|ORIGINAL RESEARCH PAPER
|Year : 2012 | Volume
| Issue : 2 | Page : 92-97
Learning Objects? Nurse Educators' Views on Using Patients for Student Learning : Ethics and Consent
C Torrance, I Mansell, C Wilson
HESAS, University of Glamorgan, United Kingdom
|Date of Submission||25-Jan-2012|
|Date of Decision||27-May-2012|
|Date of Acceptance||31-May-2012|
|Date of Web Publication||14-Nov-2012|
HESAS, University of Glamorgan, Pontypridd, CF37 1DL
Source of Support: None, Conflict of Interest: None
Introduction: This study explored the views of nursing lecturers concerning the use of patients in nursing education, particularly in light of the development of additional learning opportunities such as clinical simulation. Methods: Focus group interviews involving 19 educators from one school of nursing in the United Kingdom were held. An interview schedule was developed by the study team from the findings of a focused literature review of the area. The focus groups were audio-taped and transcribed into NVivo (version 8) for analysis and identification of emergent themes. Results: Four major categories emerged from the data analysis: clinical placement; patient consent; educator conflict; and developing competency. The themes of clinical placement and patient consent are presented in this paper. Clinical placement revealed two sub-themes: historical custom and practice and safety. Four sub-themes emerged from the theme of patient consent: informed consent; implied consent; capacity to consent; and patients' value of student involvement in their care. Discussion: Educators believed that patients benefit from being cared for by well-qualified nurses and to achieve this it is necessary for patients to participate in clinical training. The predominant view seemed to be one of historical necessity; essentially, it has always been done that way so it has to continue that way. There was an awareness of the need for staff and students to consider the patient's rights and wishes, but the prevailing sentiment seemed to be that informed consent and choice were secondary to patient safety and the need to train student nurses. There is some conflict between the need for educating health professions and the Kantian view of never using the patients as a means to an end. Using patients for nursing education may be ethical as long as the patient is fully informed and involved in the decision-making process.
Keywords: Education, ethics, focus group, Kantian, nursing, patients, students, utilitarian
|How to cite this article:|
Torrance C, Mansell I, Wilson C. Learning Objects? Nurse Educators' Views on Using Patients for Student Learning : Ethics and Consent. Educ Health 2012;25:92-7
| Introduction|| |
Patients' autonomy and involvement in decisions about their care is a key feature of modern healthcare.  Paternalistic, 'trust us we know what's best for you' from health professionals is no longer acceptable in an era of shared decision-making and patient-centred care. Patient participation in care decisions is associated with better health outcomes. , Yet, not all patients will want to take an active role in decision-making, but all should, nonetheless, have the opportunity to do so.
Patients play a central role in health professional education in teaching hospitals and in sub-acute and community settings. The assumption has been that we can only create 'expert health professionals' if we give them the opportunity to practice on patients.  Patients have had a largely passive role in decision-making and were expected to be available for student education. In medical education, they may represent an interesting case or disease; in nursing and allied health they present an opportunity to practice and sign off on essential assessment and procedural skills. With shifting perceptions of patients from passive recipients to informed, autonomous participants in their own care, the role of patients in health professional education should be re-evaluated. This study explored the views of nursing lecturers concerning the use of patients in nursing education, particularly in light of the development of additional learning opportunities such as clinical simulation. In this paper, issues related to clinical placements, ethics and patient consent are explored.
| Methods|| |
This was an exploratory, qualitative study using focus group interviews for data collection. A purposive population of 51 nurse educators across a range of clinical specialties (adult, child, mental health, learning disabilities, community, public health and occupational health) based in one school of nursing in the United Kingdom (UK) were invited to participate in focus groups held between June and July 2008. Nineteen nurse educators participated in the study; 11 participants attended the first focus group, 8 attended the second. Ethical approval was obtained from the Faculty Research Ethics Committee. Participants were provided with an information sheet and a consent form and given the opportunity to ask questions regarding any aspects of the study in advance of the focus groups. An interview schedule was developed by the study team from the findings of a focused literature review in the area. Two researchers experienced in the methodology conducted the focus groups (IM and CW). At the end of each focus group, participants were given opportunities to ask additional questions.
