2010-6
Intrinsic Motivation of Organ Transplant Coordinatorsin Europe and Japan
Yoko Uryuhara

Norio Kambayashi Tomoaki ShimadaIntrinsic Motivation of Organ Transplant Coordinators in Europe and Japan
Yoko Uryuhara, Norio Kambayashi, and Tomoaki Shimada

ABSTRACT
Deceased organ donation is much less prominent in Japan than it is in Western countries.
Since organ shortage is a serious social problem in Japan, various solutions to the problem havebeen considered. Although it was believed that the most critical factor in the organ shortage wasthe absence of a well-established in-hospital system to convert potential donors into actual
donors, no prior studies attempted to analyze the problem from the perspective of the intrinsic
motivation of in-hospital coordinators. Thus, we conducted a questionnaire survey in Europe andJapan to identify the characteristics of in-hospital coordinators, who play crucial roles in organ
donation. We compared job satisfaction, pride in one's work, professionalism, job coredimensions based on Hackman and Oldham's Job Characteristics Model, and job responsibilities
among 43 European and 73 Japanese in-hospital coordinators. Our results demonstrated that theEuropean coordinators have higher levels of skill variety, task identity, task significance,autonomy, and feedback in their job characteristics, take more pride in their work, and exhibit
more professionalism in their jobs than the Japanese coordinators. These three factors also leadto their job satisfaction and high job performance. These findings imply that the Japanese
coordinators need motivation to improve the process by which potential donors are selected as
actual donors. We suggest that if the job responsibilities of the Japanese coordinators wereredefined, they were provided with systematic education and training to foster theirprofessionalism, and they received the recognition of healthcare professionals and the public,
they would feel a greater sense of pride, and this would promote increased organ donation in
Japan.
Keywords:
Organ donation; in-hospital coordinator; intrinsic motivation; job characteristics model; survey
research; Europe and Japan

Version: June 6, 2009
(The old version was accepted and presented
in the 68th Academy of Management Annual Meeting in 2008.)

1

INTRODUCTION
Issues Concerning Organ Donation in Japan
The "Organ Transplant Law" was enacted in Japan on October 16, 1997, and yet, there
have only been 61 brain dead donors over the past 10 years, which is a very small number ascompared to other countries. The number of deceased donors per million in the Japanese
population was only 0.7 in 2005, and this number represents the lowest level in the world, as
shown in Figure 11.
-----------------------------------------Insert Figure 1 about here-------------------------------------------As a result, Japan is facing the following four social problems. (1) More than 2,000
patients die annually because they are unable to receive an organ transplant; (2) the lack ofopportunities for renal transplant has resulted in an increasing number of patients who require
dialysis2, which has consistently weighed on the national medical expenditure (roughly 7% of thetotal amount of 30 trillion yen in 2005)3; (3) a ceaseless stream of patients seeking transplants
abroad has raised ethical questions internationally regarding whether Japan is committed to theself-supply of organs for those in need; and (4) while organ transplantation relies on the
populations' altruistic organ donation, in many cases, the intention of such people is not

1
The Japanese data were obtained from the Japan Organ Transplant Network homepage and the European data from
"International figures on organ donation and transplantation-2005," Transplant Newsletter-Council of Europe, Vol.11, No.1, 2006.
2
According to the Japanese Society for Dialysis Therapy, 257,765 patients require dialysis as of the end of 2005.
3
According to Roels et al. (2003), an average 59% increase in organ donors, as realized in countries that have implemented theDonor Action program, would allow a significantly greater number of dialysis patients to receive a renal transplant, resulting in adecrease of 2.26 million Euros in the medical expenditure per million people. Whiting (2004) reported a similar medical cost
reduction of 1 million Canadian dollars in Canada.

2

appropriately reflected in the medical setting 4 , resulting in "infringement of the right of
expectation" against Article 2 of the Organ Transplant Law (fundamental principles)5.

Reasons for the Organ Donor Shortage in JapanThe Japanese perception of organ donation is very positive. In the "Public Opinion Pollon Organ Transplant" conducted by the Cabinet Office in November 2006, 41.6% of a total of
1,725 respondents aged 20 years or over replied that they were "willing to donate" organs in theevent of brain death, surpassing those who answered "not willing to donate" (27.5%). These
results lead to the question of why there is a chronic organ donation shortage in Japan. Although
there are many factors involved, the most critical one is the absence of a well-established inhospital system that arranges for the potential donors brought into donor hospitals to become
actual donors. As shown in Figure 2, the process by which a potential donor becomes an actual
donor comprises six steps, all of which are implemented at the hospital. As compared to othercountries, the organ donation shortage in Japan appears to be the result of the unsatisfactory
execution of this in-hospital process.
-----------------------------------------Insert Figure 2 about here------------------------------------------Research Questions
In Japan, organ donation shortage is attributed mainly to in-hospital factors. Spain, which
has the largest number of organ donations in the world, experienced similar problems in the4

