INTRODUCTION:

Adolescence is an important and sensitive phase of life. Liver disease is one of the major public health priorities in India, accounting for 18.3% of the two million global liver disease–related deaths in 2015.¹ Globally, liver disease—including cirrhosis, viral hepatitis, and liver cancer—results in over two million deaths annually, representing 4% of all deaths worldwide.² In recent decades, the incidence of End-Stage Liver Disease (ESLD) has risen significantly, posing a high risk of mortality and imposing a substantial economic burden globally.³ Currently, liver transplantation is the only curative treatment available for ESLD.⁴

However, there remains a considerable gap between the supply and demand for liver organs. This gap is often attributed to limited public awareness, poor knowledge, and negative attitudes toward organ donation—not only among the general population but also among healthcare workers.⁵ Over the past 17 years, liver transplantation in India has evolved from a rare procedure to a widely accessible treatment with outcomes comparable to leading international centres. Living donor liver transplantation (LDLT) has emerged as a viable option for most recipients, achieving a success rate of approximately 95% and a low incidence of vascular and biliary complications. While deceased donor liver transplantation (DDLT) has made significant strides in southern India, LDLT continues to be the predominant source of transplantable livers and remains critical in bridging the gap between demand and availability, particularly for patients with ESLD and liver-confined hepatocellular carcinoma (HCC).⁶

Despite the growing importance of liver transplantation, studies reveal that nurses often have insufficient knowledge regarding post-transplant care. For example, a study conducted in the critical care unit of Ain Shams Specialized Hospital in Cairo, Egypt, found that only 12.5% of the 40 purposively selected nurses demonstrated a satisfactory level of knowledge regarding the management of post–liver transplant patients.⁷ Despite the pressing relevance of this issue, limited research has been conducted to assess nurses’ knowledge or implement educational strategies to enhance it. Existing evidence suggests that nurses' knowledge and attitudes significantly influence organ donation rates and that targeted educational interventions can improve both awareness and attitudes.⁸

Healthcare professionals play a pivotal role in promoting organ donation awareness among the public.⁹ Furthermore, participating in organ transplantation processes is considered one of the most meaningful and fulfilling experiences in nursing practice.¹⁰ However, a lack of understanding among potential donors and missed opportunities by healthcare providers to identify eligible donors continue to hinder organ availability.

In light of these challenges, a one-day offline educational conference— “Liver Transplant 360°: Navigating Nursing Care”—was organized as an intervention aimed at enhancing the knowledge of nurses from across India who registered to attend.

MATERIALS AND METHODS:

Research Design:

A quasi-experimental design with pre- test post design was used.

Research setting:

Tertiary care hepatology hospital which is running a liver transplant program.

Ethical Approval:

Necessary permissions for conducting the conference were obtained, and written informed consent was collected from all participants prior to their involvement in the study.

Research Participants:

All the nurses who registered for the event participated in the study. Total enumerative sampling technique was used.

Research tools used:

The tools used for the study included a demographic data sheet and a knowledge questionnaire. The content validity of the knowledge questionnaire was established by a panel of five medical-surgical nursing experts. Reliability was assessed using the test-retest method, yielding a Cronbach’s alpha of 0.87, indicating good internal consistency. Google Survey link shared immediately before the start of the sessions (pretest) with the pretest questions. The link remained open for 15 minutes. The post-test was conducted in a similar manner after the conclusion of all sessions. Participants attended the event in a controlled setting, with movement restricted during sessions and permitted only during scheduled five-minute breaks following each session.

Planning of the intervention:

The educational intervention was developed in consultation with experts from medical-surgical nursing, hepatobiliary surgery, hepatology, anaesthesiology, nutrition, psychiatry, and the transplant team. A series of in-person discussions were held to determine the session content. Based on a consensus among all experts, a final program comprising ten sessions was designed, covering key topics from hepatobiliary surgery, hepatology, anaesthesia, psychiatry, and nursing.

Overview of the Educational Intervention:

The educational intervention comprised a comprehensive one-day, 8-hour conference aimed at enhancing nurses’ knowledge of liver transplantation. The program featured ten focused sessions, each led by experts from their respective specialties.

