Spirituality as a Predictive Factor for Signing an Organ Donor Card

Abstract Purpose: To examine differences in spirituality, purpose in life, and attitudes toward organ donation between people who signed and those who did not sign an organ donor card. Design: A descriptive cross-sectional survey conducted in Israel with a sample of 312 respondents from the general population, of whom 220 (70.5%) signed an organ donor card. Data were collected during April–June 2013. Methods: Participants completed a paper questionnaire and a Web-based questionnaire consisting of four sections: spiritual health, purpose in life, at- titudes toward organ donation, and social-demographic questions. Descriptive statistics, t test, chi-square test, and a logistic regression analysis were per- formed. Findings: Differences in mean scores between respondents who signed an organ donor card and those who did not were indicated in transcendental spirituality (p < .01), purpose in life (p < .05), and attitudes toward organ donation (p < .01). No statistically significant difference was found between the groups in the overall spirituality mean score. The spiritual transcendental dimension, individual’s purpose in life, and attitudes toward organ donation explained 34.3% of the variance of signing an organ donor card. Conclusions: Signing an organ donor card was found to be correlated with high purpose in life, positive attitudes toward organ donation, and low level of transcendental spirituality. Clinical Relevance: Nurses should assess the patient’s spiritual needs in or- der to construct appropriate programs for promoting signing an organ donor card. Nurses who signed an organ donor card should be encouraged to share this information with their patients. Organ donation in the Western world is entirely depen- dent on the willingness of people to donate organs af- ter their death. In Israel, organ donation from deceased donors is made following the determination of donor brain death, after which the family is required to make a decision about whether to donate the deceased fam- ily member’s organs. When family members are aware of the decedent’s wish to donate organs, they will usu- ally give consent to donate (Haddow, 2004; Merchant et al., 2008; Rassin, Lowenthal, & Silner, 2005). When the family isn’t aware of the decedent’s wishes, they usu- ally will not donate (Burroughs, Hong, Kappel, & Freed- man, 1998; Cleiren & Van Zoelen, 2002; Sque, Long, & Payne, 2005). Signing a donor card, therefore, is a means of expressing a desire to donate organs posthumously. Among the variables that can affect signing or the avoidance of signing an organ donor card (SODC) are the individual’s religious beliefs and attitudes to- ward organ donation and transplantation (Gauher et al., 2013; Karim, Jandu, & Sharif, 2013; Rodrigue et al., 2004). Religious beliefs constitute one of the barri- ers to SODC (Wakefield, Watts, Homewood, Meiser, & Journal of Nursing Scholarship, 2015; 47:1, 25–33. 25 C© 2014 Sigma Theta Tau International Spirituality and Organ Donor Card Peles Bortz et al. Siminoff, 2010), although all the monotheistic religions (Christianity, Islam, Judaism) accept organ donation. Re- ligion, viewed in a cultural context, encompasses sev- eral dimensions, one of which is a person’s spirituality (Hill & Pargament, 2003). Spirituality as a construct is de- fined as the broad personal search for meaning, purpose, and value in life (Baumsteiger, Chenneville, & McGuire, 2013; Ellor & McGregor, 2011). The sense of purpose in life was found to be a key mechanism linking the im- portance of volunteer activity to a person’s well-being (Thoits, 2012). Since SODC is a voluntary act that repre- sents the humanitarian ideal of helping unknown others, it can be assumed that perceived purpose in life will be more prominent among people who signed a donor card. The purpose of the current study, therefore, is to exam- ine the contribution of spirituality, purpose in life, and attitudes toward donation to SODC. Individuals’ Spirituality, Purpose in Life, and Attitudes Toward Organ Donation and Signing an Organ Donor Card A significant gap exists worldwide between the need for donor organs for people suffering from terminal or- gan insufficiency and organ supply. By way of example, 117,000 patients in the United States (US) and 1,075 pa- tients in Israel were registered on the transplant wait- ing lists as of January 2014 (Ministry of Health Israel, 2014b). In Israel, approximately 14% of the population has signed an organ donor card (Ministry of Health Israel, 2014a), while the proportion of the population on the Organ Donor Register in the United Kingdom was 30% in 2012 (Deedat, Kenten, & Morgan, 2013) and 45% of adult (? 