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Good record keeping | Public Health | Royal College of Nursing (rcn.org.uk)

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If we don't have your email address you can register it. If you are a paying member of the RCN, or have been in the past, you must provide your membership number in order to link your membership to your email address.

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Gaining consent – It's a yes or no situation. Think again! | Royal College of Nursing (rcn.org.uk)

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It is a general legal and ethical principle that informed and valid consent, freely given by a person with the capacity to make that decision independently, must be obtained before commencing an examination, starting treatment or physical investigation, or providing care.

This principle reflects the rights of a person to determine what happens to their own bodies or what shapes the care and support they receive. It is fundamental to good practice, and an explicitly required standard of behaviour and practice set out in (NMC, 2018). Registered nurses who do not respect this principle may be liable to both legal action by the person in their care and action by the NMC.

Consent is not a simple yes/no answer in many situations. The legal context is ever evolving. Judicial reviews and rulings by the Supreme Court mean that the need for "informed consent" is a legal requirement - see Montgomery v Lanarkshire Health Board [2015] UKSC .

Informed consent means that sufficient evidence based information must be provided to the person to enable them to make a balanced and informed decision about their care and treatment. As well as a general explanation of the procedure there is also a duty to explain the risks inherent in the procedure and the risks inherent in refusing the procedure. Information must also be provided regarding alternatives to the proposed intervention. This will assist the person to make the decision to consent to, or refuse consent for a particular intervention, whilst respecting their right to autonomously decide what happens to them. Failing to meet this legal duty can give rise to an action in negligence if the person is subsequently harmed.

It is imperative that nurses understand their role around consent and what the specifics of valid, informed consent actually mean. It is also vital that nursing staff understand the intricacies of gaining consent with specific patient populations, such as children and young people, or those who may lack capacity to make a relevant decision independently. They must understand how to proceed should the situation not be straightforward, or if consent for examination, care, treatment or support is withheld. Nursing staff should refer to the RCN resource - Consent in NI - RCN Clinical Topic whi ch provides guidance for nursing staff in understanding their role and accountability in this area.

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Gaining consent - It's a yes or no situation. Think again! | Royal College of Nursing

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It is a general legal and ethical principle that informed and valid consent, freely given by a person with the capacity to make that decision independently, must be obtained before commencing an examination, starting treatment or physical investigation, or providing care.

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Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 11

The intention of this regulation is to make sure that all people using the service, and those lawfully acting on their behalf, have given consent before any care or treatment is provided. Providers must make sure that they obtain the consent lawfully and that the person who obtains the consent has the necessary knowledge and understanding of the care and/or treatment that they are asking consent for.

Consent is an important aspect of providing care and treatment, but in some cases, acting strictly in accordance with consent will mean that some of the other regulations cannot be met. For example, this might apply with regard to nutrition and person-centred care. However, providers must not provide unsafe or inappropriate care just because someone has consented to care or treatment that would be unsafe. See the glossary for the definition of 'relevant person' in relation to Regulation 11.

CQC can prosecute for a breach of this regulation or a breach of part of the regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, CQC may also take other regulatory action. See the offences section for more detail.

CQC must refuse registration if providers cannot satisfy us that they can and will continue to comply with this regulation.

The regulation in full

11.-

* Mental Capacity Act 2005

** Mental Health Act 1983

Guidance

This sets out the guidance providers must have regard to against the relevant component of the regulation.

11(1) Care and treatment of service users must only be provided with the consent of the relevant person.

Guidance on 11(1)

When a person is asked for their consent, information about the proposed care and treatment must be provided in a way that they can understand. This should include information about the risks, complications and any alternatives. A person with the necessary knowledge and understanding of the care and treatment should provide this information so that they can answer any questions about it to help the person consent to it.

Discussions about consent must be held in a way that meets people's communication needs. This may include the use of different formats or languages and may involve others such as a speech language therapist or independent advocate. Consent may be implied and include non-verbal communication such as sign language or by someone rolling up their sleeve to have their blood pressure taken or offering their hand when asked if they would like help to move.

Consent must be treated as a process that continues throughout the duration of care and treatment, recognising that it may be withheld and/or withdrawn at any time.

