|Home | About | Journals | Submit | Contact Us | Français|
Although recent studies have demonstrated that tissue requesters’ behavior during conversations about tissue donation affects consent rates, the link between requesters’ behavior and consent rates remains unclear.
To examine whether positive/collaborative requester behaviors elicit complementary behaviors from next of kin who were initially undecided about their willingness to donate their deceased family member’s tissues.
Audio recordings of requests were coded to assess for interpersonal behavior of each interactant.
Audio recordings were gathered from a national sample of tissue banks.
One hundred and two requester–next-of-kin dyads, consisting of 102 relatives and 53 requesters.
Tissue requester and next-of-kin affiliation and interpersonal control were assessed. Tissue requesters’ persuasion, confirmation (eg, approval, empathy, reassurance) and disapproval, as well as next-of-kin approval and disapproval, were examined.
Tissue requesters and next of kin tended to match one another on affiliation and complement one another on interpersonal control. “Key topics,” which may affect the next of kin’s decision, are discussed in only about one-third of requests. Next of kin were less affiliative and more disapproving when requesters were also more disapproving. Interpersonal behavior of the tissue requester, such as affiliation, statements of disapproval, and persuasion, as well as discussion of key topics, was a significant predictor of the interpersonal behavior of the next of kin.
Positive requester behaviors elicited a positive response from undecided next of kin. Because many next of kin have limited knowledge about tissue donation before the request, the communication process may affect the next of kin’s perceptions of donation and thus affect the likelihood of consent. Findings could potentially inform communication skills training for tissue requesters; future research could examine effects of such training on consent rates.
Tissue banks commonly make requests for tissue donation over the phone. Some next of kin (NOK) have prior knowledge about tissue donation or have spoken about the possibility of donation with family members, whereas others have little or no previous knowledge. Tissue requests are generally made within 24 hours after death, which is typically a difficult and sensitive time for family members. Therefore the quality of communication between requesters and NOK most likely affects NOK’s satisfaction with the interaction and may in fact affect NOK’s perception of tissue donation overall. This study examines the interaction between requesters and NOK during the process of requesting tissue donation. Unlike most prior research on both tissue and organ donation, which has used postrequest interview data obtained from interactants, we use observer ratings to analyze interactants’ interpersonal behavior directly.
Past research on communication during donation requests has overwhelmingly been conducted in settings examining organ donation. These studies have indicated that families of potential organ donors are more likely to consent to organ donation when transplant coordinators are specifically trained to provide information and support the family during the decision-making process1–4 and that consent rates are higher among NOK who are white, have more years of education, would donate their own organs, and/or believe that the patient would have wanted to donate.5–11 However, these studies have focused on organ rather than tissue donation and typically assess the effects of demographic and other prerequest variables on consent. To our knowledge, only 3 studies have explicitly examined interpersonal aspects of the tissue donation request process and the relation of that process to the donation decision.
Rodrigue and colleagues12 conducted interviews with families after the donation request and found that although most respondents felt that the requesters were caring and compassionate, those who consented were more likely to describe the requester in this way and were more likely to report being satisfied with the request. About 15% of those who declined to donate cited negative perceptions of the request/donation process as a contributing reason for refusal.
Siminoff and colleagues13,14 used observational coding of the interaction between the requester and the NOK as well as postrequest interviews with NOK about their perceptions and recall of the request. They found that NOK were more likely to consent if requesters discussed key topics such as costs associated with donation and ability to have an open casket funeral after donation, and NOK were less likely to donate when they held incorrect or negative assumptions about donation. Regarding persuasion, NOK were more likely to consent when requesters used specific types of persuasive statements, such as establishing credibility or referring to how donation could potentially help others, although the total number of persuasive statements was not a significant predictor of consent. Finally, NOK were more likely to consent to donation when they perceived the requesters as being more caring and concerned, being less controlling, using a higher quality of communication, and using more confirmational messages, such as providing reassurance, expressing empathy, or making statements aimed at building partnership between themselves and NOK.13,14
One factor that complicates our ability to assess the role of the communication process in these 3 studies is that many of the NOK entered the conversation already knowing what their donation decision would be. For example, NOK frequently reported that they knew and intended to follow the deceased’s wishes regarding donation, or had an immediate favorable or unfavorable reaction to the request and then consented or refused, accordingly. In these situations there is less of an opportunity for the behavior of the requester to affect the NOK’s views and intention to donate, whereas among “undecided” NOK, these factors are much more likely to have an impact.