Of the deceased persons who had expressed their intention to be posthumous organ donors during their lifetime, 6.6% actually
donated organs, which is extremely low in comparison to other countries (e.g., 48.1% in Spain, 48.9% in France).
5
Article 2 in Organ Transplant Law (fundamental principle: "The wishes of deceased persons who, during their lifetime,
expressed their intention to donate their organs for the purposes of transplantation shall be respected.")3

1980s. Thus, it was mandated that there would be at least one in-hospital coordinator6 in a donor
hospital, and he or she would have clearly defined required personal characteristics and job
responsibilities, and the hospitals where the coordinators were assigned would be staffed by theappropriate personnel who would be entrusted with the authority and responsibility to execute
the entire organ transplant process to highly motivate them. Correspondingly, a national network
was established to support the coordinators.
Although in-hospital coordinators exist in Japan, their motivation is not high, and this isdue to ambiguously defined requirements for personal characteristics and job contents. The resultof such a situation is deemed to be the failure to improve in-hospital process control, thus
creating an organ donation shortage. Therefore, against this backdrop, we conducted our research
to identify the characteristics of in-hospital coordinators in high performance countries where
many organ donations are undertaken (i.e., European countries) and to present specific proposals
to increase the number of organ donations in Japan.

LITERATURE REVIEWJob Characteristics Model
Motivation theories include content theories such as Maslow's (1954) need hierarchy
theory, Alderfer's (1972) ERG (existence, relatedness, and growth) theory, Herzberg's (1966)
motivation-hygiene theory, and Deci's (1975) intrinsic motivation theory, and process theories
such as Vroom's (1964) expectancy theory and Hackman and Oldham's (1975, 1976) Job
Characteristics Model. The Job Characteristics Model states that jobs with higher levels of corejob dimensions (i.e., skill variety, task identity, task significance, autonomy, and feedback) lead

6

Medical professionals who are responsible for the six steps of organ donation in donor hospitals. In Spain, they are called "TPM
(Transplant Procurement Management) specialists."4

to greater intrinsic motivation and higher performance. This causal relationship varies dependingon the moderator variable of "growth need strength" of each individual.
Tao (1987) provided relevant data on healthcare professionals. He assessed the effects ofthe moderator of growth need in 1,391 nurses from 8 hospitals (all females; mean age: 28.5 years
old; registered nurses: 84.7%). Growth need was shown to have both a summation effect and astrong motivating effect.

Pride in One's Work
Fujita (2000) stated that "pride in one's work" is an emotional state that is built in the
cognition of external information such as social evaluation, and is subject to change dependingon the input information, through the cognitive activity involved in processing the information.
According to an empirical study conducted on white-collar employees in the finance, service,utility, and manufacturing sectors, pride in one's work strongly defines the level of motivation,either directly or via the employee's sense of self-determination, which influences what he or she
does. This finding indicates that greater pride in one's work leads to higher intrinsic motivation,and thus, higher performance.

Professionalism
In recent years, the subject of professionalism in medicine has attracted increasing
attention. In 2002, "Medical Professionalism in the New Millennium: A Physician Charter" wasannounced by the ABIM (the American Board of Internal Medicine) Foundation, ACP-ASIM(the American College of Physicians-American Society of Internal Medicine) Foundation, andEuropean Federation of Internal Medicine. Cruess (2006) stated that medical professionalism is5the basis of the contract between medicine and society, and that it reaches beyond one's code of
ethics and includes relationship building with patients, learners, and society beyond one's code of
ethics, and defines one's behavior.
The only available data regarding the motivation and performance of healthcare
professionals working in professional institutions were obtained from Tao (1987). This study
involved 1,391 nurses from 8 hospitals. Tao failed to show that professionalism is a moderating
factor for the job characteristics model. The relationships between the level of professionalism
and the levels of motivation, job satisfaction, and performance are yet to be determined.

HYPOTHESIS DEVELOPMENT
Based on our literature review, we created the analysis model provided in Figure 3. Basedon this model, we compared the in-hospital coordinators in a high performance organization (i.e.,
Europe) with those in a low performance organization (i.e., Japan) to identify the characteristics
of European in-hospital coordinators.
-----------------------------------------Insert Figure 3 about here-------------------------------------------The hypotheses tested herein are as follows.
Hypothesis 1: European in-hospital coordinators are satisfied with their jobs.
Hypothesis 2: The job characteristics of European in-hospital coordinators are associated withhigh levels of skill variety, task identity, task significance, autonomy, and feedback, and theselead to high performance.
Hypothesis 3: European in-hospital coordinators take pride in their work, which leads to job
satisfaction and high performance.