The focus groups were audio-taped and transcribed into NVivo, QSR International (version 8) qualitative analysis software.  Transcripts from the focus group interviews were analyzed using a process of constant comparison. The data were coded according to the meaning of a section of discussion and the data organized around emerging themes and sub-themes. Comparisons were made by two members of the research team (IM and CW) based on relevant topic characteristics such as patient safety, consent and other ethical considerations to develop explanatory constructs for the findings and identify patterns in the data. Inter-rater reliability was achieved by constant comparison, undertaken by research team members, and agreement reached. The focus groups sought to explore nurse educators' opinions and beliefs about the use of patients in student education, not knowledge of the relevant regulatory frameworks. Initially, nurse educators were asked 'Is it ethical for student nurses to practice on patients?'
| Results|| |
Four major categories emerged from the data analysis: clinical placement; patient consent; educator conflict; and developing competency. This paper mainly addresses the themes of clinical placement and patient consent.
In clinical placement, there were two sub-themes:
'is it expected? ' (historical custom and practice) and 'is it safe?.'
Comments suggesting that using patients for learning clinical and practical skills was the traditional and accepted way of learning included:
'…traditionally, they have always learnt by practicing on real patients, the patient in the hospital or the mental health patient in the mental health setting…' or 'It's traditional, we've always done it just so…' and 'We haven't thought about new ways of doing it enough'.
Some comments suggested educators were considering alternatives to using patients at least for some aspects of clinical skills and were aware of changing attitudes to the role of the patient:
'…, really would depend on the skill. If you were that concerned about a student then you couldn't allow them onto practice, because it depends on the skill, depends on the concern that you have'.
A further comment on clinical simulation suggested that it was not the traditional approach and that historical approaches should prevail - 'I mean we've always used patients…we can't replace actual hands on with real people in real situations, we just can't replace that, at the moment we can't'.
For patient consent, four sub-themes emerged from the theme of asking for 'patient consent' for students to perform aspects of care:
- informed consent
- implied consent
- capacity to consent
- patients valuing student involvement in their care.
Comments in both the focus groups in relation to gaining consent for student nurses to perform patient care suggested that it depended on the care being given and to what extent the patients are able to voice their views. Comments indicated that the key issue for these educators was not, 'if the student gained consent', but that the supervisor could ensure that the student's actions could be carried out in a safe manner. It was also suggested that the supervisor should make the decision rather than the patient. Feelings expressed by the nurse educators were that the supervisor is able to judge what is acceptable and unacceptable on the patient's behalf.
'The fact that somebody is in hospital, whether they have got the capacity to consent or not, if they are there is it reasonable to say that they would be expected to have certain care offered, certain things would happen as part of being a patient in hospital'.
A second comment challenged this notion suggesting that consent was important, especially in developing a therapeutic relationship between the nurse and the patient:
'It is not just part of that relationship between one nurse and one patient? I think in seeking consent for what we do creates an environment in which there is more likely to be an equalization of the power difference between patients and nurses'.
One participant stated that the 'consent issue' in terms of students related to political correctness:
'I think there is an element of political correctness here because um…the reality is that people come into hospital…because they have a moment of crisis or they have a particular health need or a particular issue. If they are an emergency (for example), I really don't believe they care too much about who is doing things to them, as long as they have some sense that the person doing it to them is safe'.
This comment was supported with the suggestion that patients generally appeared happy and valued having student nurses around to undertake procedures. Respondents further suggested that students may have more time to spend with patients and this could be one reason why patients appear to value their presence.
'…I think most patients are quite happy to have student nurses, when I've been a patient I've been quite happy to have student nurses around and my experience of being a student nurse is - you have more time to spend talking to patients. So, I don't think that there are a lot of problems with patients agreeing to have student nurses doing things for them'.
Anxieties concerning the issue of consent were highlighted by asking, 'what would happen if student nurses did not have patients on which to develop their skills':
'Where would we be if the patients started to say no? - that is the danger if they ask patients. I'm not saying we shouldn't but say, you know, but what happens if we start to have reams of people who have said no!'
One participant commented that student nurses work under the supervision of a registered nurse; they (the nurse educators) felt that patients did not need to give consent because the supervisor was ultimately responsible for the care provided:
'I agree with what you are saying, most patients would actually quite like it [being treated by student nurses] because they have not only got the student nurse but they've got a qualified nurse as well - two people doing it in tandem. So, it is not as if it's an issue for the patient'.
Another participant reflected that nurse educators themselves were often not treated by students when educators became patients. Relating details of their own patient experiences, nurse educators indicated that they were pleased when the Ward Sister had assumed that as a nurse educator they would not want to receive treatment from student nurses.