18 years of age) Americans in 2013 (Donate Life America, 2013). Two basic legal systems exist for the procurement of postmortem organs for transplantation that respect the decision of the deceased person. These systems are usu- ally classified as opt-in and opt-out, with the basic dif- ference between them the process that must be followed in cases when the deceased did not express his or her wish regarding organ donation before his or her death. In the opt-in system, the default is that no removal of the decedent’s organs will be carried out, while in the opt- out system, organ removal is possible even if the wishes of the deceased are unknown (den Hartogh, 2012). In Israel the system is opt-in, namely, family consent is al- ways required for deceased organ donation. In such a sit- uation, when the wish of the deceased to donate his or her organs posthumously is known, the family usually gives the consent for organ donation (Sque, Long, Payne, & Allardyce, 2008), but when the will of the deceased is unknown, the family usually will not donate (Cleiren & Van Zoelen, 2002; Sque et al., 2005). This underscores the importance of the organ donor card as a guarantee for donation consent and as a means to increase the amount of available organs. Morgan, Harrison, Afifi, Long, and Stephenson (2008) cited previous studies identifying cognitive and noncogni- tive variables that impact approval or avoidance of SODC. Between the cognitive-based variables are attitudes to- ward and knowledge about organ donation. Amongst the noncognitive variables are disgust (“ick” factor) and the potentiality of causing bad luck to the person who signs an organ donor card (jinx factor). Another significant factor affecting willingness to sign an organ donor card is an individual’s religious faith. Conesa et al. (2003) showed that religious motives were among the reasons given against organ donation in a Catholic population sample. They concluded that religios- ity was an excuse to explain respondents’ negative atti- tude toward organ donation, while the Catholic Church is in favor of organ donation and transplantation (Conesa et al., 2003). The question arises, therefore, as to whether the term religiosity accurately reflects the explanation for the avoidance to sign an organ donor card. Today, vari- ous researchers are exploring the nature of the relation- ship between religion and spirituality (Paloutzian & Park, 2013; Worthington, Hook, Davis, & McDaniel, 2011). Expressions of spirituality span a wide range, from the view that spirituality is one of the components of religion (Hill & Pargament, 2003), through the use of the terms religion and spirituality as synonymous (Gorsuch & Walker, 2006), to the view that they are two distinct structures with overlapping features, according to Zinnbauer, Pargament, and Scott (as cited by Fisher, 2009; Kevern, 2012). Fisher (2009) described spiritual health as a “dynamic state of being, shown by the extent to which people live in harmony within relationships.” Accordingly, the individual’s spiritual well-being consists of four domains: personal, communal, environmental, and transcendental. The personal domain is defined as personal space where one relates to oneself with regard to meaning, purpose, and values in life. The communal domain represents an interpersonal space shown by the quality and depth of interpersonal relationships between self and others, relating to morality, culture, and religion. The environmental domain is defined as something be- yond care and nurture of the physical and biological self, namely, a sense of awe and wonder. The transcendental domain is defined as the relationships of self with some- thing or someone beyond the human level (cosmic force, transcendent reality, or God). This involves faith, adora- tion, and worship of the mystery of the reality (Fisher, 1998). In the context of organ donation, a spiritual 26 Journal of Nursing Scholarship, 2015; 47:1, 25–33. C© 2014 Sigma Theta Tau International Peles Bortz et al. Spirituality and Organ Donor Card connection with the transplant recipient, a spiritual con- cern about removing organs, and attitudes toward organ donation significantly predicted willingness to become an organ donor for respondents in a study conducted in China and the US (Bresnahan, Guan, Smith, Wang, & Edmundson, 2010), and a study conducted