Nicole Xashimba, Case Manager at Medical Protection, looks at the key role of nurses in a valid consent process

Nurses have an ethical and legal duty to ensure consent is obtained before carrying out any intervention or treatment. As nurses, how many times have we witnessed consent being obtained by the primary physician, yet noticing that the patient has not adequately grasped what they are consenting to?

Where does the responsibility then lie to ensure that the patient is fully present in their own decision-making capacity? This article will focus on consent, the different types of consent and what the nurse’s role in the consent process is.

What is consent?

Consent does not end with the patient’s signature on a form. It is the permission given by the patient to proceed with interventions such as medical treatment, tests or examinations. It is vital to remember that in obtaining the patient’s consent, we are respecting the patient’s autonomy, ie their right to come to an informed decision regarding their own healthcare. Furthermore, to uphold the principle of transparency is to respect the patient’s autonomy, that is to maintain open and honest conversation between the nurse and patient, which forms part of the ethical principles of nursing as per the South African Nursing Council guidelines. Discussion with the patient and consent are needed for situations such as:

• Physical examinations
• Taking blood
• Administering of medication
• Before a surgical procedure

There are four principles of informed consent:

The patient must have the capacity (or ability) to make a decision. A patient is considered to have capacity to consent if they understand the nature of the proposed investigation or treatment, can anticipate the possible effects of the above and what the consequences may be for refusing such interventions. The patient must comprehend the relevant information and voluntarily grant consent without coercion or duress.

Information regarding the treatment, test or procedure, including the expected benefits and risks, must be explained to the patient. Ultimately this is the responsibility of the primary physician.

Types of consent include:

Verbal consent: where the patient agrees verbally for usually low or no risk procedures.

Implied consent: usually given by the patient when co-operating with your instructions for routine procedures, eg extending their arm for a blood pressure reading.

Written consent: the patient agrees by signing a document for a treatment or procedure that carries complex or significant risk.

Let us revisit the question in the opening paragraph about what our role in the consent process involves. Although we do not normally obtain written consent for nursing interventions, the ethical obligation remains ours to ensure that consent is informed. For example, nurses may assist with:

• Patient comprehension
• Facilitating documentation of consent
• Addressing patient anxiety
• Identifying the appropriate decision maker when needed

We also need to acknowledge that barriers to the consent process do exist. These could be anything from language barriers or patients simply not having enough information about their health condition. It is for reasons such as these that a more patient-comprehensive approach is needed. One of the most popular methods to becoming more patient-centred in the consent process is the “teach-back” method, whereby we test that the patient can repeat and physically prove their understanding of your conversation. This is also known as an interactive intervention, which could also include methods such as using audio or visual tools such as diagrams, videos or posters to assess the patient’s level of understanding.

It is highly recommended to provide the patient with an opportunity to ask questions or provide comments during the consent procedure. If the patient does not feel comfortable with this for whatever reason, this would be a good time to step in as the patient’s advocate. Get in touch with the patient’s primary physician to discuss the procedure in more detail, in order to make the patient comfortable and in a better position to accept or reject the information provided.

In practice

The first step in obtaining informed consent is to identify the correct person to obtain consent from. Nurses need to note that patients have the right to consent or refuse treatment when they are competent and aged at least 18 years old. Generally, an adult has the capacity to consent unless there is evidence proving the contrary, as may be in the case of a mentally impaired adult. Parents or guardians are to provide consent for minors.

An exception to obtaining consent may be in an emergency, where it could be impossible to obtain consent from the patient due to their medical condition. It is then reasonable to perform the procedures without the relevant consent in order to save the patient’s life.

Document the obtaining of consent in the patient’s records, as well as the date and time when it was obtained, if you are satisfied that the patient has voluntarily given their consent and has understood all information related to their treatment. Always ask and verify that the patient understands the information and be aware of their reactions and responses when providing clarity. Where possible, use the teach-back method, asking the patient to repeat back what they understand. It is important to note that our teaching cannot replace that of the patient’s primary physician.

If the patient remains confused about the procedure, the onus is on the nurse as the patient’s advocate to either explain the procedure again, or to get the primary physician involved in the case of surgery to revisit the consent process. Make sure you have ample knowledge of the treatment in order to answer any questions the patient has. By doing so, you can help them better understand their treatment and reduce their anxiety.

Conclusion

Other than in exceptional circumstances, nurses have both a legal and a professional obligation to ensure that:

• Their patients are informed about the proposed treatment

• Their patients are informed about the risks associated with the proposed treatment
• Their patients agree to, and provide consent before, starting treatment

Consent will only be valid if that information has been given. Nurses will be acting unlawfully, and contrary to the principles of person-centred care, if they administer care without a patient’s consent. Remember that your role as a nurse is not restricted to being a witness in the consent procedure. Your biggest responsibility lies in making sure that patients receive sufficient information and to enable them to feel less doubtful about accepting treatment.

References

Glaser J, Nouri S, Fernandez A (16 January 2020), Interventions to improve Patient comprehension in informed consent to medical and surgical procedures: An updated systematic review. [Accessed 15 March 2021 from https://journals.sagepub.com/doi/full/10.1177/0272989X19896348]

Menendez JB, Informed Consent: Essential Legal and Ethical Principles for Nurses. Lippincott Nursing Centre. [Accessed 12 March 2021 from https://www.nursingcenter.com/ce_articleprint?an=00128488-201310000-00004]

Mulaudzi FM, Mokoena JD, Troskie R, Basic Nursing Ethics in Practice; second edition; Johannesburg: Heinemann (2010).