'…and sister said, you know, given where you work I guess you wouldn't want any [students nurses]. I said, yes, if possible, I would rather not have any students around'.
Further comments indicated that it was mainly for the individual student or supervisor to decide to tell a patient that it was the student's first attempt at a clinical skill and seek consent to proceed:
'I think that it is down to the individual person [student nurse]. I would because that is the type of person I am, but there would be some people who wouldn't say that, so I think that is an individual thing'.
It was also argued that patients expect students to practice on them and that consent was implied. This was deemed to be an entirely appropriate and ethically valid practice:
'I think to the majority of patients it is not an issue, based on experiences of my clinical practice…I think for the majority of patients it [consenting to a student nurse] is not an issue'.
Participants developed their argument indicating that consent by the patient was frequently implied by the physical act of complying with the student nurse undertaking the task. An example was given of a student nurse taking a blood pressure:
'…I mean, you could say to a patient, 'Is it ok for me to take your blood pressure now?' And the patient says, yes, or you could approach a patient with the equipment, you don't exchange any words and the patient holds their arm out. That is implied [consent]. No words are actually spoken - it's acceptable in law whatever type of consent it is'. or
'It's like when you open your front door and you step aside and somebody walks into your house, you don't say, I give you my express permission to enter my house'.
The opinion on the need for patients to consent to student nurses performing clinical procedures was further refined with participants' suggestions that when patients verbally consent to student nurses performing aspects of their care, it is often the power differential between the patient and the professional that leads to consent.
'…we shouldn't assume because somebody can give consent that they actually want to allow this thing to happen. They [the patient] may still feel obliged because if you are rolling towards a patient with a trolley you have got certain expectations…you [as the professional] still hold that balance of power, even if you are asking them [the patient]'.
This position was challenged, with a participant cautioning that they should not over-generalize whether patients could give consent. There was a growing recognition that the culture of healthcare delivery is changing and more emphasis is being placed on protecting patient autonomy:
'I think the climate is such now that things are changing, whereas before care was very paternalistic and healthcare providers did what they thought was best, I think particularly protecting the autonomy of a lot of vulnerable patients is actually going through an assessment of whether that person has got some capacity to make a choice or no capacity at all…I think students need to be aware of that just as much as they do about good manual handling techniques, for example'.
Some participants suggested that consent from patients was unambiguous; while others argued that the patient always has a choice relating to the care they receive:
'Patients have always got informed choice haven't they? They have always got a choice to say, yes, I don't want that person, be it a student or be it a trained nurse. They can say, no, I don't want you to do that, or yes, you can do that'.
Both the groups showed little recognition the patient needs to be provided with information about the student's level of skill and learning to make an informed decision. This was exemplified by one comment:
'I'm not saying that we run roughshod over the patient or totally disregard her, but if it is part of a package of care that has been assessed and planned by a number of people within a multi-disciplinary team does it really matter about that student as an individual, is she not part of a wider team and the accountability is really with the wider team?'
| Discussion|| |
All nurse educators supported the view that patients benefit from being cared for by well-qualified nurses and, in order to achieve this, it is necessary for patients to participate in clinical training. The majority strongly supported the relationship between how they established their own level of expertise (when they were a student nurse) and current student learning practices: ' Historically, it's the way it's always been done'. The predominant view seemed to be one of historical necessity; essentially, that it has always been done that way so it has to continue that way. There was a general awareness of the need for staff and students to consider the patient's rights and wishes, but the prevailing sentiment seemed to be that informed consent and choice were secondary to patient safety and the need to train student nurses. There was also a strong view that patients in hospital expected to be cared for by students and that the clinical supervisors were best placed to decide if it was safe and appropriate for a student to undertake a particular task. None of the educators explicitly stated that patients had an obligation to take part in clinical training, but they did consider it as an expectation of being in hospital.
Surprisingly little discussion was found in the nursing literature on the ethics of using patients to support student learning. Cain reviewed some of the ethical issues related to using patients for nursing students' professional development in terms of reflection on practice, as expressed in written work and discussions, and the arguments for and against gaining patient consent to use their case materials for coursework.  Hargreaves similarly focused on ethical and moral issues related to student nurses' use of reflection on their patients' experiences for educational gain.  Bindless, one of the few nurses to discuss the issue in more general terms, concludes that the needs of the patient must come first if we are to narrow rather than widen the theory-practice gap. 
