International Journal of Collaborative Research on Internal Medicine & Public Health

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Competency of gaining consent: a Foundation trainee ’s perspective in the North Western Deanery

Hiew K, Eyres G, Chauhan S , Ekta P, Haddock C, Heath R, Jawaheer L, Looi E, Rai. C ,Thampy A, Baker P.

Hiew K.*1, Eyres G.1, Chauhan S.2, Ekta P.3, Haddock C.4, Heath R.5, Jawaheer L.6,Looi E.7, Rai. C8 and Thampy A.9 and Baker P.10
  1. Blackpool Teaching Hospitals NHS Foundation Trust, UK
  2. Salford Royal NHS Foundation Trust, UK
  3. Pennine Acute Hospitals NHS Trust, UK
  4. East Lancashire Hospitals NHS Foundation Trust, UK
  5. University Hospitals of South Manchester NHS Foundation Trust, UK
  6. Bolton NHS Foundation Trust, UK
  7. Wrightington, Wigan, and Leigh NHS Foundation Trust, UK
  8. Stockport NHS Foundation Trust, UK
  9. University Hospitals of Morecombe Bay NHS Foundation Trust, UK
  10. North Western Deanery, UK
Corresponding Author: Hiew K, Blackpool Teaching Hospitals NHS Foundation Trust, UK
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Abstract

Introduction The General Medical Council (GMC)1 and the National Health Service Litigation Authority (NHSLA)2 have strict guidance on how informed consent should be gained and how trainees should be supported when learning to take consent, however foundation trainees often feel vulnerable when expected to gain consent for a procedure they have little or no expertise for.

Objective (1) To examine the perceptions and confidence level of new Foundation year 1 doctors in gaining consent. (2) To look at the factors that favourably influenced confidence. (3) To outline the best method of teaching in gaining a valid consent of a procedure.

Method Questionnaires were distributed in 9 hospital trusts in the North Western Deanery and completed by 203 FY1s in the first 6 months of their post.

Result 71% had taken written informed consent, of these 43% felt they had been put in a position in which they were unhappy to do so, 33% were supervised and 16% were formally supervised. Confidence levels were increased by: supervision (Mean confidence 7.26 vs 6.58, 2 sided P value 0.0036); and formal assessment (Mean confidence 7.26 vs 6.64, 2 sided P value 0.0277). Respondents preferred the following modes of teaching consent: one-to-one session with supervisor (47%), organised tutorial session during induction (21%), and medical school (20%).

Conclusion Results show low levels of supervision and formal assessments in gaining consent, despite being key factors in increasing confidence. A mandatory Mini CEX or similar activity early in Foundation training could lead to better prepared doctors in gaining a valid consent.

Keywords
consent, training, foundation programme.

Introduction
Gaining informed consent to t reatment forms one of the vi tal roles a doctor has to perform day to day. The General Medical Counci l ’s (GMC) Good Medical Pract ice states, the responsible cl inician must be sat isfied that they have consent or other val id author i ty before they undertake any examinat ion or invest igat ion, provide t reatment or involve pat ients in teaching or research.1
In the revised GMC guidance, Consent : Doctors and Pat ients making decision’s together 2008, i t states the doctor undertaking an invest igat ion or providing treatment , is responsible for discussing i t wi th the pat ient . If this is not pract ical , they can delegate the responsibi l i ty to someone else, provided they make sure that the person they delegate to: a. is sui tably t rained and qual i fied, b. has suf ficient knowledge of the proposed invest igat ion or treatment , and understands the risks involved, c. understands, and agrees to act in accordance wi th the guidance.2
In day to day pract ice, i t is often the most junior of doctors who are asked to obtain wri t ten informed consent . Cl inicians have been aware of this for some t ime and have expressed concerns regarding the ethics of delegat ing this task to i l l-prepared juniors. In a medical ethics symposium i t was stated that , if informed consent is to fulfi l the purpose of respect ing the autonomy and digni ty of pat ients sufficient resources are required to t rain young doctors to the job properly. It stated that one thing was clear: i f they cannot complete the task in accordance wi th the guidance issued by both the GMC and Department of Heal th, they should not be doing i t at al l . 3
In 1997 Houghton et al looked at the percept ions of junior doctors and pat ients in the consent process. They found that al though 95% of pat ients quest ioned were happy wi th the consent procedure per formed by junior doctors, 45% of pat ients wrongly thought the junior doctor themselves would be car rying out the procedure and of the junior doctors quest ioned 37% admi t ted to gaining consent for procedures of which they had l i t t le understanding about .4
In 2005 a study by Schi ldmann et al found that hal f of the PRHOs (FY1s) stated that they were often or always the only person involved in the consent process. The majori ty also seemed to be never or rarely receiving supervision.5 Schi ldmann fel t that despi te extensive undergraduate training in ethics and communicat ion, there was a need for appl ied educat ion regarding the cl inical procedures for which PRHOs were obtaining consent .
In 2010 the NHS Li t igat ion Author i ty publ ished the Risk Management Standards for NHS trust in the UK. This document focused on measures to ensure pat ient safety. Part of the documentat ion focused on wri t ten consent . It stated that as a minimum NHS t rust should provide generic t raining on consent along wi th procedure specific t raining for those authorised to obtain consent . It stated there should also be a process for moni toring compl iance wi th GMC guidance on taking informed consent .6
Al though the structure of Junior Doctor training has changed, the issue of i l l - prepared juniors taking informed consent cont inues. Our aim was to determine whether Foundat ion Year One Doctors (FY1s) express the same concern regarding gaining consent as shown in Schi ldmann’s study.