6Hypothesis 4: European in-hospital coordinators perform their role with professionalism, whichleads to job satisfaction and high performance.

We set our questions on the basis of the dimensions of the analysis model. "Jobsatisfaction" and "high performance" were selected as outcome parameters and "job coredimensions," "pride," and "professionalism" as motivating factors. The questions on job coredimensions were prepared by referring to the questions that were developed for Tao's (1987)
research on job characteristics, with appropriate rewording given the job status of the in-hospital
coordinator. The questions on specific job contents were formulated by referring to the job
description of Spanish in-hospital coordinators. The answers to the questions were provided on a
5-point Likert scale (i.e., 5: strongly agree, 4: somewhat agree, 3: neither agree nor disagree, 2:
somewhat disagree, 1: strongly disagree).
-----------------------------------------Insert Table 1 about here------------------------------------------RESEARCH METHODSA questionnaire survey was administered to Japanese and European in-hospital
coordinators. Complementary interviews were conducted with three European experts and one
Japanese expert in the field to facilitate the interpretation of the analysis results and to obtainfurther findings.

Questionnaire Survey
Target. In Japan, 107 in-hospital coordinators in 2 different prefectures were approached.
Currently, there are approximately 1,000 in-hospital coordinators working in Japan. The two7

prefectures were selected because they represented the Japanese average with respect to thetiming of the in-hospital coordinators' introduction and the number of organ donations, and all of
the in-hospital coordinators in those prefectures were included in the survey. In Europe, 123 inhospital coordinators in 20 countries––Norway, Sweden, Finland, Denmark, the Netherlands,
Germany, Belgium, France, Switzerland, Spain, Israel 7 , Italy, Greece, Poland, the Czech
Republic, Croatia, Slovenia, Slovakia, Romania and the U.K.––were approached to ensure a
representative European sampling.
Methods. Based on the assumption that the respondents would take time out from theirwork to complete the questionnaire, 20 questions regarding their job and 10 questions regarding
their personal profile were selected for the survey so that the time required to complete thequestionnaire would be no more than 5 minutes. The Japanese version of the questionnaire wasreviewed by three Japanese coordinators before it was finalized and the English translation
version was reviewed by the chief European coordinator (Scientific Program director of theInternational Transplant Coordinators Society). In both Japan and Europe, the questionnaire wasdistributed and collected in such a manner as to ensure the anonymity of the respondents, with
their IT environment taken into consideration. Since many of the in-hospital coordinators inJapan are not provided with their own personal computer at their worksites, it was assumed that
it would be unreasonable to expect them to fill out and return the questionnaire form on the PC.
Therefore, printed questionnaire sheets were sent to the Japanese coordinators and they wereasked to return the completed forms by mail using the enclosed envelope. For the survey inEurope, an e-mail was sent to the representative of each target country via the chief European
coordinator, and the e-mail was transferred to the target in-hospital coordinators by the
representative of each country. The questionnaire was completed either on the website or as an
7

Israel is not a European country, but the European Transplant Coordinators Organization (ETCO) categorizes Israel into Europe.

8

MS-Word file and sent via e-mail, depending on the IT environment of each respondent. The
survey period was between May 22, 2007 and June 11, 2007.
Possible biases in the questionnaire survey. The questionnaire prepared in English wasused for the European in-hospital coordinators including non-native English speakers. A possible
bias may have been introduced by the selection of only target coordinators who understood
English prior to transferring the questionnaire from the representative of each country toindividual in-hospital coordinators, and by the possible misinterpretation of questions by
respondents whose native language was not English.

Interview Survey
Interviewees. As persons capable of interpreting the survey analysis results, those in aposition to organize the in-hospital coordinators were selected. In Japan, Ms. Mariko Nishimura,a prefectural coordinator, was interviewed. For the survey in Europe, Mr. Leo Roels (Scientific
Program Director of the International Transplant Coordinators Society; Managing Director of the
Donor Action Foundation), Dr. David Paredes (Nephrologist at Hospital Clinic de Barcelona;
Head of the Transplant Procurement Management (TPM)), and Ms. Gloria Paez (Manager of theTPM) were interviewed.
Methods. For the survey in Europe, semi-structured interviews that were approximately
one hour in duration were conducted on July 9 and 11, 2007. For the survey in Japan, the resultsof the questionnaire were presented to the interviewee and an interview that was approximately
20 minutes in duration was conducted on August 4, 2007 to obtain comments on the overall
results.

9

Analysis methods. For each question, the count and percentage of respondents at eachscale point and cumulative percentage were obtained separately for the Japanese and European
respondents. The mean points were calculated as follows: 5 points for "strongly agree," 4 points
for "somewhat agree," 3 points for "neither agree nor disagree," 2 points for "somewhat
disagree," and 1 point for "strongly disagree." Moreover, the mean difference between Japan andEurope was tested using a one-tailed t-test to determine statistical significance. The level ofsignificance was taken at p < 0.05.