Given that past studies of the tissue donation request process have demonstrated an association between consent to donation and requesters displaying good communication skills and caring and compassionate behavior, the current study is a detailed examination of requesters’ communication behaviors and responses of requesters and NOK to each other. In contrast to previous studies of the tissue donation request process, this study focuses on a selected subsample of requester-NOK dyads in which the NOK was clearly undecided about his or her donation decision before the conversation. Under these circumstances, the interpersonal aspects of the request and the way the information was presented are likely to have had a greater or even decisive impact on the NOK’s response, including both interpersonal behavior and the ultimate donation decision.
Variables evaluated include descriptive and communication variables derived from the Siminoff Communication Content and Affect Program (SCCAP) observational coding system15 as well as more subjective measures of each interactant’s interpersonal behavior derived from the Impact Message Inventory (IMI).16 The SCCAP provided frequency measures of the types of statements that characterized each party’s communications (eg, approval) as well as the frequency with which key topics (eg, cost of donation to the family) were discussed. The IMI provided measures of affiliative (friendliness-hostility) and control (dominance-submission) behaviors exhibited by each interactant. These variables were of particular interest because they have been identified as universal dimensions of interpersonal behavior and as prominent communication styles that are displayed by physicians and patients during medical consultations17 and by requesters and NOK during organ donation discussions.18 We evaluated the extent to which effective complementary dyadic interactions developed between requesters and NOK during requests. According to interpersonal theory,19 effective interactions occur when there is correspondence in affiliation (eg, friendly behavior by the requester evokes friendliness by the NOK, and hostility evokes hostility) and reciprocity of control behavior (eg, dominance by the requester elicits submission by the NOK).
The initial sample consisted of 1016 audio files of interactions including 1411 NOK and 216 requesters. In order to obtain a sample of undecided NOK, cases were included only when (1) the deceased had not previously signed legal documentation indicating their preferences regarding donation; (2) NOK, in postrequest interviews, reported being initially undecided about donation; (3) the deceased was at least 18 years old because donation rates were significantly lower when the patient was a minor; (4) the NOK made a clear decision about donation; (5) the conversation was at least 2 minutes and thus provided sufficient interactional data; and (6) only 1 requester and 1 NOK were involved in the interaction.
One hundred and two NOK-requester dyads met our criteria. These consisted of 102 unique NOK and 53 requesters. The number of requests conducted by each requester ranged from 1 to 7 (mean, 1.92; SD, 1.47). Sample demographics are presented in Table 1. Paired-sample t tests and χ2 analyses were conducted to test for significant differences between the initial and final samples for continuous and categorical variables, respectively. The only significant difference was NOK education: NOK in the initial sample had more years of education (mean, 14.09 years; SD, 2.45 years) than did NOK in the final sample (mean, 13.23 years; SD, 2.27 years; P=.01). Among the tissue requesters, 88.2% were white and 71.6% were female. Experience as a tissue requester ranged from 1 month to 5 years 8 months with the mean being 17.70 months (SD, 16.89 months; median, 14 months).
The IMI16 is used to assess a person’s interactional style by evaluating what reactions (feelings, actions, perceptions) the person evokes from others. The IMI is used to assess interpersonal behaviors included in Kiesler’s interpersonal circle,19 which is based on the theory that interactions are influenced by transactional processes in which each person’s interpersonal style tends to evoke certain behavioral/emotional responses from the other. This study used the 28-item observer rating form in which trained raters assess the NOK’s and tissue requester’s interactional style. Coders respond as if they were the “other” (eg, when responding as the tissue requester, rating the extent to which the NOK “made me feel taken charge of”). This short form focuses on the 2 primary axes of the interpersonal circle, control and affiliation, and has demonstrated adequate reliability and validity.20,21 Interrater reliability for this study assessed raters’ perceptions of requesters’ and NOK’s interpersonal behavior for raters acting as one interactant and assessing the behavior of the “other.” Kappa was 0.64 (P<.001) for raters acting as the requester; kappa was 0.68 (P<.001) for raters acting as the NOK.
The SCCAP is a communication coding system based on models of relational communication theory and designed for use in a variety of health-related settings. It is used to assess topics discussed and interpersonal characteristics/behaviors of interactants.15 SCCAP measures content themes and the content and sequence of information exchanged (ie, what is said) in addition to communication types and the relational aspects of communication (ie, how it is said). Interrater reliability is high, with a previous assessment analyzing interrater reliability of donation requests in the original data set. These range from 0.82 to 0.99.15 In the present study, content themes of interest were (1) discussion of funeral arrangements, (2) that NOK have the ability to choose which tissues to donate, (3) how tissues will be distributed, (4) donation will not result in body disfigurement, and (5) that donation will not result in an additional cost to the family. Communication types of interest included approval, confirmation (which includes positive and rapport-building communication skills such as empathy, reassurance, and partnership), disapproval (eg, responding to the other in an unreceptive, unfriendly, or critical manner, or making offensive or defensive statements), and persuasion.