in Korea, Japan, and the US (Bresnahan, Lee, Smith, Shearman, & Yoo, 2007). According to Litwinczuk and Groh (2007), a corre- lation was found between spirituality and the sense of purpose that the individual gives to his or her life. Such purpose refers to the intention, a function to be fulfilled, or goals to be achieved (Reker, Peacock, & Wong, 1987). A person will be seen as having a purpose in life when he or she pursues goals and has a sense of direction, feels there is meaning to present and past life, holds beliefs that give life purpose, and has aims and objectives for living (Ryff, 1989). An act of helping other people intensifies the meaning and purpose that people give to their lives (Son & Wilson, 2012; Thoits, 2012). The most commonly identified reason for becoming an organ donor was an altruistic motivation to help others (Newton, 2011). For example, purpose in life scores were found to be overwhelmingly high among living liver and kidney donors (LaPointe Rudow, Iacoviello, & Charney, 2014), although the authors found it difficult to conclude whether the sense of purpose in life was inspired by the act of donation, or individuals with a high sense of purpose in life were more apt to choose donation. Despite the fact that organ donation has been in use for decades, and many people understand its importance, the percentages of those who sign an organ donor card are still low. Many known factors contribute to the de- cision whether to sign an organ donor card, but it seems that some are still unknown. It is important, therefore, to examine other factors that might affect willingness to sign an organ donor card, such as spirituality, the mean- ing that one gives to life, and attitude toward organ do- nation and transplantation. Based on preceding studies, we examined the following hypotheses: ? There are differences in spirituality, purpose in life, and attitudes toward organ donation between people who signed or did not sign an organ donor card. ? SODC is associated with spirituality, purpose in life, and attitudes toward organ donation. Methods Study Design and Sample The study was conducted using a descriptive cross- sectional survey. A convenience sample from the gen- eral population included 312 respondents who met the following three eligibility criteria: age 18 years or older, Internet access, and able to read and understand He- brew. The required sample size was obtained by means of the WINPEPI COMPARE2 program (USD Inc., Stone Mountain, GA, USA), used to determine power and sam- ple size for comparisons of two groups in cross-sectional designs (Abramson, 2011). Power calculations based on analysis of 43 questionnaires collected during the pilot study showed a difference of 0.299 points between the means of the “purpose in life” answer by respondents who signed or did not sign an organ donor card. To de- termine whether the difference of 0.299 between the two groups is significant at the 5% significance level with a power of 80% (Cohen, 1988), the WINPEPI COMPARE2 computer program calculated a required sample size of 297 respondents. Procedure The study was approved by the Tel Aviv Univer- sity Ethics Committee. The 43 respondents in the pilot study, recruited from a pool of researchers by a snowball method, completed a hard copy of the questionnaire in order to calculate the needed study sample and evaluate the clarity of the questions. Only one item was changed, from a negative to a positive wording. A Web-based ques- tionnaire was then created and was uploaded in various Israeli Hebrew-speaking Web forums, such as research, social action, women’s health. The questionnaire began with an explanation of the study aim, the nature of the respondent’s contribution to the research, and the man- ner in which the information would be used. The re- spondents were told that their participation in the study was entirely voluntary and that all information would re- main confidential. Their agreement to answer the ques- tions was viewed as consent to participate in the study. The questionnaire yielded 312 respondents (269 respon- dents from Web-based and 43 respondents from paper- based questionnaires), after removing duplications and questionnaries with missing data. The survey took 15 to 20 min to complete. Data were collected during April– June 2013. Measures Respondents completed questionnaires regarding their spirituality, purpose in life, attitudes toward organ do- nation, and demographic characteristics. Spirituality was measured by the Spiritual Health and Life-Orientation Measure (SHALOM) developed by Fisher (2009). The overall questionnaire includes 20 items grouped in four dimensions: personal, transcendental, environmental, and communal. Each dimension includes 5 items graded Journal of Nursing Scholarship, 2015; 47:1, 25–33. 