Educational Intervention Sessions:

Session 1: From Failure to Function – The Journey of Liver Transplantation:

Delivered by a renowned liver transplant surgeon, this session explored the pathophysiology of end-stage liver failure, the need for transplantation, and the vital role of counselling during the pre-transplant phase. Emphasis was placed on 360-degree nursing care, underlining the importance of holistic, quality care for both recipients and donors.

Session 2: Organ Donation Awareness and Policy:

Presented by the Director of NOTTO, this session provided an overview of organ donation types, the Transplantation of Human Organs Act (THOTA), and public awareness strategies. National campaigns, celebrity endorsements, success stories, the role of green corridors, and the national organ allocation registry were discussed in detail.

Session 3: Role of the Transplant Coordinator:

This session, conducted by a transplant coordinator, outlined key responsibilities such as pre-transplant counselling, preparation of recipients and donors, documentation, and coordination with the multidisciplinary transplant team.

Session 4: Anaesthetist’s Perspective in Liver Transplantation:

An expert anaesthesiologist discussed comprehensive perioperative care, including preoperative evaluation, intraoperative management (covering phases such as pre-anhepatic, anhepatic, and reperfusion), anaesthetic techniques, fluid and blood product management, and immediate postoperative ICU care.

Session 5: Surgical Technique in Liver Transplantation:

Led by the hepatobiliary surgery department, this interactive session featured procedural videos detailing donor right lobe hepatectomy, cholangiography, hilar and parenchymal dissection, graft removal, back-table preparation, and recipient hepatectomy and graft implantation.

Session 6: Post-Transplant Nursing Care:

Focused on the immediate postoperative phase, this session covered monitoring for complications, maintaining hemodynamic stability, fluid-electrolyte balance, pain management, wound care, early mobilization, nutritional support, and psychosocial considerations.

Session 7: Long-Term Post-Transplant Care:

Presented by the hepatology department, the session emphasized the nurse’s role in identifying early signs of complications such as graft dysfunction, rejection, and infections. The importance of routine follow-up and symptom vigilance was also highlighted.

Session 8: Psychiatric Aspects of Liver Transplantation:

This session addressed the psychiatric assessment of patients pre- and post-transplant. Topics included substance abuse, depression, anxiety, cognitive dysfunction, hepatic encephalopathy, and psychotic disorders. Postoperative concerns such as delirium, neuropsychiatric side effects of immunosuppressants, and relapse prevention strategies were discussed.

Session 9: Nutritional Considerations in Liver Transplantation:

Facilitated by the nutrition department, the session covered the impact of malnutrition and sarcopenia on transplant outcomes. Nutritional strategies during the pre-, intra-, and postoperative phases were presented as critical to successful recovery and long-term survival.

Session 10: Nursing Practice and Research in Liver Transplantation:

A nursing expert provided a comprehensive overview of nursing responsibilities using NANDA classifications, addressing all phases of transplantation. The session also highlighted current research, innovations, and emerging challenges in transplant nursing.

Conclusion of the Program:

This structured, multidisciplinary approach ensured that participants received in-depth, practical, and evidence-based knowledge on Liver Transplant.

Statistical Analysis:

Descriptive and inferential analysis was done using SPSS (version 23).

Results:

As depicted in table 1, the demographic Characteristics of Participants shows that majority of participants (64.9%) were under the age of 30. A similar proportion (64.9%) were female and worked in private hospitals. Nearly half (48.7%) held a Diploma in Nursing as their highest professional qualification. The table 2 presents knowledge Score comparison that is Pretest vs Post-test showing a statistically significant improvement in participants' knowledge following the educational sessions.

Table 1: Demographic details of the participants n= 308

S. No	Age (Yrs)	n (%)
	<30 Years	200(64.9%)
	30-39 years	53(17.2%)
	40- 49 years	55(17.8%)
1.	Gender
	Males	108 (35.0 %)
	Females	200(64.9%)
	Professional education
	Diploma in Nursing	150 (48.7%)
	Graduates	102 (33.1%)
	Post Graduates	56 (18.8 %)
4.	Setting of the work area
	Government Hospital	108 (35.0%)
	Private Hospital	200 (64.9%)

Table 2: Comparison of correct response percentages in pretest and post test scores. n=308

