future. This study aimed to examine 1) attitudes and knowledge about post-mortem organ donation, 2) how past transplantation scandals have affected those attitudes and 3) how satisfied respondents were with the knowledge provided on the courses. Methods A cross-sectional study was conducted between 20 March and 8 July 2019 at a university hospital and nursing schools in Berlin and Potsdam, Germany. Study participants were 209 medical students, 106 health sciences students and 67 trainee nurses. Results Of the respondents 29.3 and 50.8% knew the tasks of the German Organ Transplantation Foundation and Eurotransplant, respectively. All brain death questions were correctly answered by 56.3% of the medical students, 25.7% of the health sciences students and 50.9% of the trainee nurses (Fisher’s exact test p < 0.001, Cramer’s V = 0.242). Transplantation scandals had damaged attitudes towards organ donation for 20.7% of the medical students, 33.3% of the health sciences students and 13.6% of the trainee nurses (χ2-test p = 0.001, Cramer’s V = 0.164). Asked whether post-mortem organ donation was sufficiently addressed in their courses, 39.5% of the medical students, 60.4% of the health sciences students and 51.9% of the trainee nurses said this was not or tended not to be the case (Kruskal-Wallis H-test p < 0.001, Spearman’s rho r = −0.112). Conclusion Given the knowledge gaps identified and the respondents’ dissatisfaction with the knowledge they received, organ donation should be better integrated into curricula and training programs.


Introduction
Between 2010 and 2018, the number of post-mortem organ donors in Germany fell from 1217 to 933 [7]. Despite past transplantation scandals at German transplantation centers being widely discussed in the media, acceptance for post-mortem organ donation among the general population remains as high as ever [11]. The number of people holding organ donor cards in Germany has risen from between 11 and 12% in the period 1999-2003(Forsa [19992], N = 1,003, German survey, respondents older than 18;Forsa [2001;2], N = 3,254, German survey, respondents older than 14;Forsa [2003;2], N = 1,001, German survey, respondents between the ages of 14-24 [2]) to 36% in 2018 (figures from the Federal Center for Health Education, Bundeszentrale für gesundheitliche Aufklärung [BZgA], N = 4001). The majority of respondents in the BZgA survey were in favor of their organs being donated after death [2,3,11]. Nevertheless, with 11.3 post-mortem organ donors per million people in 2018, Germany has the lowest donation rate in the Eurotransplant network, which covers Belgium, the Netherlands, Luxembourg, Germany, Austria, Slovenia, Croatia and Hungary [8]. In Germany, the German Organ Transplantation Foundation (DSO) is responsible for coordinating the organ donation process, while Eurotransplant manages organ allocation and the waiting list [19,20].
The type of organ donation system affects attitudes to organ donation. In countries with an opt-in system, organ donation can be perceived as more altruistic than in opt-out countries, where consent to organ removal is presumed and non-consent must be recorded in writing [6]. Opt-out countries have higher post-mortem organ donation rates than opt-in countries [14,18]. In 1997, Germany legally established an extended opt-in system which requires consent from potential donors in the form of an organ donor card or living will. If a person dies without having documented their consent in this way, the family will be asked to decide on their behalf. Under the decision model adopted in 2012, people in Germany receive postal information about organ donation and an organ donor card, from their health insurance provider every 2 years [13,17,19].
Germany's organ shortage is partly the result of problems experienced by hospitals in identifying donors and reporting them to the relevant authority. Although an analysis by Schulte et al. [16] of German donor data collected between 2010 and 2015 found that the number of potential organ donors had risen, it also found that the contact quotient regarding organ donation had declined [16].
In light of this, healthcare students and trainees must be informed at an early stage about the practical aspects and problems of post-mortem organ donation in Germany. In 2013, a nationwide survey of medical students (N = 1370) found that 75.8% of respondents carried an organ donor card. These students were more trusting and less fearful of organ donation and the organ donation system than students who did not report owning an organ donor card [22]. A 2002 survey of medical students and doctors in Freiburg found that knowledge about post-mortem organ donation increased as students advanced through their education [15]. A study conducted in the UK in 2000 found no differences in attitudes to organ donation between nursing students and medical students (N = 72) [4]. In a survey of medical staff potentially involved in the organ donation process (N = 2983) at Bavarian hospitals, nursing staff were less willing to donate (66%) than doctors (82%). In addition, 28% of respondents said that the transplantation scandals had negatively affected their attitudes to post-mortem organ donation [10].
To our knowledge, no comparative study has been carried out in Germany on attitudes and knowledge about postmortem organ donation among medical students, trainee nurses and health sciences students, who will be the future contacts for organ donation and will help to drive healthcare promotion and research. We therefore designed the present study to identify differences among the abovementioned students and trainees regarding: 1) their attitudes and knowledge about post-mortem organ donation in Germany, 2) how past transplantation scandals have affected their attitudes to organ donation and 3) their satisfaction with the knowledge that their study or training programs provide about post-mortem organ donation.