RESULTS
Responses were obtained from 43 coordinators from 11 European nations (Belgium,
Finland, Israel, Italy, Norway, Poland, Slovenia, Spain, Sweden, Switzerland, and the U.K.) at a
response rate of 35.0%, and from 73 coordinators from 2 prefectures in Japan at a response rateof 67.6%. The interview outcomes indicated that the low response rate in Europe could be
attributed to two factors: there was no response from Germany, which has the largest number of
in-hospital coordinators among the surveyed countries, and the questionnaire was written in alanguage that was not the native language of most of the target coordinators.

Respondents' Profiles
Table 2 summarizes the respondents' profiles and shows chi-square test results ofvariance difference between Europe and Japan. Complementary explanations are provided below
for each item where statistical significance was detected.
-----------------------------------------Insert Table 2 about here-------------------------------------------

10Age. The mean age of the respondents was higher in Europe than in Japan. Those aged 50
years or over constituted 43.1% of the respondents in Japan, while in Europe, this rate was low at
16.3%.
Professional category. In Europe, 100% of the respondents were medical professionals(e.g., medical doctors, nurses, clinical laboratory technicians, pharmacists), while in Japan,
34.2% were non-medical staff (e.g., administrative staff and others). There was a statisticallysignificant difference between Europe and Japan. In the interviews with the European experts,
the following account was given: the personnel lacking a qualification in the medical field are
not regarded as fellow workers by the ICU (Intensive Care Unit) staff, where organ donation isundertaken. Furthermore, the explanations of the definition of a potential organ donor and theadministrative measures provided to doctors and nurses cannot be considered reliable when they
are given by someone without satisfactory medical knowledge or experience in the medical field.
The post of in-hospital coordinator should be assumed only by someone in the medical
profession. Whether a medical doctor or a nurse is suitable for the post of in-hospital coordinator
depends on the location in Europe. In Southern Europe (Israel, Italy, Slovenia, and Spain), 23.1%of the coordinators were nurses, while in Northern Europe (Finland, Norway, Sweden, and theU.K.), the rate was high at 100%. The educational level of nurses and demand for medical
doctors were suggested as factors to explain the result because, in general, the level of educationof nurses is higher and the number of medical doctors is lower in North Europe than in South
Europe.
Field of specialty. In Europe, 51.2% of the respondents specialized in anesthesia,
ICU/emergency, and neurosurgery, where potential donors are managed, while in Japan, the rate
was low at 9.6%.

11

Experience as an in-hospital coordinator. The years of experience as an in-hospital
coordinator were significantly (p < 0.001) higher in Europe than in Japan. A possible explanation
for this is that in Japan, the in-hospital coordinator system was introduced fairly recently.
Percentage of the in-hospital coordinator work as compared to the full job profile. In
Europe, 39.5% of the respondents were categorized as full-time workers and 60.5% as part-timeworkers. Among those respondents who were working part-time, 61.5% answered that thepercentage of in-hospital coordinator work was less than 25% of their responsibilities. In the caseof Japan, all the in-hospital coordinators worked part-time, and 100% of the respondents said thatthe ratio of coordinator work was less than 25%. There was a statistically significant (p < 0.001)
difference between the two groups.
Organ transplant program. In Europe, 76.2% of the respondents answered yes when
asked whether their hospital had a transplant program, while in Japan, the rate was low at 35.6%.
There was a statistically significant difference (p < 0.001) between the two groups.

Europe-Japan Comparison of Performance
Performance was defined as "organ donations per million persons" in 2005. The numberof organ donors per million in the 11 European respondent countries was 19.4, as opposed to 0.7
in Japan, demonstrating a higher performance in Europe.

Hypothesis 1: European in-hospital coordinators are satisfied with their jobs
The Europe-Japan comparison of the answers to the question about job satisfaction, "1-8:
I am satisfied with my job as an in-hospital coordinator," is shown in Table 3. The level of job
satisfaction was significantly (p < 0.001, t-test) higher among Europeans. The effects of the12differences in the respondents' profiles were examined, but no influential factors at the 5%
significance level were detected.
The interview outcomes indicated the presence of a virtuous cycle among the European
in-hospital coordinators, i.e., compared with the coordinators in Japan, those in Europe obtainhigher education, receive more training, and are more "ambitious". Therefore, when assigned a
job with heavier responsibilities, the European coordinators are better motivated, which leads tohigher job satisfaction. The above findings support Hypothesis 1.
-----------------------------------------Insert Table 3 about here------------------------------------------Hypothesis 2: The job characteristics of European in-hospital coordinators are associatedwith high levels of skill variety, task identity, task significance, autonomy, and feedback,and these lead to high performance.
As shown in Table 4, the level of each of the five job core dimensions had higher
statistical significance in Europeans. The Motivating Potential Score (MPS) was calculated using
the formula MPS = (V + I + S)/3 × A × F, where V is skill variety, I is task integrity, S is tasksignificance, A is autonomy, and F is feedback 8 , and the scores of Japan and Europe werecompared. The MPS was significantly (p < 0.001, t-test) higher in the European coordinators(Table 5). These results indicated that the coordinators in Europe were assigned jobs with highjob core dimensions and were driven by strong intrinsic motivation, which resulted in highperformance. Hypothesis 2 was thus supported.
-----------------------------------------Insert Table 4 about here------------------------------------------8