27 C© 2014 Sigma Theta Tau International Spirituality and Organ Donor Card Peles Bortz et al. on a 5-point scale (5 = very high, 1 = very low), indicating how each item reflects the respondent’s experience most of the time. The questionnaire was back-translated, and Cronbach’s coefficient ? values for the translated version in the current study of personal, transcendental, environ- mental, and communal domains were .80, .93, .85, and .80, respectively, and .89 for all items together, indicating high internal consistency of the scale and of each domain. Purpose in life was assessed using a 14-item measure derived from Ryff and Keyes’s scales of psychological well-being (1995), graded on a 5-point scale (5 = strongly agree, 1 = strongly disagree). Higher scores indicated greater purpose in life and a greater sense of direction; hav- ing meaning to present and past life; and having beliefs that give life purpose. Back-translating the questionnaire showed that Cronbach’s coefficient ? for the translated version in the current study was .83, indicating a high level of internal consistency. Attitudes toward organ donation were measured by the Organ Donation Attitude Scale (ODAS) developed by Rumsey, Hurford, and Cole (2003). The original ques- tionnaire included 15 items after factor analysis, and par- ticipants responded to each ODAS statement on a 4-point scale (4 = strongly agree, 1 = strongly disagree). One item in the questionnaire was adapted to the Israeli organ dona- tion policy and included in the demographic characteris- tics (“I signed an organ donor card” instead of “I signed an organ donor card on the back of my driver’s license”), as it was an independent variable. Back-translating the questionnaire showed that Cronbach’s coefficient ? of the 14 statements for the translated version in the current study was .87, indicating a high level of internal consis- tency. After back-translating, face validity for the three questionnaires was attained. Demographic characteristics included respondents’ age, gender, level of education, level of religiosity, acquain- tance with someone who signed an organ donor card, and acquaintance with the activities of the Israel Trans- plant Center (ITC). Data Analysis Data were analyzed using the IBM R© SPSS R© English version 19 software (SPSS Inc., Chicago, IL, USA). Means and percentages were used for the descriptive statistics of the social-demographic characteristics and the main re- search variables. A chi-square test and t test for assessing the differences between the two groups (signing or not signing an organ donor card) were used. A logistic regres- sion was performed to determine how much variance in SODC could be accounted for by spirituality, purpose in life, and attitudes toward organ donation. Results Social-Demographic Characteristics and Differences Between Respondents Who Signed or Did Not Sign an Organ Donor Card The majority of the respondents (75.9%) were women, Israeli born (87.2%), and 19 to 84 years of age (mean = 44.15, SD = 15.12). Most respondents (61.2%) had an academic degree. The mean level of religiosity on a 10- point scale (1 = not religious, 10 = very religious) was 2.48 (SD = 2.00). Most of the respondents had signed an or- gan donor card (n = 220, 70.5%). Social-demographic and general information regarding both groups’ famil- iarity with the issue of organ donation are presented in Table 1. The percentage of SODC was higher among respondents who considered themselves as secular (55.3%), compared to the percentage of SODC among the nonsecular (34.8%; p < .01). Respondents who were ac- quainted with someone who signed an organ donor card had significantly higher rates of SODC (93.1%) compared to respondents who had no such acquaintance (58.9%; p < .001). Respondents who were aware of the activities of the ITC (74.1%) had significantly higher rates of SODC than those who were unaware of the activities (57.6%; p < .01). Group Differences in Spirituality, Purpose in Life, and Attitudes Toward Organ Donation The mean scores of the main study variables for all participants were above moderate, meaning that the re- spondents tend to consider themselves as being spiritual, having some kind of purpose in life, and positive atti- tudes toward organ donation (Table 2). No