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.

@Promleafyus

Okay I mean repeating the same thing over and over doesn't really help. The issue of consent overall is a lot deeper in MH care settings when the majority of patients haven't actually consented to being there anyway, but by the by- interested what alternative for having mental health nursing students around mental health patients you propose whilst they train?

You are a bad faith poster. I've answered your question. You can prattle on all you like as if its a 'gotcha'. I don't think you are looking for the answer. I think you are trying to beat people with a stick to comply and submit to something they are uncomfortable with 'for the greater good' (said in hot fuzz tones).

If the NHS hadn't got itself in such a mess over consent and wasn't so oblivious to the needs of people (women in particular) who have had traumatic experiences, trust might well have not been lost in the first place. This is the nub of the issue.

You don't regain trust by coming out with emotional blackmailing. You rebuild trust by institutional level cultural change.

That ultimately requires people to say 'hang on a second, wtf are we doing tolerating the current system and why aren't we overhauling it completely?' 'Why are we making it a big deal that certain practices about requests over students are utterly outdated?' 'Why are students shadowing doctors in particular situations in large groups?' 'Why are students shadowing doctors, when they aren't actively participating, when the logistical practicalities of being stood in the corner of the room, mean they get no benefit?' 'Why are we teaching students about bedside manner with patients at all? Is this something we could do in other ways?'

As I will keep saying, the onus keeps being put back on patients in a way that applies undue pressure - including asking patients to come up with alternative ways to train doctors it seems.

Its so reminiscent of the culture of victim blaming, I find it disturbing.

@Latara

When I've recently had psychiatrist or psychologist appointments recently I've been asked if students can attend. I say yes or no depending on how I feel at the time. For example there was a trainee police officer and I refused because I felt paranoid around the police at the time but recently I said yes to a trainee psychologist because she seemed quite alright.

You know you can always withdraw consent DURING an appointment or procedure too if you are not comfortable with the student.

Easier said than done. Sadly.

YANBU - I say this as a Healthcare Professional. I regularly have already Qualified Post-Graduate Students come to undertake placements within my clinic, not only do a pre-warn my patients and allow them the opportunity to reschedule, but on the day, I then ask each and every one of my patients if they are happy for the student to observe, and if appropriate to undertake their examinations which are not intimate in any way. Some don't want to be observed, some are happy to be observed but not for the student to undertake the assessment, some are happy for the student to crack on under my supervision. Every single person should be able to give informed and unbiased consent. If someone is in no fit state to consent, then in my opinion the student should not participate - I feel very strongly about bodily autonomy and my role as a patient advocate. I would be disgusted to play any part in a situation where someone felt that they could not speak up for themselves or felt pressured into agreeing to something they were not comfortable with.

As a patient I am more than happy for students to participate in pretty much any aspect of my care, as is my right to consent to. But nobody should feel bullied into it. As students, whilst opportunity is sometimes thin on the ground, you expect that some people will not want you to participate, and it forms a huge part of our education as healthcare professionals about balancing the best interests of the person with their capacity to consent. I'd argue that unless I was about to bleed out everywhere, and the rest of the medical team had been murdered leaving only the student capable of saving me, that it still wouldn't be in my best interest to violate my consent in almost every situation to put it bluntly. Students can't become confident and competent practitioners in their own right if they're enabled to ride roughshod over a persons' bodily autonomy.

I wonder how many agree to it when they wouldn't ordinarily

And when 'consent' is obtained in that manner how can it be true consent? It's really unpleasant actually- apply that to another situation where someone may feel vulnerable and they are being pressured to consent. And that is where we appear to be in some areas of the NHS.

However if I did manage to get there I would not be happy about students being there but DH not being allowed to support me.

This is such a good point- people haven't even been able to have support from a loved one when being told the most devastating news about their health during the pandemic- yet it's ok for medical students to be present, increasing the number of people?

Yes they have to learn (not the job of the patients to figure out how this is best done btw) but once again- it's all about what suits the medical profession and the NHS and nothing to do with what is best for patients.

@Orangesox

How do you think we should manage students in areas where very few patients have capacity (say PICU or a forensic ward)?

@LumosSolem

it's all about what suits the medical profession and the NHS and nothing to do with what is best for patients.

Sums up the current state of the NHS perfectly really.

@RedToothBrush no I am not, if anything you are twisting things and not reading posts properly. You are obviously ignorant to mental healthcare settings and the training nurses do who go on to qualify as nurses in this speciality, so perhaps just don't comment on stuff you don't have a clue about :)

I agree OP, fortunately (it should be standard so it's sad I feel fortunate) I have always been asked and had my wishes respected, but this should absolutely be the case across the board without any exceptions. Although I can see how some mental health settings can be more complex- many don't consent to being sectioned at all let alone particular treatments and members of staff who they see; although there must be tight guidance that considers this surely?!