When a person using a service or a person acting lawfully on their behalf refuses to give consent or withdraws it, all people providing care and treatment must respect this.

Where a person lacks mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.

Consent procedures must make sure that people are not pressured into giving consent and, where possible, plans must be made well in advance to allow time to respond to people's questions and provide adequate information.

Policies and procedures for obtaining consent to care and treatment must reflect current legislation and guidance, and staff must follow them at all times.

11(2) Paragraph (1) is subject to paragraphs (3) and (4).

11(3) If the service user is 16 or over and is unable to give such consent because they lack capacity to do so, the registered person must act in accordance with the 2005 Act.

11(4) But if Part 4 or 4A of the 1983 Act applies to a service user, the registered person must act in accordance with the provisions of that Act.

11(5) Nothing in this regulation affects the operation of section 5 of the 2005 Act, as read with section 6 of that Act (acts in connection with care or treatment).

Guidance on 11(2), 11(3), 11(4) and 11(5)

Providers must make sure that staff who obtain the consent of people who use the service are familiar with the principles and codes of conduct associated with the Mental Capacity Act 2005, and are able to apply those when appropriate, for any of the people they are caring for.

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Our guidance explains how care providers can meet this requirement, which is one of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Its intention is to make sure that all people using the service, and those lawfully acting on their behalf, have given consent before any care or treatment is provided.

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https://pin.it/3BhLpGsSQ

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https://www.medicaltranscriptionservicecompany.com/wp-content/uploads/2022/01/key-elements-in-nursing-documentation.jpg

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How to DOCUMENT your nursing notes | Clinical Skills Series

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We are now going to spend some time debriefing.

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Scenario:

A year 1 nursing student is assisting a nurse with a procedure for a patient who has recently been admitted to the hospital. The patient is elderly and has some cognitive impairment, but is still able to understand basic information and communicate his preferences.

The nurse explains to the student that they need to insert a urinary catheter for the patient to monitor his urine output. The student notices that the nurse did not discuss the procedure with the patient or obtain his consent before preparing to insert the catheter.

The student, feeling unsure about what to do, decides to speak up and ask the nurse about obtaining informed consent from the patient. The nurse brushes off the student's concerns, stating that because the patient has cognitive impairment, it is not necessary to obtain his consent for such a routine procedure.

As the student watches the nurse proceed with the catheter insertion without the patient's consent, they start to feel uncomfortable and realize that the nurse's actions may be ethically questionable and potentially illegal.

After the procedure is done, the student reflects on the situation and decides to discuss the issue with their nursing instructor to understand the ethical and legal implications of not obtaining informed consent from patients, especially those with cognitive impairments.

Using the scenario discuss the importance of obtaining informed consent from patients, regardless of their cognitive status, and the potential consequences of not doing so in terms of ethical considerations and legal implications.

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Scenario 1: Pre-Operative Informed Consent

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Scenario 1: Pre-Operative Informed Consent

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You are in a virtual hospital setting where you are assigned to a patient scheduled for a surgical procedure. Your task is to decide in your group on a patient going for eg a tonsillectomy (the group decides the condition). You will create a scenario where you have to devise and review the patient's medical history, explain the surgical procedure and potential risks, discuss alternative treatments, consider and answer any questions the patient may have, and obtain informed consent. Be prepared to present back to the group.

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Scenario 2: Medication Administration Informed Consent

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Scenario 2: Medication Administration Informed Consent

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You are working with your practice supervisor performing medication administration as part of your competency formative assessment. You in your group consider 2 medications to review, explain the purpose of the medication, discuss potential side effects, obtain the patient's consent, and document the process accurately.

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Scenario 3: Ethical Dilemma in Informed Consent

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Scenario 3: Ethical Dilemma in Informed Consent

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Researchers are conducting a study on the effects of virtual reality therapy on individuals with social anxiety disorder. The study aims to assess the effectiveness of virtual reality therapy in reducing social anxiety symptoms.

Informed consent is an ethical and legal requirement for research involving human participants. It ensures that participants are fully informed about the study, its purpose, procedures, potential risks and benefits, and their rights as participants. Informed consent also allows participants to make an autonomous and informed decision about whether to participate in the study [[1]](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3777303/) [[2]](https://www.intechopen.com/chapters/1123544).