S. No	Item	Pre-test (%)	Post-test (%)
1.	What is the most important function of Liver?	69.8	79.9
2.	What are the causes of liver failure ?	90.6	93.8
3.	What is a liver transplant?	88.3	91.2
4.	Common indication for Liver Transplant	62.0	74.0
5.	Diet after Liver transplant	75.0	87.7
6.	Does the liver regrow after donation?	72.1	87.0
7.	Length of stay for a living donor stay in the hospital.	38.6	40.3
8.	Liver disease for which Liver Transplant is advised	18.8	32.5
9.	Identify the stage of transplant rejection in the case given.	45.5	60.4
10.	Most common late complication of liver transplantation.	28.2	35.1
11.	Advantages of using a living donor for a transplant	79.2	87.7
12.	What is not true for living donor surgery?	73.1	81.5
13.	An absolute contraindication for liver transplant is ?	28.6	46.4
14.	What is the Full form of THOTA ?	23.7	50.0
15.	Important lab test to monitor early signs of graft rejection.	74.7	78.9
16.	Primary treatment for acute rejection of a LT includes?	16.9	38.6
17.	Common side effect of immunosuppressive drugs	20.5	35.1
18.	Important patient instruction in post-LT medication regimen is?	62.7	82.5
19.	Recommended lifestyle modifications Post LT is ?	76.0	84.1
20.	What is the normal range of TAC (Tacrolimus)?	33.1	66.9
21.	Best coagulation profile for liver transplant patient	47.4	64.9
22.	Doppler examination which is mandatory after liver transplant	61.4	76.6
23.	Immediate post operative care for LT patients includes	77.3	87.7
24.	Signs of active bleeding in post operative LT	67.9	89.9
25.	Incorrect about C- Hepatic allograft function.	22.7	43.2
26.	Indication for Satisfactory allograft function is ?	73.7	82.1
27.	What are anaesthetic challenges in LT?	70.1	87.0
28.	Which organization manages organ and tissue donation and transplantation in India ?	84.1	96.1
29.	Common preservation solutions used for static cold and storage in donated organs are ?	64.0	72.4
30	What are current challenges in Liver Transplantation?	82.1	92.5
	Mean	17.28	21.26

Table 2 presents a comparative analysis of the percentage of correct responses in the pretest and post-test assessments. The results indicate an overall improvement in knowledge following the educational intervention. The mean knowledge score increased from 17.28 to 21.26 out of a maximum of 30, reflecting a 23% gain in correct responses post-intervention.

Certain items, such as Items 2, 3, 5, 11, and 28, showed relatively high pretest scores, indicating that participants were already well-informed about general concepts. However, even in these areas, further improvement was observed—for example, correct responses to Item 5 increased from 75.0% to 87.7%.

Notable gains were seen in areas with initially low baseline knowledge. Item 20, related to post-transplant monitoring, showed the most substantial improvement, rising from 33.1% to 66.9%—a 33.8% increase. Similarly, Item 16 (management of acute rejection) improved from 16.9% to 38.6%, and Item 14 (causes of fever post-transplant) from 23.7% to 50.0%. These findings highlight the effectiveness of the intervention in enhancing participants' understanding of critical post-transplant care aspects.

However, certain items showed limited improvement. For example, Item 7 (hospital stay for donor) increased only marginally from 38.6% to 40.3%, possibly indicating confusion or insufficient emphasis during the session. Likewise, Item 10 (late complications) improved modestly from 28.2% to 35.1%.

Several items—specifically Items 8, 10, 13, 14, 16, 17, and 25—remained below a 50% correct response rate, even after the intervention. These items pertained to more complex clinical aspects of liver transplantation, suggesting that such topics may require more detailed or repeated instructional strategies to enhance comprehension.