Material and methods
A survey of students studying medicine or for a bachelor of arts in health sciences at the Charité-Universitätsmedizin Berlin, and trainee nurses from participating nursing schools was carried out between 20 March and 8 July 2019 via online and paper and pencil questionnaires. People who were training to be nurses or studying medicine or health sciences in Berlin or Potsdam and were at least 16 years of age were included in the study. Regarding the medical students, the study included both new students (in semesters 1-3) and those approaching graduation (in semesters [9][10][11][12] in order to compare their levels of knowledge. Those who were under 16 years of age, studying or training outside Berlin or Potsdam, or did not agree to participate were excluded. The following nursing schools participated in the survey: Wannsee-Schule e. V. Schule für Gesundheitsberufe, biz Bil-dungszentrumfürPflegeberufederDRK-Schwesternschaft Berlin e. V., Alexianer Akademie für Gesundheitsberufe Berlin/ Brandenburg, Gesundheitsakademie der Charité-Universitätsmedizin Berlin, Evangelisches Zentrum für Altersmedizin. Before the survey began, 39 participants completed an online pretest between 24 January and 6 March 2019. The online survey took place between 20 March and 31 May 2019, and the paper and pencil survey took place between 1 June and 8 July 2019. In total, 67 trainee nurses, 106 students in the health sciences bachelors program, and 209 medical students met the inclusion criteria (N = 382).

Abstract
Objective. In 2018 Germany had the lowest rate of post-mortem organ donation in the Eurotransplant network. Healthcare trainees and students will be important advisors on organ donation for patients in the future. This study aimed to examine 1) attitudes and knowledge about post-mortem organ donation, 2) how past transplantation scandals have affected those attitudes and 3) how satisfied respondents were with the knowledge provided on the courses. Methods. A cross-sectional study was conducted between 20 March and 8 July 2019 at a university hospital and nursing schools in Berlin and Potsdam, Germany. Study participants were 209 medical students, 106 health sciences students and 67 trainee nurses. Results. Of the respondents 29.3 and 50.8% knew the tasks of the German Organ Transplantation Foundation and Eurotransplant, respectively. All brain death questions were correctly answered by 56.3% of the medical students, 25.7% of the health sciences students and 50.9% of the trainee nurses (Fisher's exact test p < 0.001, Cramer's V = 0.242). Transplantation scandals had damaged attitudes towards organ donation for 20.7% of the medical students, 33.3% of the health sciences students and 13.6% of the trainee nurses (χ 2 -test p = 0.001, Cramer's V = 0.164). Asked whether post-mortem organ donation was sufficiently addressed in their courses, 39.5% of the medical students, 60.4% of the health sciences students and 51.9% of the trainee nurses said this was not or tended not to be the case (Kruskal-Wallis Htest p < 0.001, Spearman's rho r = -0.112). Conclusion. Given the knowledge gaps identified and the respondents' dissatisfaction with the knowledge they received, organ donation should be better integrated into curricula and training programs.

