Abstract
Nursing professionals in a variety of practice settings routinely use implied consent. This form of consent is used in place of or in conjunction with informed or explicit consent. This article looks at one aspect of a qualitative exploratory study conducted in a Day of Surgery Admission unit. This article focuses on the examination of nurses’ understandings of implied consent and its use in patient care in nursing practice. Data were collected through one-on-one interviews and analysed using a thematic analysis. Nurses participating in this study revealed that they routinely used implied consent in their nursing practice. This article will look at whether implied consent supports or impedes a patient’s autonomy.
Introduction
It is important for health professionals to understand the complexity of the consent process, as the health professional has a major role in ensuring that the three precedents of consent are fulfilled. These precedents ensure that the choice made by the patient is voluntarily, without coercion and that the patient comprehends the choice that he or she is making. 1 Health professionals need to understand the concepts and complex meanings that influence and underpin their actions in relation to the process of consent.
The need to obtain consent during routine nursing care, whether informed or implied, is not under debate. The use of implied consent is commonplace in many health-care settings. The question that needs to be reviewed is whether relying on implied consent when providing nursing care to patients is ethical in relation to upholding and promoting patient autonomy.
Autonomy is perhaps the most influential ethical principle and the main focal point in health care. 2 –4 Autonomy is a major concept in relation to consent and in its simplest form can be seen as the patient’s right to determine what will be done or not to his or her body. 4 –6 The process of consent is designed to protect the autonomy of the patient and their ability to self-determine. 7 Societal values and the shift to a consumer-driven health-care system have seen the principle of autonomy overriding the other ethical principles that influence nursing practice. 8
As many of the nursing care procedures undertaken in practice have the potential to limit a patient’s autonomy, it is then important that nurses understand autonomy in relation to consent and nursing practice. One example that can be used to highlight this point is in end-of-life care where a patient may refuse to undergo a life-saving treatment. This is when patient autonomy comes into conflict with the ethical principles of beneficence (to do good) and non-maleficence (to do no harm).
Literature review
Working within Day of Surgery Admission (DOSA), the clinical needs of the patients are significantly different to those patients admitted to a ward environment. 9 The literature specifically around the clinical area of Day Surgery is limited especially in relation to the nurse’s role in the consent process.
Implied consent
Implied consent is based on asking a specific question and waiting until permission (or affirmative consent) is given or by the observation of a person’s behaviour that implies that they agree to the intervention. 10 A common example of implicit consent in nursing care is when taking a patient’s blood pressure. Many patients recognise the blood pressure cuff and will automatically roll up their shirtsleeve or hold out their arm. In fact, there is an expectation that as a patient, it is expected that certain procedures will be carried out without the need for obtaining consent. 11 It is recognised that most nursing care provided would fall under implied consent, provided a minimal explanation is given to the patient to explain the nurses’ actions. 12
Touching patients without consent can lead to nurses acting unlawfully and failing in professional standards. 13 Legally, touching a patient without their consent constitutes battery, and ethically, it constitutes a breach in the patient’s autonomy. 14 It is recognised that even benign nursing procedures, such as hygiene, may be unwanted by patients and therefore constitute a breach of professional standards.
Autonomy
Ethically, a person has the right to make their own decisions about their health-care treatment without interference. 15 This includes treatments provided by doctors, nurses and allied health professionals. Autonomy can be described as the ability for an individual to self-rule, to have self-governance and self-determination. 16 –20
As an ethical principle, autonomy can be seen as formative in the development of national codes of conduct, ethics and practice standards, which guide nursing practice. 21 There are many competing factors influencing autonomy, including personal and cultural beliefs around health and illness. Upholding a patient’s autonomy is seen as an obligation of the health-care provider or the institution in which care is provided. 22
With regard to ethics, consent is a manifestation of autonomy, which in return is the philosophical justification of consent. 23,24 The process of consent is designed to protect the autonomy of the patient and their ability to self-determine. 7 The importance of consent and the concept of autonomy become the overriding ethical principle for the basis of consent. It is the ethical principle of autonomy on which information disclosure and the process of consent is based.
Method
The larger interpretive exploratory study investigated DOSA nurses’ perceptions of their role in consent. Through this larger study, the concepts around informed and implied consent were developed. Data were collected using semi-structured, one-on-one interviews guided by the opening statement of ‘tell me, in as much detail as you can, about your day’. By using a very broad introductory question, it allowed participants to develop the conversation and allowed the researcher to ask specific questions where appropriate. Another question specifically asked of all participants was ‘have you heard of implied consent and can you explain what this term means’.
Using purposive sampling, participants were recruited via a letter of invitation. Eight registered nurses volunteered to participate in the study and were provided with a Plain Language Information Statement (PLIS) and Informed Consent Form. Ethical approval was received from the University of Ballarat Human Research and Ethics Committee (HREC).