statistically significant differences were found between the groups in mean total spirituality (t310 = -1.60, p = .11). There was, however, a statistically significant difference between the groups in the transcendental spirituality dimension (t136.94 = -4.12, p < .01). Transcendental spirituality was higher among respondents who did not sign an organ donor card than among respondents who did sign (n = 91, mean = 2.42, SD = 1.27; n = 219, mean = 1.81, SD = 0.98, respectively). Respondents who had signed an organ donor card reported higher purpose in life than those in the other group (n = 219, mean = 4.79, SD = 0.69; n = 91, mean = 4.60, SD = 0.75, respectively; t308 = 2.22, p < .05). Lastly, a statistically significant difference was found in attitudes toward organ donation between respondents who signed and those who did not sign an organ donor card (t115.9 = 7.91, p < .01). Attitudes toward organ donation were more positive among respondents who signed a card as compared to 28 Journal of Nursing Scholarship, 2015; 47:1, 25–33. C© 2014 Sigma Theta Tau International Peles Bortz et al. Spirituality and Organ Donor Card Table 1. Social-Demographic and General Information Regarding the Familiarity of Signatories and Nonsignatories With the Issue of Organ Donation Signed an organ donor card Didn’t sign an organ donor card pa Mean years of age (SD) 44.50 (14.74) 43.31 (16.05) .53b Gender (%) .09c Female 78.5% 69.6% Male 21.5% 30.4% Education (%) .59c High school and less 10.9% 13.0% Post–high school 89.1% 87.0% Level of religiosity, mean (SD) 2.11 (1.65) 3.36 (2.47) .00b Acquaintance with someone who signed an organ donor card (%) Yes 93.1% 58.9% .000c No 6.9% 41.1% Acquaintance with the activities of ITC (%) .004c Yes 74.1% 57.6% No 25.9% 42.4% Note: ITC = Israel Transplant Center. ap value for differences between the groups. bt-test. cChi-square test. Table 2. Means and Differences Between the Groups (t Test) Variable Entire sample Signed an organ donor card Didn’t sign an organ donor card t Mean (SD) Mean (SD) Mean (SD) Total spirituality 3.34 (0.57) 3.30 (0.57) 3.42 (0.57) ?1.60 Personal 3.92 (0.63) 3.94 (0.59) 3.88 (0.72) 0.86 Communal 3.99 (0.58) 4.00 (0.59) 3.96 (0.58) 0.57 Environmental 3.43 (0.86) 3.44 (0.89) 3.41 (0.79) 0.31 Transcendental 1.99 (1.11) 1.81 (0.98) 2.42 (1.27) ?4.12?? Purpose in life 4.74 (0.71) 4.79 (0.69) 4.60 (0.75) 2.22? Attitudes toward organ donation 3.53 (0.46) 3.68 (0.31) 3.19 (0.56) 7.92?? Note: ?p < .05; ??p < .01. respondents who did not (n = 220, mean = 3.68, SD = 0.31; n = 92, mean = 3.20, SD = 0.56, respectively). Explanation of Signing an Organ Donor Card Transcendental spirituality was found to differ statisti- cally between respondents who signed an organ donor card and those who did not. In order to measure the pre- dictive contribution of transcendental spirituality, pur- pose in life, and attitudes toward organ donation to SODC, a logistic regression analysis was performed. The analysis demonstrated that transcendental spirituality, purpose in life, and attitudes toward organ donation ex- plained 34.3% of the variance of SODC (p < .001), while attitudes toward organ donation and the transcenden- tal dimension of spirituality explained SODC significantly (Table 3). Attitudes toward organ donation made the largest contribution in the model. Discussion The hypotheses of the current study were that there are differences in spirituality, purpose in life, and attitudes to- ward organ donation between people who signed or did not sign an organ donor card and that SODC is associated with spirituality, purpose in life, and attitudes toward or- gan donation. The main study results showed that respondents who signed an organ donor card had more purpose in life, a more positive attitude toward organ donation, and a lower level of mean transcendental spirituality than the respondents who did not sign. The importance of the findings is that they deepen the understanding of factors affecting the decision to sign or not to sign an organ donor card. Various approaches to the relationship between reli- gion or spiritual beliefs and organ donation have been shown (Bresnahan et al., 2010; Lam & McCullough, Journal of Nursing Scholarship, 2015; 47:1, 25–33. 