The audio files of requester-NOK interactions analyzed were derived from a larger study of tissue donation requests gathered from a national sample of tissue banks that routinely audio record requests both for quality assurance and to verbally record the NOK’s donation decision and consent to donation. Audio files were coded by 7 trained raters who used the SCCAP to assess for positive and negative affect of requesters and NOK, and persuasive statements made by the requester. Coders were blinded to the study hypotheses. See Siminoff et al13,14 for details of the SCCAP coding process.
Interrater reliability was assessed throughout the training process, and when coders consistently achieved sufficient interrater reliability (κ≥0.75), study coding began. Coders listened to each audio file and coded for NOK behavior and then listened to the audio files a second time and coded for requester behavior.
Skewed and/or kurtoic variables were transformed for normality by using log transformations. Because the variable requester disapproval was highly skewed (with requesters making 1 or more statements of disapproval in <10% of cases), this variable was dichotomized (0 = no statements of disapproval, 1 = one or more statements of disapproval). IMI axis scores of affiliation (friendliness-hostility) and control (dominance-submissiveness) were used.
Preliminary analyses were conducted by using bivariate correlations and independent-sample t tests. For higher level analyses, linear regressions and multivariate analyses of variance were conducted that controlled for effects of requesters who conducted multiple requests by controlling for requesters’ characteristics of sex, race, experience (measured in months), and number of requests within the current sample. Hierarchical linear regression analyses examined the relationship between requester and NOK interaction variables while controlling for requesters’ characteristics; NOK interpersonal behavior was predicted by entering requesters’ characteristics in block 1 and requesters’ interpersonal behavior in block 2. Four regressions were conducted to examine the relationships between requesters’ interpersonal predictors (persuasion, confirmation, disapproval, affiliation, and control) and 4 NOK interpersonal behaviors (affiliation, control, approval, and disapproval). In order to examine the relationships between discussion of key topics and interpersonal behavior while controlling for requesters’ characteristics, multivariate analyses of variance were conducted to examine the effect of each key topic on interpersonal behavior (requester persuasion, requester confirmation, requester affiliation, requester control, NOK approval, NOK disapproval, NOK affiliation, NOK control) while controlling for requesters’ race, sex, experience, and number of requests within the sample.
Mean frequencies of statements expressing approval/confirmation, statements expressing disapproval, and persuasive statements, as assessed by using the SCCAP, are presented in Table 2.
At least 1 persuasive statement was made by the tissue requester in 83.2% of cases. The most common persuasive technique used was to establish credibility (eg, the tissue requester stating that they work for or with the hospital or funeral home), which occurred in 65.3% of cases, followed by altruism in 27.7% of cases. NOK made more statements of approval when requesters made more persuasive statements (r=0.31, P<.001).
Key topics were discussed relatively infrequently (Table 3). How tissues are distributed and the NOK’s right to choose which tissues to donate were discussed in only 2.0% and 14.7% of cases, respectively. The remaining key topics were discussed in 36.3% to 40.2% of cases.
Both tissue requesters (mean, 0.83; SD, 0.73) and NOK (mean, 0.21; SD, 0.80) were perceived as affiliative (more friendly than hostile), and both were perceived as only slightly more submissive than dominant (mean, −0.05; SD, 0.29; mean, −0.05; SD, 0.39, respectively). Consistent with interpersonal theory, tissue requesters and NOK “matched” on level of affiliation, and complemented one another on level of interpersonal control. Requesters who were more affiliative were also less controlling (Table 4).
Independent-samples t tests were conducted to examine the relationship between requesters’ use or lack of use of disapproving statements and other requester and NOK interpersonal variables. Results showed that both NOK (P = .001) and requesters (P = .02) were more affiliative when requesters did not use statements of disapproval. There was also a marginally significant finding for NOK disapproval: NOK tended to make more statements of disapproval when requesters also made 1 or more statements of disapproval (P= .06). Bivariate correlations were conducted to examine relationships among interpersonal variables assessed by means of the IMI and SCCAP. No significant within-person correlations among subscales were apparent, indicating that each variable captured a unique aspect of interpersonal behavior. When requesters were perceived as more affiliative, NOK made more statements of approval (r=0.22, P<.05).