Table 3: Mean, standard deviation, mean difference, t and p value for pre-test and post test knowledge scores n=308

Group
	Mean± SD	MD	df	t-valve	P value
PRE-TEST (n=308)	17±4.4	38	307	11.5	0.000***
POST TEST (n=308)	21.26±4.6

An increase in the mean knowledge scores from pretest to post-test, with a mean

Table 3 shows difference (MD) of 3.98. This improvement was further evaluated using a paired t-test, yielding a p-value of <0.001 (*), indicating a highly significant difference

Table 4: Depicting levels of Knowledge among Participants from pretest to post test N=308

Level of Knowledge	Pretest f (%)	Post test f (%)
Adequate knowledge (>80%)	9(2.9)	65(21.1)
Moderate knowledge (60%to 80%)	164(53.2)	180(58.4)
Inadequate knowledge (<60%)	135(43.8)	63(20.4)

Table 4 illustrates the distribution of participants across knowledge categories before and after the intervention. The number of participants with adequate knowledge increased markedly from 9(2.9%) in the pretest to 65 (21.1%) in the post-test. A majority of participants fell into the moderate knowledge category in both assessments, with a slight increase from 164(53.2%) pre-intervention to 180(58.4%) post-intervention. Notably, the number of participants with inadequate knowledge decreased significantly—from 135(43.8%) in the pretest to 63(20.4%) in the post-test—indicating an overall improvement in knowledge levels following the educational intervention.

DISCUSSION:

The purpose of this study was to evaluate the impact of an educational intervention on nurses’ knowledge about liver transplantation across India. The intervention led to a significant improvement in post-test knowledge levels. Notably, substantial gains were observed across nearly all areas covered during the educational sessions, with a highly significant p-value of 0.000, indicating the effectiveness of the intervention. There was an increase in the number of participants with adequate knowledge and moderate knowledge and there was a decrease in the number of participants with inadequate knowledge. The findings of this study are supported by several previous studies that have demonstrated the positive impact of educational programs on improving participants' knowledge related to liver transplantation and organ donation in general. In one study it was observed that an organ donation educational program significantly enhanced nurses’ knowledge, with a statistically significant increase observed from pre-test to post-tests.¹¹Similarly another study reported that most nurses in their study had unsatisfactory knowledge about postoperative liver transplantation care before the educational intervention, which improved notably after the program.¹²

In yet another study it was also noticed that an increase in participants’ knowledge scores following an educational program on brain death and organ donation.¹³The consistent results were reported in a study where participants in the experimental group who underwent an educational program gained significantly more knowledge about hematopoietic stem-cell donation compared to the control group.¹⁴ Likewise similar findings were observed in a study where the participants' knowledge levels were unsatisfactory before the intervention but improved afterwards.¹⁵

Furthermore in a study using an alternative educational approach based on argumentation activities, showed that students’ misconceptions decreased significantly and their awareness of organ donation increased post-intervention.¹⁶

Although the present study involved an one-day educational intervention based on offline sessions, it still led to a measurable improvement in nurses knowledge regarding liver transplantation. This aligns with another study which demonstrated that even a brief educational intervention could significantly enhance medical students’ perceived knowledge of organ donation.¹⁷ Additionally, a related study concluded that educational guidelines were effective not only in increasing knowledge but also in improving nurses’ performance in caring for post-liver transplantation patients in critical care settings.¹⁸ The findings of the current study are consistent with many other studies which either assessed effectiveness of a structured or a planned teaching program on improving the knowledge of the target participants.^19-27

LIMITATIONS OF THE STUDY:

The study employed a total enumerative sampling method, wherein all eligible participants who registered for the conference were included. While this approach ensured complete participation from the available population, it may limit the generalizability of the findings beyond the study sample. The possibility of self-selection bias cannot be ruled out, as participants who chose to attend the educational intervention may have been inherently more motivated or interested in liver transplantation, potentially skewing the results. Furthermore, sampling bias may have occurred due to overrepresentation or underrepresentation of certain subgroups, such as nurses from private institutions or specific geographic regions. Additionally, data collection was conducted using Google Survey forms, which may have introduced response bias. Factors such as varying levels of digital literacy, internet connectivity issues, or distractions during online form completion could have affected the accuracy and completeness of responses.

CONCLUSION:

The educational intervention, delivered as a one-day conference, led to a significant improvement in nurses’ knowledge levels. It is recommended that similar short-duration educational programs be conducted at regular intervals to provide focused and effective knowledge enhancement on specialized topics such as liver transplantation.

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Received on 28.05.2025 Revised on 22.08.2025

Accepted on 30.10.2025 Published on 30.04.2026

Available online from May 02, 2026

Int. J. Nursing Education and Research. 2026;14(2):141-146.

DOI: 10.52711/2454-2660.2026.00028

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