Hackman, J. R. and Oldham, G. R., (1980), p. 90

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-----------------------------------------Insert Table 5 about here------------------------------------------Hypothesis 3: European in-hospital coordinators take pride in their work, which leads tojob satisfaction and high performance.
The levels of pride in one's job in high-performing Europe and in low-performing Japanare as shown in Table 6. In Europe, 97.7% of the respondents replied that they took pride in theirwork, whereas 37.5% of the respondents in Japan replied the same. The Europeans' sense of
pride in their work was significantly (p < 0.001, t-test) higher. A regression analysis was thenperformed with pride in one's work as the independent variable and job satisfaction as thedependent variable. A positive correlation was detected (p < 0.01). This result shows that greater
pride was associated with higher job satisfaction.
Earlier research indicated that favorable social evaluation and recognition brought pridein one's work. This led to a comparison of the social recognition levels of Japanese and European
coordinators. The related question is shown in Table 1. While 76.7% of the European
respondents answered that the in-hospital coordinator job was recognized by society, only 11.0%of the Japanese respondents replied similarly, showing a significantly (p < 0.01, t-test) higher
level of recognition in Europe. Additionally, the interviews revealed that to foster pride in inhospital coordinators, it was important to improve the recognition of their role inside and outside
hospitals through education and enlightenment activities in their hospital and community, by
engaging with the media, and by feeling appreciated by hospital directors and other medical staff,
including the transplant team. It was also shown that such opportunities were more abundant inEurope. Given these results, Hypothesis 3 was supported.

14

-----------------------------------------Insert Table 6 about here------------------------------------------Hypothesis 4: European in-hospital coordinators perform their role with professionalism,
which leads to job satisfaction and high performance
Table 7 summarizes the comparison of the levels of professionalism in high-performing
Europe and low-performing Japan. Compared to the result of 100% in Europe, 13.9% answeredin Japan that they conducted their work with professionalism, demonstrating a significantly (p <0.001, t-test) higher level of professionalism in Europe. A regression analysis conducted withprofessionalism as the independent variable and job satisfaction as the dependent variable
demonstrated a positive correlation (p < 0.05) between the two variables, showing that higher
levels of professionalism were associated with higher job satisfaction.
In the interviews, a concrete image of a professional in-hospital coordinator waspresented as a "highly educated and trained individual who makes contributions in the processesof conducting studies and preparing research papers, and who determines the standard protocols
for the organ donation process." This indicated that to foster professionalism in coordinators, it
was essential to provide them with systematic education and training and introduce them to thequalification system.
In Spain, the University of Barcelona, which has developed transplant procurement
management training programs, offers five face-to-face training courses and four e-learning
courses ranging from a one-day introductory course to an advanced (five-day practical approach)course. With regard to the face-to-face training, 90 courses had been offered as of 2007, with
5,240 participants from across the world, leading to the training program's provision of a global
major in coordinator education. The university also offers well-developed programs for medical

15

staff besides coordinators who are involved in organ donation. The Organizacion Nacional de
Transplantes (ONT) headquarters allocates an annual budget of 390,000 US dollars to educate
the nation9. In Northern and Central Europe, it is common for nurses to become coordinators
after earning a master's degree. To acquire the requisite expertise and skills, they further undergo
special training in emergency and operating rooms, and regularly make oral presentations at
academic conferences or publish research papers. As a result, coordinators have received
recognition as professionals and have earned respect in the medical field.
Regarding the qualification system, the European Transplant Coordinators Organization(ETCO) established the European Certification System in 2001 to demonstrate an achieved levelof competence in the field of transplant coordination. Demonstrating the required experience andpassing the examination allow the individual to attach the credential designation of "Certified
European Transplant Coordinator (CETC)" to his or her name. In the U.S., the North American
Transplant Coordinator Organization (NATCO) provides the world's highest level ofcertification. The interviews revealed that certification brought pride, motivation, and highperformance to coordinators because they perceived certification as assurance of professionallevel quality in their service. Therefore, these results support Hypothesis 4.
-----------------------------------------Insert Table 7 about here------------------------------------------Europe-Japan Comparison of the Job Content of the In-Hospital Coordinator
The in-hospital coordinator's job in Europe was shown to be associated with greater skill
variety, task integrity, task significance, autonomy, and feedback. Additionally, a comparison of

