To: Ethics Advisory Board

From: Nurse from Milan, Italy

Subject: Professional responsibilities with informed consent

I recently was asked to obtain a signed informed nursing consent before delivering prescribed care to a patient in an outpatient chemotherapy center. Is this form required in the United States? How do the principles of informed consent apply to routine nursing practice?

From: ANA Center for Ethics and Human Rights 

To answer this question, we completed an informal query of several nursing colleagues across the country. Although the concept of an informed nursing consent piqued their interest, none have ever used or heard of a stand-alone informed consent for routine nursing care. A cursory view of the literature doesn’t find this to be routine practice. 

Nurses may be involved in formal informed consent processes that address operative and other invasive procedures, blood product administration, research or clinical trials, and protocol implementation designed to ensure safe administration of high-risk medications such as chemotherapy. The nurse’s role in structured informed consent processes has technical and professional components. Technically, the nurse serves as a witness to the patient (or proxy) signing the form, but nurses don’t abdicate their professional responsibility or commitment to the patient in those moments. Nurses have agency and ought to question and advocate as needed. Our professional responsibilities to ensure quality informed consent extend well beyond witnessing. A permission-to-treat form in admission packets or electronic health records may address general consent and financial responsibilities. 

There is a mutual (frequently unspoken) understanding that the nurse intends to do no harm while delivering quality, safe, person-centered, evidence-based care. This involves partnering with patients to design the plan of care, providing teaching, and engaging in simple consent processes. For example, nurses use anywhere from five to 12 rights of medication administration and seamlessly integrate education and consent into these moments. Nurses preemptively assuage fears and articulate the rationale for and range of possible discomforts associated with painful nursing procedures, such as nasogastric tube insertion, and support and reinforce teaching throughout the procedure. We review the potential risks and benefits of specific wound care products, highlighting the directions, discussing practical alternatives, and reviewing the risks of refusing treatment. Nurses talk to their patients who are intubated and sedated, walking them through the steps associated with mouth care or turning to prepare them for the sensations they may experience. We also provide information, gauge capacity and understanding, and secure consent with individuals who are at their most vulnerable. It is simply our professional duty. 

When delivering routine nursing care, nurses provide information, support, and guidance while considering any emergency or individual circumstances. Consent may be implied or explicitly communicated verbally, nonverbally, or in electronic or written form. Nurses ought to include documentation of these interactions in their charting. A blanket consent statement simply couldn’t cover every instance of independent nursing care or implementation of medical orders and prescriptions based on standards of care and sound clinical judgment. 

The Code of Ethics for Nurses with Interpretive Statements (Code) (nursingworld.org/coe-view-only/) addresses consent in its discussion of privacy and confidentiality protection (Provision 3.1), research participants (Provision 3.2), and autonomy. Provision 1.4, the right to self-determination, seamlessly integrates human dignity, moral and legal rights, patient values and processes, autonomy, support via the nurse-patient (proxy) relationship, and informed decision-making. Thus, the Code provides support for nurses in both the formal informed consent and simple consent processes.

— Response by Jennifer L. Bartlett, PhD, RN-BC, CNE, CHSE, member of the ANA Ethics and Human Rights
Advisory Board.