Material and Method
The study took place wi thin the North Western Deanery in England. A survey was developed using the GMC’s guidance on consent as a basis. The survey was approved by the North Western Deanery and each survey was opt ional and anonymous. Par t icipants were asked about thei r involvement in taking informed consent . They were asked about which procedures they had been asked to consent for and whether they were supervised when ini t ial ly taking consent . They were also asked whether or not they fel t they could refuse taking consent when they fel t unknowledgeable. A total of 9 hospi tal trusts were recrui ted in to the survey and an FY1 representat ive f rom each trust was charged wi th distr ibut ing and col lect ing the surveys. The surveys were dist ributed to al l FY1s wi thin each t rust who at the t ime of taking part were just over 6 months in to thei r fi rst year of training.

Results
Nine hospi tal t rusts wi thin the North Western Deanery were represented wi th 203 FY1’s taking part in the survey. The part icipants involved were graduates from 25 di f ferent Universi t ies, wi th the Universi ty of Manchester having the greatest representat ion (49%). Of the 203 representat ives, 71% admi t ted to taking informed consent as an FY1. Of those that said they had taken consent 61% said they fel t sui tably t rained to take informed consent and 43% of part icipants fel t that they had been put in a posi t ion to take consent which they were unhappy to do.
When asked where they had learnt to take informed consent , 94 respondents were trained dur ing thei r medical school years, 136 respondents were trained by a senior col league on the job. 17 respondents denied being taught how to take consent in thei r medical t raining.
33% of respondents who experienced gaining consent were supervised and 16% of respondents were formal ly assessed during gaining consent .
Al l respondents were asked to rate thei r confidence level in taking consent f rom 1-10 (score 1, being least confident to 10, most confident (Table 1).
The mean confidence level measured for respondents who gained consent wi th and wi thout supervision is 7.26 and 6.58 respect ively. There is a stat ist ical signi ficance when comparing these two groups (Cri t ical values for 2 tai led T test 1.98, 2 sided P value 0.0036) . We also measured the mean confidence level for those who were formal ly assessed and those who were not whist taking consent . These were 7.26 and 6.64 respect ively. There is also a stat ist ical signi ficance when comparing these two groups. (Cri t ical values for 2 tai led T test 1.98, 2 sided P value 0.0277). (Table 2).
We also asked the survey respondents’ percept ion on what is the prefer red mode of teaching informed consent . The major i ty, 47% fel t that a one to one tutorial session by thei r supervisor would be the preferred mode. 21% of the respondents fel t that an organised tutorial session during their induct ion would be best and 20% fel t that i t should be best taught at Medical School .