9

Uryuhara Y. (2004), p. 159

16

the specific content of the job revealed significant differences between Europe and Japan in thepercentage of coordinators that is actually assigned to each task, as shown in Table 8.
The interview outcomes indicated that the specific job content was strongly related to job
core dimensions, and that the job content itself led to motivation (Figure 4). Coordinators inJapan are merely designated the abstract role of "promoting the medical practice oftransplantation," which lacks the specific characteristics required of the coordinator or job
descriptions. Therefore, the in-hospital coordinators do not know what they are expected to do orwhat their role is. On the other hand, in Europe, the presence of specific job descriptions andrecognition by the director of the institution and other staff allow the coordinators to engage intheir jobs in cooperation with other staff, and this helps the coordinators realize their
responsibilities and feel motivated to do their job.
The above findings show that in Japan, redesigning the coordinator's job, defining job
descriptions, and ensuring that the relevant personnel and general public are informed about thecoordinator's job can motivate the coordinators.
-----------------------------------------Insert Table 8 about here-----------------------------------------------------------------------------------Insert Figure 4 about here------------------------------------------DISCUSSION
In Japan, the organ donation shortage is attributed to various factors including culturaland legal aspects. Our study involved analyses that focused on the status of organ donor hospitals,
since the root of the problems related to organ donation has been traced to hospitals. Legal
reforms and increased awareness among the enlightened public alone will not persuade a greater

17

number of potential organ donors to come forth unless the situation in the medical setting whereorgan donation takes place is improved. In terms of the intrinsic motivation of in-hospital
coordinators, who play a major role in the practice of organ donation, our analysis suggests thatthe organ donation shortage in Japan is attributable to the situation in which poorly motivated inhospital coordinators are engaged in their work in the environment where they are assigned tasksof low task identity, low task significance, low autonomy, and low feedback, without social
recognition and satisfactory education and training, which deprives them of job satisfaction,
pride in their work, and professionalism. This finding indicates the possibility that coordinators
may be motivated if their job profile is redefined, they can obtain systematic education andtraining, be recognized by healthcare professionals and society, and other appropriate measures
are taken to improve the process by which potential donors become actual donors, and in turn,this may increase the number of organ donations in Japan.
In this study, the states of in-hospital coordinators in Japan and Europe were compared.
American coordinators were not included because Japan is deemed to have a system similar tothat of Europe, where the personnel in charge of the entire organ donation process work at donor
hospitals. However, in the U.S., the Organ Procurement Organization (OPO), an independent
organization that operates outside of donor hospitals, is engaged in organ donation10.

CONCLUSION
The principle contribution of this study is that it demonstrated that Hackman andOldham's established Job Characteristics Model can be applied to the profession of in-hospital
coordinator––a medical profession that is based on a new concept––by extending the scope of
the application of this model. Secondly, we showed that greater professionalism was associated10

Manyalich M., Valero R., Paredes D., and Paez G. (2007), p. 18

18

with higher job satisfaction and performance for an individual who belongs to a group of
professionals.
This research also contributed to the medical practice of organ transplantation in that it
was the first one to be conducted on the organ donation shortage in Japan from the perspective of
in-hospital coordinators' intrinsic motivation, including job characteristics, thereby presenting a
new aspect of the issue of organ donation. Additionally, the research findings have led to thefollowing five specific proposals regarding in-hospital coordinators and encouragement for organ
donation in Japan: (1) To define the mission and the goal of the in-hospital coordinator, toredesign the coordinator's job, and to provide clear job descriptions in order to inform the otherstaff and the public about the job; (2) to create a precise profile of the coordinator and to appoint
personnel that satisfy the requirements; (3) to allow coordinators to participate proactively in
education and enlightenment activities inside and outside hospitals in order to provide them with
opportunities to receive recognition and acknowledgment; (4) to develop systematic educationand training programs for in-hospital coordinators and to support them at the national level; and(5) to introduce a coordinator qualification system.
The remaining areas of further research include the organizational structure of nationwide
support for in-hospital coordinators. Pierce and Dunham (1976) proposed that individual
responses to job characteristics might be advanced by relating the participants' responses toproperties of macro organization that encompass jobs and individuals. Oldham and Hackman(1981) hypothesized that the properties of organizational structure (i.e., size, number of
hierarchical levels, formulation, and centralization) can determine job characteristics to a certain
degree. In the 1980s, in order to solve the same problems that Japan is currently facing, Spain not
only created the in-hospital coordinator job profile but also established a national network to

19

support these professionals. In the interviews conducted as part of this research, the absence of awell-organized system that supports in-hospital coordinators in Japan was highlighted.
Investigating the proper function of organ donation staff-supporting organizations based on
existing organizational theories is another important research topic that should be explored tosolve the organ shortage issue in Japan.
[2010.2.22 956]

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Uryuhara Y. 2004. Approaches to solve organ shortage in European countries (in Japanese).
Japanese Journal of Transplantation, 39(2): 145-162.