Hierarchical linear regression analyses were conducted to examine the relationships between requesters’ interpersonal behavior (persuasion, confirmation, disapproval, affiliation, and control) and 4 NOK interpersonal behaviors (affiliation, control, approval, and disapproval). In all 4 analyses, requesters’ race, sex, months of experience, and number of requests within the sample were entered in block 1. In all 4 analyses, model 1 was not significant, indicating that these variables were not significant predictors of NOK interpersonal behavior. Results are presented in Table 5. NOK were perceived as more affiliative when tissue requesters were also more affiliative and when requesters did not use any statements of disapproval. NOK were perceived as more controlling when requesters were perceived as less controlling and when requesters used 1 or more statements of disapproval. NOK used more statements of approval when requesters made more persuasive statements, when requesters were more affiliative, and when requesters made more statements of confirmation. Finally, NOK made more statements of disapproval when requesters made 1 or more statements of disapproval.
In order to examine the relationships between discussion of key topics and NOK interpersonal behavior (affiliation, control, approval, disapproval) while controlling for requesters’ characteristics, multivariate analyses of variance were conducted to examine the effect of each key topic on interpersonal behavior while controlling for requesters’ characteristics. Of the 6 key topics examined, only the model for requesters’ discussion of NOK ability to choose which tissues to donate was significant (F4,93 =3.10, P =.02). Results of tests of between-subjects effects showed that, when controlling for requester variables in interactions in which NOK ability to choose was discussed, NOK were more affiliative (P= .03) and used more statements of approval (P = .04), and also tended to use fewer statements of disapproval (P=.07).
To our knowledge, this study is among the first to examine the process of requesting tissue donation, and it is the first to examine the interaction between tissue requesters and “undecided” next of kin specifically. These next of kin are those whose donation decisions are most likely to be swayed, whether positively or negatively, by the quality of communication with requesters and the information provided to them. Requesters made at least 1 persuasive statement in most cases (83.2%), most commonly a statement to establish their credibility by associating themselves with the hospital or funeral home, or a statement of altruism aimed at enhancing the NOK’s desire to donate in order to help others. NOK responded positively to these strategies; the number of persuasive statements made by the tissue requester was a significant predictor of the number of statements of approval made by the NOK. The frequency with which persuasive statements were made by requesters is consistent with Anker and Feeley’s study22 in which organ procurement coordinators reported frequently using persuasive messages with families when discussing organ donation.
Both tissue requesters and NOK were more friendly than hostile, and consistent with the interpersonal theory concept of complementarity as well as prior findings on interpersonal behavior during physician-patient consultations, they tended to match one another on affiliation (ie, friendliness elicited friendliness) and complement one another on interpersonal control (ie, dominance elicited submissiveness and vice versa).17,19,23
Frequency of discussion of “key topics” ranged from 2.0% of cases (for discussion of how tissues are distributed) to 40.2% (for discussion of the fact that donation will not delay or affect funeral plans), indicating that these topics, which may affect the NOK’s donation decision, are discussed in fewer than half of cases and sometimes only rarely. Given that the general public generally does not have a good understanding of the tissue donation process, it seems plausible that clearing up misconceptions about donation (eg, that donation would lead to mutilation or other dramatic change in appearance of the body; that donation would preclude the possibility of an open casket funeral) may affect consent rates. We found that, of the topics examined, the only topic significantly associated with NOK behavior was NOK’s ability to choose which tissues to donate. However, although NOK responded positively in interactions in which ability to choose was discussed, it is unclear whether this directly translated into increased rate of consent, or if discussion of other key topics may have affected consent rates despite lack of impact on NOK’s interpersonal behavior. Future research could examine whether discussion of key topics can influence consent rates regardless of any potential impact on NOK’s interpersonal behavior.