Schlüsselwörter
Transplantation · Gewebe-und Organvermittlung · Deutschland · Medizinstudierende · Auszubildende der Krankenpflege A total of 12 trainee nurses, 26 medical students and 2 health sciences students were excluded from the study because their semester data were missing, false (number of semesters exceeded the standard program duration), or did not meet the inclusion criteria. Other healthcare students and trainees (scrub nurses, students on an MSc in public health or in health professions education) at the Charité-Universitätsmedizin Berlin and other universities and nursing schools in Berlin who were initially included were later excluded because the sample size was too small for statistical analysis (see . Fig. 1). The sociodemographic characteristics of the study participants are shown in . Table 1, grouped according to degree/training program.
Data analysis was performed with SPSS Statistics 25 (IBM, Armonk, NY, USA). A number of group comparisons, correlation analyses, and tests for normal distribution were carried out in this exploratory study. In what follows, p-values were specified as exploratory and as significant at ≤0.05; they should not, however, be interpreted as confirmatory. To ascertain group differences, the χ 2test was used for nominal characteristics with sufficient cell size, and Fisher's exact test was used for those with small cell sizes. For ordinal variables, normal distribution was excluded using the Shapiro-Wilk test, and then the Kruskal-Wallis H-test was applied. The degree of association (correlation) was measured using Cramer's V for nominal characteristics, and Spearman's rho for ordinal variables. A correlation measured with a Cramer's V of <0.20 was described as a very low association, 0.2-0.5 as a low association, and 0.5-0.7 as a medium association [23]. A Spearman's rho of r = 0.1 corresponded to a small effect size, r = 0.3 to a medium effect size, and r = 0.5 to a large effect size (see . Table 2; [5]).
The participants' attitudes and knowledge were mostly assessed using a 5-point Likert scale (ranging from either negative to positive, or disagree to agree). More information on the questionnaire are given in . Table 3. Missing answers were not included. For all knowledge questions, the answer "don't know" was included in the statistical analysis and presented in this paper. For the other questions, "don't know" was only included if it accounted for >5% of all answers. This study was approved by the university ethics committee. Participation was voluntary.  Among the medical students, 32.4% and 23.8% rated their knowledge about post-mortem organ donation as mostly good or good, respectively. This was compared to 27.5% and 17.6% of the health sciences students, and 21.1 and 7.0% of the trainee nurses (N = 185, N = 102, N = 57). Subjective assessments of knowledge differed significantly between medical students at the start and end of their studies (the answer good rose from 3.4% to 42.3%; Kruskal-Wallis H test p < 0.001, Spearman's rho r = 0.438; N = 185). The same was true of the health sciences students (the answer good rose from 9.1% to 21.7%; Kruskal-Wallis H test p = 0.029, Spearman's rho r = 0.217; N = 102).

