The Human Tissue (Authorisation) (Scotland) Act 2019: qualitative research - October 2019 to January 2020

Section 3: Reflections on how NHS Staff Training can support a successful move to an opt-out system

This section relates to research question 4:

What are key areas that training should target to raise awareness and knowledge of, and support for tissue and organ donation, and opt-out authorisation among NHS staff?

Key Findings:

NHS staff members were asked to reflect on the implementation activities that will be rolled out in preparation for the new law, namely training and awareness raising sessions aimed at staff. In general, across the different staff groups, key issues centred on wanting:

• Clarification on legal stipulations of the move to an opt-out authorisation system and how it would affect their practice.
• Clarification on issues regarding communication with SNODs/TDCs, other ICU units, and with ED staff.

In general, staff felt confident that this would be covered in the training/sessions organised by Scottish Government and the NHSBT.

The key areas staff hoped would be addressed in these sessions, are detailed below and organised according to NHS staff role type.

3a. Views of SNODs and TDCs

Views among SNODs and TDCs centred on viewing training as a necessary opportunity to gain clarity and better understanding of legal stipulation of the change to a deemed authorisation system, and how to ensure “all the new rules are followed.”

The key items identified as important to address training/events were:

• SNODs and TDCs hoped for greater clarification on any changes that will be made to the authorisation form.
• SNODs and TDCs also hoped for greater clarification on the legal stipulations of ‘deemed authorisation’, wherein a patient has opted into donation on the ODR and/or clearly stated a wish to donation, however families do not wish to proceed with donation – or a vice versa situation. SNODs particularly sought this clarification so as to be prepared to explain best practice in these complex situations to consultant and nursing colleagues.
• This group also suggested that discussion of different kinds of scenarios in which ‘duty to inquire’ is pursued would be useful, so as to build their confidence with ‘putting it into practice’ with families.
• Discussion of best practices for Specialist Requester/SNOD teamwork was also requested, so that speaking with families and organising tests to assess the potentiality of a donor progresses efficiently and ensures patient family support.
• This group also sought clarification on pre-death procedures: what changes will be made to current procedure lists, and when these changes will be made official.

3b. Views of CLODs and ICU/ED consultants

Views among ICU consultants covered a wider spectrum than for other staff groups, with some consultants not viewing training as particularly necessary and others seeing them as an important opportunity to get clarity and better understanding of the organ/tissue donation in general.

The key items to address that were identified by those positively anticipating training/events were:

• Clarification of the legal stipulation of ‘deemed authorisation’: akin to the clarification sought by SNODs (as described above). Many CLODs and consultants mentioned wanting to have a more confident understanding of what “deemed authorisation actually means in practice”. CLODs recounted more confidence with this concept than consultants did, with more consultants wondering whether they “would have to move forward with donation if someone’s on the register despite what families say”.
• Many expressed curiosity about the public marketing campaign to support the implementation of the opt-out system. They were specifically interested in learning about the public messages about the importance of registering donation wishes on the ODR, and how the marketing campaign might impact knowledge about “what donation entails” and “deemed authorisation” among their future patients/patient families.^[7]
• Consultants, in particular ICU consultants, were interested in ways in which more communication between ICUs could be supported so that ‘best practices’ and ‘problem solving’ techniques regarding donation developed within different health boards/other sites could be shared across different teams.
• Many suggested that signposting that ‘SNODs are the experts – it’s best to always refer to them when in doubt’ alongside case studies. In line with this, a number of consultants requested clarification on research showing that SNODs ‘in the room’ during end-of-life conversations correlates with higher authorisation rates as a few mentioned conflicting evidence on this finding.
• This group also hoped for training/sessions to create great clarity on ‘duty to inquire’ stipulations; staff expressed varying levels of confidence in their understanding of what this practice entailed and how it would affect families in practice. Some staff suggested the inclusion of different ‘duty to inquire’ scenarios to remain confident that potential donor and donor families’ wishes would be taken into account in authorisation conversations, and that trust in the ICU/NHS would not be hurt by deemed authorisation conversations.
• ED consultants and nurses also highlighted the need for greater awareness raising of tissue donation among ED staff, with ‘clear, simple guidelines how to speak with families’ of the recently deceased so that ED staff’s confidence in raising this topic is raised and encouraged.