Nhs students and lack of consent.

[MarbleQueen]

I’m wondering if something has changed within the Nhs. At one time you were asked if you minded having a student being present.In my area they are present at every appointment without any discussion and I’m getting fed up with it.

In the last two years these things have happened.

A student midwife was brought into my room and participated in my delivery without any discussion. She was instructed to break my waters and deliver my baby without any discussion with myself. The midwife focused on talking her through things instead of supporting me. I was alone because of covid restrictions. I later discovered it was the first baby she delivered. I felt like a piece of meat.

I went for a smear and when I walked in the room there was a nurse and 3 very young women present. When I asked who they were I was told they were trainee health care assistants. I objected and the nurse insinuated I was being a bit silly and shy. I left that appointment without it being done.

I had a dentist appointment for my first ever dental treatment. I told them I was nervous. Again when I went in, I was told, not asked that the 2 people present were dental students and would only be observing. The dentist focused on explaining things to them and actually allowed one to place the filling. I didn’t agree to this.

I went to a gp apointment for something intimate to find a man around 18 years old sat in the room. Again I had to ask who he was and was told he was a student. I had to ask for him to leave and it was really uncomfortable.

I had an apointment to have a very unpleasant procedure. There was the usual student perched in the corner without any discussion. Again I had to ask who they were and was told, not asked, that they would be observing. The doctor focused on explaining things to them and when the procedure was finished I actually realised 3 more students had been brought in to watch without me noticing.

I have previously had a type of abdominal cancer. I have checks with scans and have seen the same consultant for years. On my last visit there was the usual student perched in the corner without any discussion. On this occasion, and this occasion only, the surgeon suggested doing a VE. I asked him what information he was hoping to get from this considering he had a recent MRI scan in front of him and he simply dropped it. I strongly suspect this was going to be for the students benefit because it certainly wasn’t going to benefit me.

Each of these places have standard notices in their waiting rooms informing you that a student might be present but this is not consent. I think this is now something you have to actively opt out of instead of opting in.

Has anyone else noticed this happening? I worry about what these students are learning about consent in these circumstances.

@mbosnz

from what you've said, you feel the onus is on you to ensure you give informed consent, as a patient?

As said

Practitioners aren't mindreaders, we can use all the best clinical judgment in the world but as per the clearly fictional example (but poss real situation) i gave you. It isn't perfect

Patients need to be honest when the question of informed consent is asked.

Informed consent needs to be asked

Communication is vital

I'd rather student is in the room when I'm asked, i'd ask that if they weren't ... however people were clearly up in arms when i said how if you are uncomfortable with student being present for qs being asked/appointment, let them know. Then obviously at appoointment incormed consent would still be asked

What's the difference between me being willing to begrugenly adapt to having to ask the potential student to be in room so i can decide ... And people having to adapt to having to ask if student is not there for informed consent qs ?

Then there's your average lot who wouldn't care there's 1 potential extra in room at standard appointment

....

‘Consent is a constant thing, and should be sought at very new interaction.‘

This is the right way to do it. This is why I previously said all this guilting of OP is a bit rapey. It’s a violation to treat people as mannequins, like they owe you their body to practice or observe their on. Consent not freely given is not real consent. There is a huge entitlement problem with surgeons, they freely discuss on open forums how they feel like they don’t have to ask consent for their student to do pelvic exam on anaesthetised woman cause the surgeon is cutting your abdomen up anyway later.

[quote HonestwithHope1]@mbosnz

from what you've said, you feel the onus is on you to ensure you give informed consent, as a patient?

As said

Practitioners aren't mindreaders, we can use all the best clinical judgment in the world but as per the clearly fictional example (but poss real situation) i gave you. It isn't perfect

Patients need to be honest when the question of informed consent is asked.

Informed consent needs to be asked

Communication is vital

I'd rather student is in the room when I'm asked, i'd ask that if they weren't ... however people were clearly up in arms when i said how if you are uncomfortable with student being present for qs being asked/appointment, let them know. Then obviously at appoointment incormed consent would still be asked

What's the difference between me being willing to begrugenly adapt to having to ask the potential student to be in room so i can decide ... And people having to adapt to having to ask if student is not there for informed consent qs ?

Then there's your average lot who wouldn't care there's 1 potential extra in room at standard appointment

....[/quote]
I would say the difference, is in the imbalance of power.

The patient is in the medical practitioner's room, on their turf, their place of authority. With their student. So, it's two against one. It's being effectively presented as a fait accompli, that a patient could potentially feeling they're going to be judged, or upsetting the apple cart, if they don't go along with the status quo as it's being presented.

Many people feel vulnerable when seeking medical treatment, insecure and unequal to the person that has the knowledge and the power in that situation. It's simply adding to the inequity of the situation.