21

Whiting J. F., Kiberd B., Zoltan K., Keown P., Roels L. & Kjerulf M. 2004. Cost-effectivenessof organ donation: Evaluating investment into donor action and other donor initiatives.
American Journal of Transplantation, 4(4): 569-573.

22

TABLE 1
Dimensions and Questions
Category

DimensionNo

jobsatisfaction

job satisfaction

8

I am satisfied with my job as an in-hospital coordinator.

1

The job of an in-hospital coordinator requires various types of skills andknow-how.

2

The job of an in-hospital coordinator is very diversified every day.

skill variety
task identity
motivators
based onJDS model

motivators

task significance3
4

I can accomplish my job as an in-hospital coordinator under my own
responsibility.
I think I can help families handle grief through my work as in-hospital
coordinator.
The job of an in-hospital coordinator contributes to saving lives.
I can change the procedure and method of work of an in-hospital
coordinator at my own discretion.
I am able to find out whether my work as an in-hospital coordinator is
helpful for patients and their family.

autonomy

5

feedback

6

pride

9

I am proud of my job as an in-hospital coordinator.

socialrecognition

20

I think the job of an in-hospital coordinator is socially acknowledged.

professionalism

10

remuneration

18

remuneration
requirement
coverage ofprocess
education to
medical staff
education to
general public
job
contents

7

Question

R&D
resource
management
media
management
reporting system

19
11
12
13
14
15
16
17

I am carrying out my work as an in-hospital coordinator with all the
professionalism required for this job.
I am in a higher salary scale than my colleagues who are not involved in
the donation process, irrespective of my donation activities.
I think it is necessary to provide additional remuneration to in-hospital
coordinators for their role.
As an in-hospital coordinator, I am involved in the whole process of organ
donation.
I provide the medical staff of my institute with education and training onorgan donation.
As an in-hospital coordinator, I provide the general public withinformation and education about organ donation or transplantation.
I am involved in research to develop a better methodology for further
improvement of the process of organ donation in my institute.
As an in-hospital coordinator, I am engaged in the management of
resources (such as financial budget) related to organ donation.
As an in-hospital coordinator, I am dealing with the mass media and theircoverage of the medical practice of organ transplantation.
We (coordinator team) are reporting the outcome of our work as an inhospital coordinators directly to the director of our institute.

23

TABLE 2
Europe-Japan Comparison of Respondents' Profiles
Items

Category

p-value
of χ2
Test

Age

20-29, 30-39, 40-49, 50-59, 60-69

0.048*

GenderMale, female

0.651

Professional category

Medical doctor, nurse, clinical laboratory technician, pharmacist,
administrative staff, others

p < 0.001

Field of specialty

Anesthesia, ICU/emergency, neurosurgery, urology, general surgery,
nephrology, general internal medicine, others, no specialty

p < 0.001

Experience as a medical
professional

0-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39 years

Experience as an in-hospital
coordinator

0-1, 1-2, 3-4, 5-9, 10-14, 15-19, 20- years

p < 0.001

Percentage of the work as an
in-hospital coordinator out
of total job

0-24, 25-49, 50-74, 75-100 %p < 0.001

Appointed a formal inhospital coordinator

Yes, no0.217

Organ transplant program

Yes, nop < 0.001

0.667* p < 0.05

24

TABLE 3
Europe-Japan Comparison of Job Satisfaction
Q8: I am satisfied with my job as an in-hospital coordinator
5.Strongly
agree

4.Somewhat
agree

3.Neitheragree
nor disagree

2.Somewhat
disagree1.Strongly
disagree

Total

N

24

17

0

2

0

43

%

55.8%

39.5%

0.0%

4.7%

0.0%

100%

N

0

6

49

13

4

72

%

0.0%

8.3%

68.1%

18.1%

5.6%

100%

Europe

Japan

Mean

S.D.

4.47

0.73

2.79

0.67

Mean Difference: 1.68, t-value: 12.20, p-value: p < 0.001

25

TABLE 4
Europe-Japan Comparison of Job Core Dimensions

Dimension

Mean

Questiont-valuep-value

4.08

8.08

p <0.001

4.4

2.96

8.07

p < 0.001

I can accomplish my job as an in-hospital
coordinator under my own responsibility.