[quote Promleafyus]@RedToothBrush no I am not, if anything you are twisting things and not reading posts properly. You are obviously ignorant to mental healthcare settings and the training nurses do who go on to qualify as nurses in this speciality, so perhaps just don't comment on stuff you don't have a clue about :)[/quote]
Yeah whatever. Im just a patient.

I've already said its about trust and a failure on the part of the nhs to build that up from the ground up.

Many mental health patients are the result of systematic failure and a breakdown of trust much earlier in the NHS system than when they reach a ward.

Patients continue to have rights over consent even when incapacitated. If your answer to consent not being duely considered, obtained and part of a due process of assessing whether a patient is in a state to feel able to object or because you think training is more important than rights, then you are asking the wrong questions and aren't taking the problem seriously. Freely given consent remains just an inconvenience to you that can be ridden rough shot over. As I say I find it disturbing that rights (and consent is a right rather than a desire or want) are deemed lesser than medical students. If your culture is to ignore the issue and use emotional blackmail to say 'well if you don't put up with the way things are then there will be no doctors', then your entire culture isn't right.

And beside that I certainly don't trust you.

Think about how you regain trust and rebuild it. Its certainly not through 'questions' like the ones you've been asking. Your 'questions' are actually closed statements because instead of saying 'how can we improve the situation for patients?' you immediately through in the barrier of 'but what about the staff needs?' which sets up a particular chain of conversations which centre the doctor not the patient.

What you need to do is say 'what does this patient need? What are their rights?', first and foremost without cavets or conditions and then work backwards from that and say 'this is a patient with trauma - are they suitable for students at all? Do we think they would be ok with a build up to that over time and how would we guide them through that? Etc etc.

If your starting point is about the staff, you miss the point.

You balance competing rights against each other. You dont balance rights versus desires. If a patient just isnt up to a student then their right trumps everything.

Even when it comes to mental health there will be people who just aren't arsed. But you also have others for whom putting the educational needs of a student first can ultimately be harmful.

I don't know why this is a difficult concept to get.

A patient with systematic distrust of hcps isn't the person to be training on. Full stop.

How you frame a question matters. It will elicit certain responses if you constrain it or set up certain limitations of thought.

Honestly, for me personally, they can have a whole room of students in there, they have to learn, much as the medical staff before them did.

[quote JennieTheZebra]@Orangesox

How do you think we should manage students in areas where very few patients have capacity (say PICU or a forensic ward)?[/quote]
Interesting question - thank you for asking! Having working on PICU and long-term BPD rehab prior to training as an adult nurse, I think there's a time and a place for student intervention and all the nurses that I worked with seemed to feel the same way based on my interaction with them. I also returned to my old wards whilst undertaking my alternative placement during my RNA training - even though I had worked on those wards, and knew some of the patients still, I still asked for their consent as to whether I could observe deeply intimate and personal aspects of their care.

Our students joined us initially undertaking a HCA capacity to get the lay of the land, ward routines, observed ward round if patients were happy for them to sit in, or discussed the ward round afterwards if they weren't present, before becoming more involved in the individual care of specific patients. As you will know, capacity is not binary, and whilst someone may be detained under the MHA and therefore have limited capacity to make decisions about the place of their care or treatment, they should still be involved in decisions about their care wherever possible, and usually will have the capacity to decide if they're happy for a student to observe their 1:1 sessions with their named nurse, to make their feelings known about whether they're happy for a student to be involved in close obs or accompanying them on S17 leave if applicable for instance.

I know my views are quite contentious though... so I'd be really interested to hear your views on it if you haven't already expressed them? If you have, my apologies I will go back and read through the rest of the replies.

I’m really surprised some people think I’m a baby about the dentists.

My dentist knew I was really nervous. I’ve previously had a jaw injury so it’s painful to open my mouth wide for any period of time. The dentist knows this.

My dentist waited till I was flat on my back with a light shining in my face with instruments in my mouth then invited the student to get involved. I could not do a thing about it. The student banged something against my front teeth as she tried to do it, she was shaking. When you can’t get something into someone’s mouth without banging instruments against their front teeth you shouldn’t be near patients.

The whole process took far longer than it should have and who on earth would have students involved in a nervous patient having their first treatment.

I previously liked and trusted this dentist and now I don’t want to go back. Nhs dentist are not taking on new patients in my area so I don’t have any other options apart from paying privately and I can’t afford it.