@AutomaticMoon

Don't get me started on sweeps!!

I've had 4 children, I know what a sweep feels like. I was examined in my last labour and despite verbalising it moments before the examination and despite it being written in my birth plan, the midwife did a sweep. I know this because when I asked to her why have you done a sweep? I've not consented to that.

She told me
'Well I was there anyway so just thought I might as well.'

@mbosnz ‘Many people feel vulnerable when seeking medical treatment, insecure and unequal to the person that has the knowledge and the power in that situation. It's simply adding to the inequity of the situation.’

That’s exactly it, for some people who have chronic illness or struggling to get a diagnosis or MH problems and have no quality of life, it’s a life and death matter. There’s a huge imbalance there but it seems as only a v small minority are aware of this fact

@mbosnz

But I'm still having to be out of my comfort zone as a patient having to ask the student to be in room for consent question.

... If i have to be out of my comfort zone because the blanket rule is no students exist in room (until consent is asked) due to others feeling uncomfortable not able to ask students to leave the room for the answer to consent question (and possibly the appointment) ...

How is that taking into account my needs ?

This is what I mean. It's complex.

@AutomaticMoon

But there's an imbalance of power making me feel uncomfortable having to ask for their student to be present before i can make informed consent. ...

@RegardingMary She thought she might as well!🤦🏻‍♀️ The entitlement of it is astounding.,Like she was doing you a favour and sweeping the floor! I’m sorry I don’t have children cause of ptsd and Tokophobia so not sure what a sweep is but I bet it’s not a favour to you since you requested NOT to have it 😞 At this point I’m starting to think that it’s true that 30% of people are authoritarians, v demoralising

“I would say the difference, is in the imbalance of power.

The patient is in the medical practitioner's room, on their turf, their place of authority. With their student. So, it's two against one. It's being effectively presented as a fait accompli, that a patient could potentially feeling they're going to be judged, or upsetting the apple cart, if they don't go along with the status quo as it's being presented.

Many people feel vulnerable when seeking medical treatment, insecure and unequal to the person that has the knowledge and the power in that situation. It's simply adding to the inequity of the situation.”

You could say that about anything though, patients may feel like they’re going to be judged if they refuse anything the HCP asks consent for, simply because of the perceived power imbalance there. Consent should be freely given without pressure, if there is no actual pressure or consequences for declining and consent was given then that’s valid consent. We can’t read minds, we never know what someone is really thinking or why they’re giving consent, all we can do is ask for consent and make sure that we aren’t doing anything that pressured them into agreeing, if someone happily agrees then we have to take that as consent. It’s up to you as an individual to speak up if you don’t want to consent, you can’t consent to something and then later complain your consent wasn’t valid because you imagined there would be negative consequences for your refusal when in reality there would have been none.

Some people would prefer to see the student before consenting and others wouldn’t so as HCP what are we supposed to do when everyone is different? We have signs everywhere saying students may be present and you have the right to refuse, so if we ask you to consent to a student being there and you happily say yes with no hesitation how are we supposed to know that you weren’t happy for the student to be there?

There is a compounding of the inequity, with two medical professionals (albeit learning), already located in the room, prior to the patient being admitted to the medical professional's place of work - their turf.

There is no compounding of inequity with you being enabled to request a person who is not yet there, to become present, prior to you making your decision.

And yes, if there are signs up, saying that students may be present, then the onus is on the patient to say at the time of reporting to the clinic that they do not wish for students to be present at their appointment. And the onus is then on the practice to ensure this is communicated to the practitioner and students, and that this is respected by them.

If there are no signs up, then this should still be clearly communicated at the time of reporting to reception, as far as I'm concerned, and then the patient can say no students, or can say, I want to see the practitioner and the student before I made a decision.

Patients aren't mind readers, either, and they're often in something of a tizzy when they get there, one way or another.

@RegardingMary ‘MrsDeanWinchester75

Mine did, she said she was checking how I was progressing and whatever she did hurt so much I burst into tears, she then said she'd done a sweep.
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16/03/2019 23:17 StyleOfTheTimes

I had a midwife do the exact same thing to me. She was supposed to be checking how far along I was and was basically elbow deep inside me as I was trying to crawl up the bed in agony. Once she’d given up I said I didn’t think an examination would hurt so much she then told me she’d “tried to give you a sweep” never asked for one she never said she was going to do one.
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16/03/2019 23:35 ZippyBungleandGeorge

Mine said she was checking progress but did a sweep, it hurt so much I nearly kicked her’

Apparently it’s a common thing. They’re supposed to ask consent as it’s invasive procedure.