4.16

2.69

8.37

p < 0.001

I think I can help families handle grief through mywork as an in-hospital coordinator.

4.44

3.33

8.66

p < 0.001

The job of an in-hospital coordinator contributes tosaving lives.

4.53

3.57

6.17

p < 0.001

autonomy

I can change the procedure and method of work of
an in-hospital coordinator at my own discretion.

3.42

2.55

3.76

p < 0.001

feedback

I am able to find out whether my work as an inhospital coordinator is helpful for patients and theirfamily.

4.33

3.10

7.33

p < 0.001

EuropeJapan

The job of an in-hospital coordinator requires
various types of skills and know-how.

4.95

The job of an in-hospital coordinator is very
diversified every day.

skill variety

task identity

task
significance26

TABLE 5
Europe-Japan Comparison of MPS
NMin. - Max.

Mean

S.D.

Europe4315.3 - 120.8

68.2

33.3

Japan

72

1.0 - 73.3

25.5

14.2

27

Mean
difference

t-valuep-value

42.7

7.90

p < 0.001

TABLE 6
Europe-Japan Comparison of Pride in One's Work
Q9: I am proud of my job as an in-hospital coordinator
5.Strongly
agree

4.Somewhat
agree

3.Neitheragree
nor disagree

2.Somewhat
disagree1.Strongly
disagree

Total

N

23

19

1

0

0

43

%

53.5%

44.2%

2.3%

0.0%

0.0%

100%

N

2

25

34

8

3

72

%

2.8%

34.7%

47.2%

11.1%

4.2%

100%

Europe

Japan

Mean

S.D.

4.51

0.54

3.21

0.83

Mean Difference: 1.30, t-value: 10.05, p-value: p < 0.001

28

TABLE 7
Europe-Japan Comparison of Professionalism
Q10: I am carrying out my work as an in-hospital coordinator with all the professionalism required forthis job.
5.Strongly
agree

4.Somewhat
agree

3.Neitheragree
nor disagree

2.Somewhat
disagree1.Strongly
disagree

Total

N

35

8

0

0

0

43

%

81.4%

18.6%

0.0%

0.0%

0.0%

100%

N

0

10

31

24

7

72

%

0.0%

13.9%

43.1%

33.3%

9.7%

100%

Europe

Japan

Mean

S.D.

4.81

0.39

2.61

0.84

Mean Difference: 2.20, t-value: 18.89, p-value: p < 0.001

29

TABLE 8
Europe-Japan Comparison of Job Contents

Dimension

Mean

Question

EuropeJapant-valuep-valuecoverage ofprocess

As an in-hospital coordinator, I am involved in thewhole process of organ donation.

4.60

2.08

14.33

p < 0.001

education to
medical staff

I provide the medical staff of my institute witheducation and training on organ donation.

4.44

2.05

13.27

p < 0.001

education to
generalpublicAs an in-hospital coordinator, I provide the generalpublic with information and education about organ
donation or transplantation.

4.28

2.13

9.85

p < 0.001

R&D

I am involved in research to develop a bettermethodology for further improvement of the processof organ donation in my institute.

3.79

1.92

7.72

p < 0.001

resource
management

As an in-hospital coordinator, I am engaged in the
management of resources (such as financial budget)
related to organ donation.

2.88

1.49

5.63

p < 0.001

media
management

As an in-hospital coordinator, I am dealing with themass media and their coverage of the medical practiceof organ transplantation.

3.76

1.45

10.10

p < 0.001

reportingsystemWe (coordinator team) are reporting the outcome of
our work as in-hospital coordinators directly to thedirector of our institute.

4.37

2.03

10.22

p < 0.001

30

FIGURE 1

Deceased Donors (per Million Population)

Deceased Donors in 2005 (per Million Population)
40
35
30
25
20
15
10
5

0.7

0

31

FIGURE 2
Model of Organ Donation Process from a Potential Donor to an Actual Donor

Potential
Donor
Detection

ActualDonor
ReferralCheckcontraindication

Decision

MaintenanceEx- & transplantation

Spain
100%

48.1%

Japan
100%

6.6%

32

FIGURE 3
Conceptual Model

Social cognition,
Approval by related people
Job Characteristic ModelPridein one’s work

Job core dimensions
Skill variety
Task identity
Task significanceAutonomy

Intrinsic motivation
Job satisfaction
High performance
Professionalism

Feedback
Need for growth

Education, Training

33

FIGURE 4
The Relationship between Job Contents in Spain and Job Core Dimensions

Job contents in Spain

Job core dimensions

Cover whole process of donation

Skill variety

Education/training for medical staff

Task identity

Education for the public

Task significance

Quality management & develop research
Resource management
Relations with the mass media

34

Autonomy
Feedback