Comparison of attitudes and knowledge among the students and trainees
Subjective assessments of knowledge among the trainee nurses  Regarding the extended opt-in system that exists in Germany, 88.8% of the medical students (N = 178), 86.3% of the health sciences students (N = 102) and 53.6% of the trainee nurses (N = 56) were able to name it correctly (1.8% answered don't know; Fisher's exact test p < 0.001, Cramer's V = 0.273). Of all the respondents, 57.6% said they would prefer an extended opt-out system, while just 12.1% preferred the current extended opt-in system (Fisher's exact test p = 0.033, Cramer's V = 0.142; medical students: 64.6%, N = 178; health sciences students: 45.5%, N = 100; trainee nurses: 51.8%, N = 52).
To evaluate knowledge about brain death, a score by Tawil et al. [21] was adapted and included six general, closed questions [21]. A total of 12.5% of the respondents did not say that a brain dead person cannot breathe without a ventilator (8.7% answered yes , 3.9% answered don't know ; N = 178, N = 102, N = 55). A further 5.7% were of the opinion that a brain dead person can wake up and recover, while 5.1% answered don't know (N = 178, N = 102, N = 55). Asked whether a brain dead person can react (grimace, pull away), 22.1% said they could (15.2% of the medical students, 34.3% of the healthsciences students, 21.8% of the trainee nurses), and 11.9% did not know the answer (N = 178, N = 102, N = 55; χ 2 -test p < 0.001, Cramer's V = 0.193). A total of 3.9% of respondents said that a person cannot be brain dead if the heart is still beating, while 4.2% did not know the right answer (N = 178, N = 101, N = 55). A further 5.4% and 9.3% did not know that brain death differs to a coma or persistent vegetative state (1.5% and 3.3% answered no, 3.9% and 6.0% answered don't know; N = 178, N = 102, N = 55). In total, 56.3% of the medical students, 25.7% of the health-sciences students and 50.9% of the trainee nurses who answered all the questions gave correct answers to all the questions related to brain death (Fisher's exact test p < 0.001,

Medical students
Documented attitude towards organ donation 18

Trust in the healthcare and organ donation systems
A total of 28.3% and 41.7% of the medical students trusted or mostly trusted the German healthcare system. The same was true for 9.8% and 32.4% of the health sciences students, and for 5.3% and 19.3% of the trainee nurses (N = 180, N = 102, N = 57). Takentogether, 23.1% and 36.8% of all respondents said that they trusted or mostly trusted the organ donation system (N = 176, N = 97, N = 56).
When asked about doctors determining brain death, 78.7% of the survey participants said they trusted or mostly trusted them to do this reliably (N = 181, N = 99, N = 57). Asked whether the transplantation scandals had negatively affected their attitudes, 23.2% said yes (20.7% of the medical students, 33.3% of the health sciences students, 13.6% of the trainee nurses). A further 16.2% (13.0% of the medical students, 13

Satisfaction with knowledge provided during studies or training
A total of 39.5% of the medical students, 60.4% of the health sciences students and 51.9% of the trainee nurses were not or mostly not of the opinion that postmortem organ donation is sufficiently addressed by their degree or training programmes (8.5% answered don't know; Kruskal-Wallis H test p < 0.001, Spearman's rho r = -0.112; N = 177, N = 101, N = 52) (see . Fig. 3). Just 28.3% of respondents agreed or tended to agree that they could explain the process of postmortem organ donation, and 46.5% disagreed or tended to disagree (N = 176, N = 99, N = 50). In addition, 46.6% of respondents disagreed or tended to disagree that they could explain the legal foundations of post-mortem organ donation (N = 176, N = 100, N = 50).
Medical students at the beginning and end of their studies did not differ significantly in their satisfaction with the knowledge that their programs provide about organ donation (N = 177); however, the students at the end of their studies rated themselves as significantly more able to explain the process of post-mortem organ donation (Kruskal-Wallis H test p < 0.001, Spearman's rho r = 0.435, N = 176), the concept of brain death (Kruskal-Wallis H test p < 0.001, Spearman's rho r = 0.570, N = 176) and the legal foundations of organ donation (Kruskal-Wallis H test p < 0.001, Spearman's rho r = 0.320, N = 176).
Similarly, health sciences students at the start of their bachelor's (semesters 1-3) and at the end (semesters 4-6) did not differ in their levels of satisfaction regarding the knowledge provided about organ donation and in their assessments of their knowledge about the concept of braindeath. Theydid, however, differsignificantly in terms of how they assessed  Regarding the trainee nurses, satisfaction with the knowledge provided about organ donation differed significantly depending on the number of years in training, and a negative correlation was identified (Kruskal-Wallis H test p = 0.021, Spearman's rho r = -0.349, N = 52). Of the nurses in their first training year (N = 12), 41.7% answered don'tknow, and 41.7% gave an average satisfaction rating. Of the trainees in their second (N = 29) and third (N = 11) year, 62.0% and 63.7%, respectively, disagreed or tended to disagree that their training program suffi-ciently addressed post-mortem organ donation. No significant differences existed between the training years regarding selfassessments of the ability to explain the process of post-mortem organ donation, the concept of brain death, and the legal foundations.