Discuss in your groups what may be challenges in obtaining informed consent from participants. What are the potential issues.

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Scenario:

You are a year 1 nursing student completing a clinical rotation in a busy hospital ward. During your shift, you are assigned to care for a patient who has just undergone a surgical procedure. The patient is experiencing post-operative pain and has been prescribed pain medication by the healthcare provider.

As part of your responsibilities, you are required to administer the pain medication to the patient and monitor their pain levels and response to the medication. After administering the medication, you carefully assess the patient's pain levels, documenting their pain score before and after the medication administration, as well as any side effects or changes in the patient's condition.

Later in the shift, the patient's condition takes a turn for the worse, and they begin experiencing severe respiratory distress. The healthcare team rushes to stabilise the patient, and the healthcare provider asks for the patient's recent pain assessments and medication administration details.

You quickly retrieve the patient's chart and present the documented pain assessments and medication administration records to the healthcare provider. Your detailed documentation clearly outlines the patient's pain levels, response to medication, and any relevant observations, which helps the healthcare team make informed decisions about the patient's care and treatment plan.

Discuss what this scenario has demonstrated. Think of your clinical environment, discuss types of documentation you have seen in practice and the effects good and poor documentation has on the patient and nursing team.

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DO'S AND DON'TS IN DOCUMENTATION AND HEALTHCARE RECORDS

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Situation:

You are a year 1 nursing student assigned to a surgical unit in a hospital. You are caring for a patient who is scheduled for a surgical procedure the next day. The patient has expressed concerns about the surgery and has requested further information about the procedure and risks involved. The healthcare provider has informed you that the patient's informed consent needs to be obtained before the surgery can proceed.

Background:

The surgical procedure planned for the patient is a laparoscopic cholecystectomy to remove the gallbladder due to gallstones. The patient has a history of gastrointestinal issues and has been experiencing recurrent episodes of abdominal pain. The healthcare provider has explained the benefits of the surgery in alleviating the patient's symptoms but also emphasized the potential risks and complications associated with the procedure.

Assessment:

As the nursing student responsible for the patient's care, you assess the patient's understanding of the surgical procedure and informed consent process. You explain the purpose of informed consent, ensuring that the patient is aware of the risks, benefits, and alternatives to the surgery. You answer any questions the patient may have and assess their capacity to make an informed decision about their care.

Recommendation:

Discuss and document in the feedback section what would you recommend and why?

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Scenario:

You are a year 1 nursing student working in a hospital setting. You have been assigned to care for a patient who is scheduled for a surgical procedure the following day. Before the surgery, the patient's healthcare provider explains the risks and benefits of the procedure to the patient and obtains their informed consent.

As part of your responsibilities, your practice supervisor has asked you to ensure the documention for the patient's informed consent is filed in their medical record. However, you notice that the consent form is missing important details such as the specific risks discussed with the patient and any alternative treatment options that were considered.

You understand the importance of accurate and thorough documentation in healthcare practice and understand that incomplete or inaccurate documentation could have serious consequences for the patient. You bring this to the attention of your practice supervisor. What process would you go through and what is required to ensure the documentation is compliant?

Working through this scenario and discussion will enable a deeper understanding of the role documentation plays in ensuring patient safety, quality of care, and legal compliance in healthcare settings.

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Preparation - Patient, Equipment, Environment  Personal preparation (PEEP)

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Preparation - Patient, Equipment, Environment  Personal preparation (PEEP)

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As a year 1 nursing student, the concept of Preparation - Patient, Equipment, Environment, Personal Preparation (PEEP) can be used to ensure documentation is in legal compliance Discuss and document the ways.

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Lesson Goal
To gain some knowledge and understanding of documentation and Informed consent. Using scenario-based learning work in groups through a scenario.

Outcomes

1. Students will be able to identify the components of informed consent and explain why it is important in healthcare practice.

2. Students will understand the ethical and legal implications of not obtaining informed consent from patients.

3. Students will be able to effectively communicate with patients and their families about the informed consent process, including explaining risks and benefits of treatment options.

4. Students will be able to demonstrate proper documentation of informed consent in a clinical setting, following institutional guidelines and best practices.