Discussion
The North Western Deanery discourages FY1s from taking informed wri t ten consent , yet 144 did so in thei r first 6 months of t raining. Only 61% of this number fel t sui table trained to take informed consent and i t was clear a large number of doctors were regular ly being put in to a posi t ion in which they fel t uncomfor table at car rying out this task.
One aim for this survey was to sample junior doctors from a range of di f ferent medical schools. Where previous studies have been held back by a cohort of junior doctors sampled f rom the same medical school , our respondents came from 25 dif ferent medical schools, el iminat ing the educat ional profi le of one medical school as a bias.
Al though previous studies had cal led for fur ther investment in to teaching medical students and junior doctors in taking consent , juniors are st i l l expressing the same concerns. Despi te NHSLA6 guidance on the t raining of taking consent there st i l l seems to be a lack of clear structure to educat ional programmes and supervision of foundat ion trainees when taking consent . Supervision when consent ing happened for only 33% of FY1s, and formal assessment of this for only 19%. Formal assessment and supervision i tsel f was highl ighted as the preferred method of teaching and of the two, formal assessment al lowed respondents to be signi ficant ly more confident in their pract ice.
When we talk about formal assessment we mean a work-based assessment . The Foundat ion Training Programme in the UK is competency-based and individuals are rout inely assessed through workplace-based assessments. This format ive system can ident i fy deficiencies, problems, and gaps in training7 whi lst also al lowing for posi t ive observat ional feedback. Formal assessment of gaining consent could be done using a Mini CEX or CBD.
As an FY2, the expectat ion to take informed consent wi l l be higher and there is l i t t le to suggest that an FY2 wi l l be more knowledge and prepared than an FY1. Junior doctors need educat ion and assessment during the first year of Foundat ion training before being al lowed to pract ice independent ly in taking informed consent .

Conclusion
FY1s are taking informed consent despi te the associated problems. They report they are breaking the GMC guidance on consent2 by taking consent when not possessing suf ficient knowledge of the procedure and of ten not being supervised.
Those who have been formal ly assessed and supervised when taking informed consent , have a significant ly higher level of conf idence than those who have not .
We recommend greater clar i ty regarding who can and cannot take informed consent . We bel ieve al l FY1s should be supervised and formal ly assessed during the ini t ial stages of gaining consent . A mandatory Mini CEX in the f irst year of foundat ion t raining could lead to bet ter prepared doctors when they become FY2s.

Abbreviat ions
Mini CEX (Mini -cl inical evaluat ion exercise), DOPs (Direct Observat ion of Procedure), CBD (Case Based Discussion), FY1 (Foundat ion Year 1 Trainee Doctor), FY2 (Foundat ion Trainee Year 2 Doctor)

Conflict of Interest
None declared. (Or mention here if any)
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References

  1. Good Medical Pract ice. Relat ionships wi th pat ients; Consent . Sect ion 36. General Medical Counci l 2011. ht tp: / /www.gmcuk. org/guidance/good_medical_pract ice/ relat ionships_wi th_pat ients_consen t .asp
  2. Consent : Pat ients and doctors making decisions together (2008); Responsibi l i ty for seeking pat ient’s consent . Sect ion 26. Consent guidance: Responsibi l i ty for seeking pat ients consent Part 26
  3. Schi ldmann J, Cushing A, Doyal L, Vol lmann J, Symposium on consent and confident ial i ty. Journal of Medical Ethics 2003; 29:2-40.
  4. Houghton D.J, Wi l l iams S, Bennet t J.D, Back G, Jones A,S, Informed Consent : pat ient’s and junior doctors’ percept ions of the consent procedure. (1997) Cl in.Otolaryngol 22, 515-518.
  5. Schi ldmannn J, Cushing A, Doyal Len, Vol lmann J. Informed Consent in Cl inical Pract ice: Pre- regist raiong house officers’ knowledge, di fficul t ies and the need for poast graduate training. Medical Teacher Vol 27, No 7, 2005, pp 649-651.
  6. Consent t raining; Standard 2 Sect ion 10. NHSLA Risk Management Standards for NHS Trusts providing Acute, Communi ty, or Mental Heal th & Learning Disabi l i ty Services and Independent Sector Providers of NHS Care January 2011. NHS Li t igat ion Author i ty.
  7. Car r SJ. Assessing cl inical competency in the medical senior officers: how and why should we? Postgrad Med J 2004; 80:63-66 doi : 10.1136/pmj .2003.011718
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