Discussion
Active and passive acceptance for postmortem organ donation is high among healthcare students and trainees in Germany. The majority have also recorded their attitude in writing and would document their attitude on their electronic health card. The majority would also agree to organ donation on behalf of family members. Only roughly half of the respondents were able tocorrectlyname the German Organ Transplantation Foundation (DSO) as the institution responsible for coordinating organ donation. Nearly half of the respondents were dissatisfied with the amount of knowledge provided about post-mortem organ donation, and no positive change occurred at later stages in their degree/training programs. Over half of the medical students and trainee nurses were in favor of an opt-out system being introduced. Overall, medical students outperformed the other two groups on the knowledge questions. A minority in all three groups said that the transplantation scandals had changed their attitudes to post-mortem organ donation, while 16.2% responded with don't know.
Terbonssen et al. [22] identified a high willingness among medical students to document their attitudes to post-mortem organ donation in the form of an organ donor card [22]. The representative survey that the BZgA carried out for the general population in Germany in 2018 found that 39% had documented their attitude in writing. A further 84% reported a positive view of post-mortem organ donation, and 54% said they would agree to organ donation on behalf of a deceased relative [3]. The groups included in the present study all showed a comparably frequent positive or generally positive opinion, had more frequently recorded their attitude in writing, and would mostly agree to an organ donation on behalf of a deceased relative. The BZgA used closed questions for its survey, while the present survey used a 5point Likert scale.
The study by Tawil et al. [21] found that just 33% of the medical students surveyed could answer all 5 brain death questions correctly. The last question on differentiating between a coma and a persistent vegetative state was divided into two questions for the present survey. The medical students and the trainee nurses gave the right answers more frequently than the respondents in the previous sample [21]; however, only roughly half of all respondents answered all the questions correctly. This highlights the need for a greater focus on the topic of brain death.

Conclusion
To our knowledge, the present survey is thefirsttimethatattitudesandknowledge among healthcare students and trainees have been compared in a German-speaking country. Deficits in knowledge about the way organ donations are organized and about aspects of brain death were identified among the health sciences students and trainee nurses in particular. Dissatisfaction with the provision of content about organ donation was primarily expressed by these two groups.
Course content on this topic should be expanded and/or deepened in order to prevent misconceptions and make it easier to communicate with patients and relatives on this topic. Particularly among the trainee nurses, the survey showed no subjective increase in knowledge as training progressed. Regarding medical students, the German national competence-based catalogue of learning objectives in medicine states that medical students should know different definitions of death and apply those in a clinical setting. Furthermore, they should be familiar with clinical and ethical implications of organ transplantation [12]. More than one third of included medical students were dissatisfied or relatively dissatisfied with the provision of content about organ donation at medical school.
To improve satisfaction, standardized patients can be used to teach social, ethical and medical aspects of organ donation and brain death [1]. Interventions such as lectures on the organ donation process, donor eligibility and policies including a small group discussion with standardized patients have been proven to significantly increase knowledge on organ donation [9].
All groups surveyed were in favor of introducing an opt-out system and would record their attitude to post-mortem organ donation on their electronic health card. The survey participants generally had a positive view of these potential changes in the law. In light of these documented views and a corresponding potential increase in organ donation rates, these aspects should continue to be discussed by German lawmakers and in the media.

Limitations
The small sample size means that the data collected are not representative of all students and trainees in Berlin. The universities and nursing schools did not provide sociodemographic data about their trainees and students, which makes it impossible to compare the sample with the population. It was also not possible to randomize the inclusion of the participants because they had to be contacted for the online and paper and pencil surveys.