Interviews were audiotaped and later transcribed by the researcher to assist in the manual thematic analysis and extraction of significant statements. 25 –27 Validation of transcripts for authenticity was facilitated by returning the transcripts to participants to read. 28,29 The identified themes and statements highlighted the nurses’ experiences and their perceived meaning of implied consent. 30,31 Excerpts from transcripts were not only used to preserve the uniqueness of participant responses but also permitted an understanding of the phenomena of interest. 32
Results
Nurses’ understanding of implied consent
From the interviews conducted, the participants illustrated their understanding of what implied consent was and how it was used in clinical practice. Many of the nurses were able to give a reasoned and explained definition of implied consent in their daily practice.
When discussing nursing procedures, the concept of implied consent becomes an important consideration. Implied consent is a form of consent routinely used by nurses when performing nursing procedures. Most nurses presumed that introducing themselves to the patients along with a brief explanation of the particular procedure is sufficient for the patient to give implied consent.
One participant reflects on implied consent within DOSA. I think … the initial introduction and letting them know what you are going to be doing. I guess that I assume that when I say hi my name is … I am going to admit you …. start by doing your vital signs …I assume that the patient would say that they are not happy to do that … I guess that by introducing myself I have their consent if they don’t say I am not happy for you to do that.
Another participant describes it within the context of taking a blood pressure. … you are looking at them saying okay, well now I am going to take your BP … looking at them for the consent, where they put their sleeve up …
One participant described implied consent as being like an unspoken contract between the nurse and the patient. I think it’s not a direct can I take your BP … it is very much an unspoken type of contract … I find that most people are offering their arm before I have even reached the machine.
One participant also described that it is a sense of intuition that the nurse has with interaction between the patients. … it is something, you just get the feeling or it seems obvious that it is okay for you to do it … You don’t need to ask a patient every time you need to do something.
How nurses’ use implied consent
When participants were asked about using implied consent in clinical practice, nurses highlighted the fact that no matter what consent framework they used, they were still required to provide an explanation of care to the patient. This highlighted that an essential component of the consent process is the education of the patient. …When you are giving medication I would say this is Heparin … it is a drug to help with clotting … I would always explain what I am doing to the patient.
Another participant also highlighted this as an important part of implied consent. … I don’t think I have ever had anybody refuse but I can see someone who is of a different background or rarely in hospital that they may not understand and my explanation might not be enough so then you would need to probably give them more explanation and hopefully they can understand it.
Participants were asked to reflect on a time in clinical practice where the use of implied consent would not be sufficient and when nursing staff should introduce a framework of informed consent. … most people come into the hospital with the expectation that certain things are going to be done … it all depends on how you talk to people and how you approach the subject … in a sense you are informing them what they are in there for.
From the above example, it is also highlighted that the role of communication is an important aspect of the consent process. The way that nurses communicate with patients is a pivotal and vital skill.
Another participant who described implied consent as being appropriate as many patients have certain expectations of what hospitalisation entails also highlighted this. I think when patients come into hospital they expect these thing to be done to them and I think that’s probably implied consent.
The above example also alludes to the concept of advocacy, recognised by participants as important in the consent process. This is highlighted by the following sections.
Components of implied consent
Common themes that were noted in the thematic analysis included information disclosure, education, advocacy and communication. These four key areas were all acknowledged to be important in implied consent.
Information disclosure
Many of the nurses interviewed acknowledged that part of their role was to ensure the patient had received comprehensive information from the treating doctor. … ensuring that the patient is aware of the procedure they are having and they have discussed it with the doctor.
Education
Linked closely with information disclosure is the necessity of educating patients during the consent process. The nursing role was more of clarification rather than pertaining to the responsibility of educating the patient. You make sure they have an adequate explanation from the surgeon.
Part of the role as an educator was to provide information in a comprehensive form for the patient and also ensure that the patient had enough information to make an informed health-care decision.
Advocacy
Advocacy is linked to information disclosure and education of the patient. When participants were asked to explain the notion of advocacy, they asserted it was not solely up to nurses to advocate for patients, even though they were in an ideal role to facilitate patient advocacy due to the amount of patient contact in the DOSA unit.
Participants were asked to explain what they perceived advocacy to be. Advocacy had varied meanings to different participants, and this was closely linked to their perception about their role within consent. Someone that is there for the patient … like a protector that explains things.
Communication
Nurses facilitated patient autonomy with the use of open communication in the DOSA unit.