There has been greater debate on this issue in the medical education literature. The intrusive nature of many medical procedures and concerns over controversial past practices have served to focus more discussion on the role of the patient in the education of medical students. Two areas of particular concern in medical training were the practicing of procedures on the newly deceased and intimate pelvic examinations carried out on the unconscious. In 2003, a survey published in the British Medical Journal reported that 24% of intimate examinations of anaesthetised women by students were without valid consent and in many instances more than one student examined the patient.  A recent study  reported that despite policies requiring informed consent, medical students in the UK were still reporting having observed or performed intimate examinations without having ensured valid consent. In exploring the reasons for this, the authors identified a number of factors in why students went ahead without consent, including feelings of obligation - 'I had to', insufficient confidence to say no and the apparent acceptability of the social environment of the practice (failure of peers, nurses and doctors to object).
Commentators have not tended to defend the practice of performing pelvic examinations without consent, but the issue of practicing procedures such as endotracheal intubation on the newly deceased has created more debate in medical education. Iserson, for example, champions the view that necessity outweighs the need for consent - 'the logic and necessity of the practice heavily outweighs possible ethical concerns'.  Goldblatt, however, clearly articulates that this would be 'a hidden practice that is unlawful and unethical'. In the end, the debate revolves around the arguments for the greater good represented by well-trained health professionals versus the rights of the autonomous, informed individual. All patients need well-trained health professionals, but do all patients have an obligation to take part in their training?
Two conflicting ethical principles seem to be at the heart of this debate. From the Utilitarian standpoint, as exemplified by philosophers such as Jeremy Bentham or John Stuart Mills, it can be argued that more patients benefit in the longer term from healthcare students practicing their clinical skills on individual patients - the greatest good for the greatest number of people. However, the Kantian perspective suggests that the patient should never be treated only as a means to an end - 'Act so that you use humanity, as much as your own person as in the person of every other, always at the same time as end and never merely as means'.  Thus, to use a patient as a means to an end, that is, as a vehicle for skill development could be viewed as unethical.
There is no doubt of the views of the regulatory bodies in the UK. The General Medical Council 'requires doctors to be satisfied that they have consent from a patient, or other valid authority, before undertaking any examination or investigation, providing treatment, or involving patients in teaching and research'. The British Medical Association also emphasizes that valid consent requires that 'patients must be aware of who will be present, why they will be present and what their level of involvement will be'. The Nursing and Midwifery Council code is similarly clear on consent for nursing procedures:
'You must ensure that you gain consent before you begin any treatment or care;
You must respect and support people's rights to accept or decline treatment and care;
You must uphold people's rights to be fully involved in decisions about their care'.
Is it ethical to use patients for nursing education? Yes, it probably is, as long as the patient is fully informed and involved in the decision-making process. Fully informed means that they need to know that care will be provided by a student and they also need to appreciate the student's knowledge and skill level in relation to the care or procedure being undertaken. Nursing and medical training are not identical. Many nursing care procedures carried out by students are essential for patient care - student nurses in the UK are not always supernumerary, for some of their rostered hours they are part of the workforce.
However, patients are never obliged to accept care from students. In modern healthcare, there is a need to move from the paternalistic, professional-centred 'Bolam test' approach to a more patient-focused approach.  What counts is giving patients enough information to make informed decisions from their perspective, not that of a healthcare professional. Goedken,  in a thoughtful and sensitive discussion of the issue of pelvic examination under anaesthesia, highlights some key points of relevance to this debate. Patients and healthcare professionals may view a procedure quite differently; routine to one may be invasive and disruptive to the other. Attendance at a teaching hospital or clinic does not in itself imply consent to students undertaking any procedure. This is equally important for nursing - a simple procedure such as bathing the patient in bed may not be insignificant to the patient and fully informed consent is still required for student participation.
Although these data were collected in 2008, they deal with a central issue for health professional education that is becoming important as advances in educational technologies offer increasingly more realistic alternatives to learning at the bedside. Patients do not have a duty to take part in nursing or medical education, but healthcare professionals do have an obligation to provide honest disclosure. Partnership and trust between the patient and the health professional will be built on open discussion and disclosure on the role and skill levels of learners providing care. Anecdotally, most patients are more than willing to allow students to practice on them and gain experience. Healthcare education needs to embrace this generosity and ensure that each patient can make a fully informed choice and that appropriate use is made of viable alternatives to the traditional clinical learning environments.
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