29 C© 2014 Sigma Theta Tau International Spirituality and Organ Donor Card Peles Bortz et al. Table 3. Predictors of Signing an Organ Donor Card (n = 309; Logistic Regression Analysis) Predictors B SE Wald (df = 1) p Odds ratio 95.0% confidence interval Attitudes toward organ donation 2.61 0.39 45.88 .000 13.58 6.38–28.88 Transcendental spirituality ?0.31 0.14 5.01 .025 0.74 0.56–0.96 Purpose in life 0.39 0.21 3.60 .058 1.48 0.99–2.22 Constant ?9.43 1.72 30.08 .000 0.00 2000; Morgan et al., 2008; Rachmani, Mizrahi, & Agabaria, 2000). Spirituality and attitudes toward organ donation significantly predicted willingness to sign an organ donor card among respondents in both China and the US, while religiosity did not (Bresnahan et al., 2010). By contrast, religion was found to be the most significant factor in the decision to donate organs or not among first-degree relatives of decedents in Israeli hospitals (Ashkenazi & Klein, 2012). The authors found that a direct association exists between the depth of religious belief, adherence to accepted cultural and traditional norms, and avoidance to donate organs. Notably, in some studies, the terms religion, spirituality, and cultural values are used interchangeably. Furthermore, each study defined spirituality differently and used a variety of measurement scales. It seems, therefore, that this field is still undefined and requires further clarification through research and practice. SODC may reflect and fulfill part of purpose in life through the wish to donate organs after one’s death. As- suming that there can be a reciprocal effect, people might have a sense of purpose in life because they signed an or- gan donor card. This kind of relationship was mentioned by LaPointe et al. (2014) regarding living organ donation. In a similar vein, the need to give purpose to life may be explained by findings that volunteers in medical settings experienced a high degree of life meaningfulness (Schnell & Hoof, 2012) and that social integration and the quality of personal relationships were associated with a higher purpose in life (Pinquart, 2002). The variable that contributed most to the explana- tion of SODC in the present study was the individ- ual’s attitudes toward organ donation. Previously it was found that subjects with a strong positive attitude toward posthumous organ donation were especially willing to sign an organ donor card (Wakefield et al., 2010). Yet, positive attitudes are not always translated into behavior (Wallace, Paulson, Lord, & Bond, 2005), and positive at- titudes toward organ donation alone are not enough for a behavioral commitment to sign an organ donor card (Ashkenazi, Guttman, & Hornik, 2005; Cohen & Hoffner, 2012). It seems that thinking about the possibility of do- nating organs after one’s own death evokes conflicting emotional feelings that may lead to barriers and inhibi- tions regarding SODC. In addition, noncognitive reasons for avoiding SODC and low self-benefits might restrict the influence of positive attitudes in the decision to sign an organ donor card (Morgan et al., 2008). Another variable in this study that might have caused an avoidance to sign an organ donor card could be the familiarity with the activity of the ITC. Surprisingly, the current study results showed that 57.6% of the respon- dents who did not sign an organ donor card were ac- quainted with the activities of the ITC. This result might point to embedded causes for not signing a donor card, such as cultural beliefs, religion, fear of one’s own death, and public mistrust of the medical system. It is important to assure the public, therefore, that the information and the processes of organ allocation and donation are trans- parent, and that organs for transplantation are provided according to accredited supervised regulation. The finding that respondents who were acquainted with someone who had signed an organ donor card had significantly higher rates of SODC, compared to respon- dents who had no such acquaintance, might be explained by social learning theory, whose principles are based on imitation and modeling (Bandura, 1977). It can also be explained by research exploring reasons for donating blood among blood donors (Sojka & Sojka, 2008), which found that a direct influence from friends/relatives and media appeal were commonly reported. Furthermore, it is logical to assume that people with similar cultural, de- mographics, and behavioral characteristics will tend to follow shared norms. Thus, a person who signed an or- gan donor card is likely to be acquainted with someone who also signed. The present study focused on spirituality and purpose in life as affecting willingness to SODC—issues that are relevant in countries with the (opt-in) law, as in Israel, where signing is voluntary for donating organs. How- ever, it is important to emphasize that there are some