@RegardingMary ‘Membrane sweeping should never be done without the explicit permission of the birthing person. But membrane sweeping is an invasive medical procedure meant to ripen the cervix or induce labor contractions, and it should never be done without an informed consent discussion. ...‘

The birthing person 🙄

@AutomaticMoon

No. You took a swipe at the NHS for bringing it in overnight in 2020 and you had no idea, no warning etc.
It was a new law that was in the news for literally years before it happened. So how was it the NHS? And how did they do it with no warning

@mbosnz

There is no compounding of inequity with you being enabled to request a person who is not yet there, to become present, prior to you making your decision.

Yes there is. I am a physically vulnerable disabled woman with MH issues. Why should i be distressed at speaking up re needing to see student, manouvere a wheelchair potentially to make way for another person in room ect

All because other people want a blanket ban on students in room before consent qs is asked??

Neither 'wins'

Which is why I don't get people freaking and literally insulting me on here when i suggested communication

before appointment if you don't feel you can answer question with student there ...

Same for me. I'd recommend I communicate my wishes pre appointment.

Which I've been told to do yet the above example is apparently outrage worthy ...

Just one other thing, assuming that signs being up is sufficient, is assuming that everyone is able to read and understand those signs - which is not an assumption we should make, and certainly not in such circumstances.

So perhaps the onus remains with the practice to ensure that each patient is verbally informed at reception, and as far as is practicable, that they understand?

Okay, let me put it another way. If the student is already in place, it presents an appearance of assumption of consent. Surely the default should be an assumption of lack of consent, until consent has been given, and this is the situation as it should be presented?

@Isthisprivate

Plus I love it when they explain loads of stuff to the student as I get to know so much more about the process, which fascinates me.

I once forgot they weren’t teaching me and started asking questions about the process too 😂

I love that.

I’m a qualified nurse learning a new role, I always ask if it’s ok to stay and observe/participate. I also ask when I’ve had my own students.

Med students sometimes seem to think its odd when I say unless they have documented consent from the patient then they are not touching them when the patient is anaesthetised.

Sorry, misphrased that comment “some med students think….”

I’ve always been asked if I mind having a student in and you should always be asked that question.

The thing is you can’t please everyone, some people want to see the student before agreeing others don’t. You could argue without seeing or meeting the student who they are agreeing to let into the room then the patient doesn’t have all the information needed to give consent for them to be present, because they don’t know who they are allowing in to the clinic room until after they have consented.

Patients may (and often do) incorrectly assume a student nurse means a young female and then a middle aged man walks in, in that situation I think it would be significantly more embarrassing and uncomfortable for most people to then revoke consent upon seeing the student than it would have been to ask the student to leave the room so they could discuss it with the HCP and then refuse. All you need to say is “can I discuss this with you in private first?” to the HCP if you really don’t want to refuse in front of the student.

I think if you’re particularly nervous or sensitive about this topic it’s best to tell the person at the desk or call ahead first, or if possible bring someone with you to advocate for you, because as HCP we aren’t perfect and one size doesn’t fit all. If we change the policy to suit one group of patients another group isn’t happy and complains.

I was a nursing student 3 years ago, when I was doing placements in general practice, for anything like smears the nurses would go and fetch the patient from the waiting room and ask them if it was OK while I wasn't present, so people didn't feel pressured to say yes.

On wards it wasn't really an issue unless I was doing a procedure, in which case they would always check the patient was okay for a student to do it. Normal day to day care wasn't consented in any different way than it would be if an HCA or nurse who worked there did it.

Back in the day (not that long ago) students would be left in charge of their patients on a ward and do pretty much everything. In the 60s and 70s it was more like they were left with a whole ward, overnight!

OP, the experiences you have had are mostly stepping over the line because of the intimate nature. There's no way anyone should be observing or participating without your consent and understanding of why they are there.

@Itsalmostanaccessory Why are you being wilfully obtuse? They could have easily sent a text out to everyone to say ‘you’re organ donors’. Why do you feel personally attacked by this? I already said I was trying to not commit suicide and was advised by a MH professional to avoid the news.

I was troubled with attitude at a recent GP appt. I phoned for an appt and was told it would be a phone consultation unless I agreed to a medical student appt with GP supervision. Clear intention that if I wanted face to face I had to accept a medical student.

Patients may (and often do) incorrectly assume a student nurse means a young female and then a middle aged man walks in, in that situation I think it would be significantly more embarrassing and uncomfortable for most people to then revoke consent upon seeing the student

Then the answer surely is “Do you mind if a female student observes?” or “Do you mind if a male student observes?” rather than shoving all the responsibilities onto patients?

Especially when the most vulnerable patients are the ones least likely to feel able and confident enough to object in front of said student.