Finally NOK were less affiliative when the tissue requester made at least 1 statement of disapproval during the interaction, although the nature of this relationship remains unclear. It is possible that disapproval from the tissue requester elicited a less friendly response from NOK; conversely, it is possible that when NOK were less friendly, this elicited a disapproving response from the requester. Overall, these findings are consistent with the physician-patient literature demonstrating that when the target interactant (patient or NOK) expresses more positive affect and/or is a more active participant in the interaction, the medical information providers (physicians or tissue requesters) provide more information and are more supportive and collaborative.24–26
Because some tissue requesters made multiple requests, hierarchical linear regressions were conducted to control for possible effects of requesters’ characteristics on NOK’s interpersonal behavior. These analyses indicated that when requesters were more affiliative, NOK made more statements of approval and were also more affiliative. This suggests, as mentioned earlier, that positive and collaborative behavior on the part of one party tends to elicit the same from the other. In addition, when tissue requesters made at least 1 statement of disapproval, NOK were less affiliative, more controlling, and also made more statements of disapproval, suggesting that requesters’ disapproval tends to elicit a less collaborative and more negative response from the NOK, and vice versa. Finally, as with the preliminary analyses, requesters’ interpersonal control tended to elicit a complementary response from the NOK (eg, requesters’ dominance elicited NOK’s submissiveness and vice versa), and NOK made more statements of approval when requesters made more persuasive statements. Overall these findings suggest that when tissue requesters are warm and friendly, and establish their credibility by making affiliations with the hospital or funeral home known, NOK tend to respond positively by also being friendlier and more approving, whereas when requesters express disapproval, NOK tend to respond more negatively, which is consistent with interpersonal theory as discussed earlier.
There were some similarities and differences in interpersonal behavior in the current sample of “undecideds” and the total sample as described by Siminoff and colleagues.13,14 In both samples, tissue requesters made statements of reassurance, empathy, and approval relatively frequently, and the most common types of persuasion used involved establishing credibility and framing donation as an altruistic behavior. However, in the current sample, requesters made fewer statements of disapproval and more statements of persuasion. Requesters may have been less likely to make statements of disapproval with undecided NOK because this group excluded those NOK who reported in postrequest interviews that they were not favorable about donation upon receiving the phone call. Regarding persuasion, in the total sample, requesters may have had less of an opportunity or need to use persuasive statements because more of the NOK may have already made a decision, whereas in the undecided sample there was more of an opportunity for requesters to make persuasive statements about donation.
The current study has several limitations. The study used a number of exclusion criteria in order to include only dyads in which the NOK reported being undecided about donation when the requester first broached the topic. However, several of these criteria were based on interview data about the NOK’s initial feelings regarding donation, which were collected 2 months after the request and could have been affected by recall, particularly considering that the request was conducted during an emotional time for the NOK. About three-quarters of both NOK and requesters in this sample were female; this may have influenced the results because males and females may use different interpersonal behaviors during tissue donation requests (although no significant differences between the sexes were found during preliminary analyses). Although past studies have not examined differences between men and women specifically in this context, the physician-patient literature suggests that compared with male physicians, female physicians provide more reassurance and are more likely to discuss psychosocial issues and emotions with patients; further, physicians generally focus more on partnership-building and providing reassurance to their female patients.27 It is therefore recommended that future studies examining larger samples should include a greater proportion of male participants and should investigate possible differences between the sexes in interpersonal behavior during interactions.
In addition, although use of this limited sample of undecided NOK increased the internal validity of the study, the findings may not be generalizable to NOK who already have a preference about donation before discussing it with tissue requesters. Also, the descriptive nature of the analyses make it difficult to determine directionality of effects, and leave us only to conclude that certain types of behaviors tend to co-occur rather than determining if certain behaviors on the part of the tissue requester directly cause or elicit certain other behaviors from the NOK.
The findings of the current study have implications for tissue banks or other organizations involved in selecting and training tissue requesters. Because most individuals have limited knowledge of tissue donation, for most NOK, the interaction with tissue requesters represents their first real introduction to the topic, and the way this information is presented and the manner in which the NOK and tissue requesters interact may affect NOK’s perceptions of donation and the likelihood of consent. Specifically, we found that positive/collaborative behaviors on the part of the requester tend to elicit positive/collaborative behaviors from the NOK and vice versa, and that disapproval by one party tends to elicit a similar response from the other.
Past studies on organ donation have demonstrated that when coordinators are specifically trained to respond sensitively to the families’ needs while guiding them through the decision-making process, consent rates increase.1–4 We hypothesize that similar effects would be found in the area of tissue donation. Thus, communication skills trainings for tissue requesters that focus on (1) increasing affiliative behaviors (eg, being warm, friendly, and empathic), (2) reducing unfriendly behaviors (eg, statements expressing disapproval or criticism), and (3) establishing credibility, may help improve the initial reaction of NOK to both the requester and to tissue donation in general.
To purchase electronic or print reprints, contact: The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656, Phone (800) 899-1712 (ext 532) or (949) 448-7370 (ext 532), Fax (949) 362-2049, reprints/at/aacn.org
Notice to CE enrollees:
A closed-book, multiple-choice examination following this article tests your ability to accomplish the following objectives:
This work was supported by grant R01 HS-13152 “Understanding Consent to Tissue Donation” from the Agency for Healthcare Research and Quality.