Open communication allows the patient to participate in their proposed plan of care and the opportunity to discuss this with the nurse. Communication was an essential skill at the heart of the therapeutic relationship. Participants demonstrate this as follows: … when I say hi and I am going to admit you and we are going to start by doing your vital signs … I assume that the patient would say that they are not happy to do that when I let them know that’s what I am going to do.
The findings reported in this article are a summary of part of the findings of the full study. These results indicate that nurses working within the DOSA unit routinely use the process of implied consent when providing routine nursing care to patients.
Discussion
The larger study conducted was exploratory in nature and explored issues around consent within a specific clinical setting. There were several other areas of interest arising from this research, but these have not been explored in the context of this article. Therefore, readers need to understand that this is not a comprehensive account of consent within DOSA, but it allows for investigation into a previously unexplored topic.
Currently, in the DOSA unit, there is a reliance on implied consent for performing what is seen as routine nursing care. As presented in the findings of the participants, there was an overall consensus that implied consent was routine practice. The question that needs to be addressed is in relation to whether implied consent is actually beneficial to the patient in relation to patient autonomy and supporting the patient’s right to consent to or refuse treatment.
Autonomy has become the prevailing bioethical principle influencing the health-care professionals’ interactions with patients. 33 Patient autonomy is the basis of informed consent and influences the relationship between the nurse and the patient. 19 When making treatment decisions, the patient is required to have sufficient information, advice and support of the treating health-care professionals and the autonomy to make the decision. 33 –35
Patient autonomy relies on the patient having been educated regarding their treatment options and that this education has been understood and communicated with the patient. Therefore, to enable and encourage patient autonomy, the nurse requires in-depth knowledge of, and interaction with, patients in the context of each particular nursing encounter. 19
DOSA nurses believed that patient autonomy was enhanced by advocacy, communication and education provided to patients. These factors were described as influencing the formation of a therapeutic relationship between the nurse and patient, which was considered by the participants to be vital to the delivery of comprehensive nursing care. DOSA nurses assisted patients in their decision making through the education of patients by providing information in a comprehensible manner for each individual patient within a supportive environment. 36 –40
Advocacy in nursing practice is another grey area that needs to be further explored. DOSA nurses saw this role as being essential in their clinical setting. It was discussed that being an advocate for patients ensures that care promoted patient autonomy and centred the care provided back into the patient domain.
In relation to the concept of consent, a patient requires a supportive environment to integrate and make sense of complex medical information given to them. 41 This is where the concept of communication, by all health-care professionals, plays an important role. Communication functions in the ability of a person to obtain and receive information, which is fundamental to the consent process. 42 Communication, in the context of consent and supporting patient autonomy, is a negotiation process that occurs within the social context of the patient. 19 This is an important concept in relation to patient autonomy.
Communication was seen to be very important by the participants. The lack of communication that can sometimes occur in the DOSA unit was also discussed. This was found to be due to time constraints in relation to theatre schedules. A nurse has a very limited time period with a patient while performing his or her admission paperwork. This usually means that the nurses have to be very succinct and to the point in relation to asking the necessary questions to the patients. At times, however, due to the patient, this is almost impossible to achieve. In these instances, this is where the individualised, holistic needs of the patient are required to be put first so that the patient feels the process has been beneficial and supportive to their needs and wants.
The question remains on whether implied consent should be the golden standard in relation to nursing practice, consent and patient autonomy. Implied consent, although it seems to support the concept of patient autonomy, still relies on the nurse to make some of the decisions for the patient rather than the patient having the autonomy to make his or her own decisions.
Patient autonomy, while supported during the nursing process in the DOSA unit by several different factors, can still be compromised. Patient autonomy relies on both the expertise and the knowledge of the individual nurse, and on the patient and their ability to make and support their own health-care decisions. It then becomes the nurses’ responsibility to encourage patient autonomy by providing a supportive environment to allow for patients to make their own choices regarding their health-care treatment and options.
Some of the identified limitations of this research include:
Results of this study cannot be generalised to all clinical areas of nursing since data were only gathered from one clinical area.
The sampling technique used means that the study results cannot be generalised. Participants that were willing to be interviewed may be those nurses confident in their clinical skills and their role in the process of consent and thus willing to engage in discussion around the topic. This may suggest a biased finding. This particular sample of participants may have unique features not replicated in other clinical areas.
The researcher was a member of the clinical area, which may have increased bias in the study.
Overall, the majority of nurses shared a common notion that consent processes intricately involved nurses throughout, and facilitated patient autonomy using techniques such as advocacy, communication and education. This study has opened the door to do more comprehensive research into the areas of autonomy and advocacy in nursing practice.
Footnotes
Funding
This article forms parts of a larger study that was supported by Epworth Healthcare, by being awarded a monetary scholarship (2008) in association with Advantage Salary Packaging.
Conflict of interest
The author declares that there is no conflict of interest.