of other important factors affecting SODC, since sign- ing itself evokes concerns and fears of various types, which may be influenced by cultural or religious, social, and political factors. Further, it is reasonable to assume that there are people with a high level of transcendental 30 Journal of Nursing Scholarship, 2015; 47:1, 25–33. C© 2014 Sigma Theta Tau International Peles Bortz et al. Spirituality and Organ Donor Card spirituality and low purpose in life who sign an organ donor card. Study Limitations One limitation is that the sample population included only Jews, which excluded the sizable Arab minority population in Israel due to the likelihood that a different culture and religion would affect the study results. The second limitation is that the study was conducted using an online survey, which has a number of built-in limitations, including sampling and access issues. One sampling issue might be that a significant population of respondents with little computer-related experience are unable to answer the questionnaire survey in the Internet and Web format (Anderson, 1996). Moreover, access to certain populations might be limited, as some people view participating in an online survey as an invasion of privacy (Wright, 2005). Nevertheless, the level of truthfulness of respondent reporting in online research is considered high, as Web administration raises the level of reporting sensitive information, and the accuracy of the reporting, relative to other modes of data collection (Kreuter, Presser, & Tourangeau, 2008). Lastly, 70% of the respondents in the study had signed an organ donor card, while the number of people in the adult Israeli population who have signed a donor card is approximately 14%, which may reflect the a priori positive attitudes of most respondents toward organ do- nation and SODC. It might also assume that participants who have not signed an organ donor card or those with less positive attitudes avoided participating in the study. Clinical Implications The ITC, which is one of the departments of the Israeli Ministry of Health, is led and managed by nurses. Like- wise, nurses have a leading role in public education in the community, such as in education for a healthy lifestyle and for immunization. Therefore, they can be more active and take more ini- tiative in improving the population’s attitudes to organ donation and to SODC. Community nurses can lead pub- lic symposiums adapted by age, culture, and language. Nurses can incorporate in their public symposiums and instruction religious and spiritual leaders, intellectuals, personal stories, and experiences of people who donated an organ of their loved one. These actions may integrate spirituality in the process and potentially raise positive attitudes toward SODC. Additionally, nurses can be more active in all media forms in increasing positive attitudes among media consumers. Regarding a person’s transcendental spirituality, com- munity nurses who lead health education campaigns are also in a position to assess the components of a client’s spirituality, and construct programs that accord with the spiritual needs aiming for promoting SODC. Special train- ing to heighten these nurses’ familiarity with spiritual as- sessment and needs might be directed to elevating the act of organ donation card signings. In as much as an acquaintanceship with someone who signed an organ donor card is associated with SODC, it is important to encourage nurses who signed an organ donor card to demonstrate this and explain the long- range benefits to their clients. Proposed strategies are placing posters prominently on the nurse’s desk with the nurse’s name and the phrase “I also signed an or- gan donor card.” Moreover, as an acquaintance with the activities of the ITC is connected to SODC, among the actions we would recommend to the ITC is to pro- vide the community nurses with the information about the ITC activities. Subsequently, the nurses will give lec- tures about the ITC activities to the clients. Clinical Resources ? Donate Life America: http://donatelife.net/2013- national-donor-designation-report-card-released/ ? European Society for Organ Transplantation: http://www.esot.org/# ? World Health Organization: http://www.who.int/ topics/transplantation/en/ References Abramson, J. H. (2011). WINPEPI updated: Computer programs for epidemiologists, and their teaching potential. Epidemiologic Perspectives & Innovations, 8(1). doi:10.1186/1742-5573-8-1. Anderson, A. A. (1996). 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