I’m also reluctant to make a complaint about her. She’s already demonstrated shes not to be trusted and doesn’t give a shit what I think. I feel I’ve got limited options here.

@Hadjab

Honestly, for me personally, they can have a whole room of students in there, they have to learn, much as the medical staff before them did.

I personally don't mind either. But I reckon there's not enough of us who don't mind to make consent viable when they're relying on unpaid students to make up the workforce. So they don't ask. That's wrong. It's not the student or the training that's the problem for me, it's the not asking. But if they ask and you say no, they'll have to find more paid staff and the government aren't having any of that.

It's broken and wrong.

@MarbleQueen I'm surprised too- I really, really struggle with the dentists. I'd rather have a smear test, I hate it that much! But again that's me- I really struggle with medical stuff in general though. Sometimes gynae I can cope with purely because I have never not had the option to be seen by a female HCP. And have only managed smear tests/colposcopies because of choosing a female HCP. Had male consultants do a colposcopy and LLETZ treatment before and it was awful. Never again. I'm putting off going to the GP about something really difficult for me atm because if I need to go to the hospital I don't think there are any female consultants who work in that area. I can't contemplate certain investigations etc being done by anyone other than a female HCP and no way could I deal with students observing.

I agree with all of @RedToothBrush posts.

If your starting point is about the staff, you miss the point*

@Orangesox

I largely agree with you. I think that service users should be assisted/encouraged to express their opinions on their care as much as possible and that respect and dignity is something that everyone is entitled to-and of course this includes consent to all aspects of care including student involvement. I think what I’m having trouble with is that some people on this thread have implied that MH settings should have no student involvement at all. I know that some of the skills I have I couldn’t have learned in any other setting, but I also don’t want to jeopardise consent. It’s really tricky.

@GreenWhiteViolet

Are there really people who don't understand why some women might not want students observing their gynae appointments?

If I were at such an appointment, I'd be panicky and probably in tears at the thought of getting undressed in front of a stranger. I'd insist that the practitioner was female. I'd be consenting to the examination/procedure, but very distressed by it. Can you see why I might not want extra onlookers, be they students, experienced doctors or anyone else?

I can understand that women with different views and life experiences from me would be totally fine and not mind at all who was there. Is it so hard to imagine that not everyone is like you?

A woman’s primary duty in life is to service the needs and wants of others. She has no humanity of her own.

I think what I’m having trouble with is that some people on this thread have implied that MH settings should have no student involvement at all.

Yeah I'm not sure how that would work either, surely it would be a huge risk to have nurses first enter a ward upon qualification and have the responsibility of their pin etc!

@Croissantly

I think what I’m having trouble with is that some people on this thread have implied that MH settings should have no student involvement at all.

Yeah I'm not sure how that would work either, surely it would be a huge risk to have nurses first enter a ward upon qualification and have the responsibility of their pin etc!

Do you deal with mental health on mental health wards first?

Hmmm.

Also.

Patient with a history of trauma and anxiety. Theres no automatic way to flag a patient as unsuitable for training. So patient turns up for a smear and gets put in a situation which should never have occurred in the first fucking place.

@JennieTheZebra I think what I’m having trouble with is that some people on this thread have implied that MH settings should have no student involvement at all. I know that some of the skills I have I couldn’t have learned in any other setting, but I also don’t want to jeopardise consent. It’s really tricky.

I completely agree that that is preposterous; one cannot be expected to gain sufficient experience in their field in order to be able to qualify as a RMN / RNMH without having gained a broad based experience. I think the key factor is that there are degrees of involvement, and a blanket ban would be detrimental to both ongoing patient care and practitioner education.

I personally feel that if you have been open and honest with service users that you are a student, and you have respected their wishes if they directly state that they do not want you there or to be involved if the person has capacity to consent, and you have considered whether the privacy, dignity and autonomy of the person has been maintained as far as possible if they do not have capacity to consent, then you're not jeopardising consent. As you will know, many service may not be able to fully advocate for themselves on admission, particularly to PICU, so it's all a balancing act. You might find it helpful to spend some time with an IMCA as part of your studies if this is something that you're interested in.

Sorry I'm not sure what you mean, mental health nurses wouldn't be doing smear tests? Yes I agree that everyone should be given a choice without any coercion, but the poster was saying about mental health nurses and placements.

Thank you @Orangesox your posts have been very insightful and interesting.

I’m getting more and more worried. I’ve got a gynaecology appointment coming up and it definitely will involve being examined. I’m already stressed and upset about the condition I’ve got and the prospect of being examined without having to worry about being ambushed on the day by students.

I’ll phone ahead and speak to the receptionist on arrival too.If the receptionist makes a note of it will the doctor see that before I go in?