Trapped in the Chasm: Adequacy of Informed Consent as An Ethical Dilemma for Perinatal Nurses

Problem statement: Adverse events are relatively rare in perinatal settings, making evaluation of care processes an important avenue for improving safety. Nurses provide the majority of bedside management of patient care during labor and birth in the United States. Uncovering nurses’ perspectives on safety may reveal unrecognized threats to safe perinatal care.

Conceptual Framework: Symbolic interactionism

Literature Review: Perinatal nurses conceptualize safety broadly as protecting the physical, emotional, and psychological integrity of the childbearing woman (Lyndon, 2007). However, despite recognition of nurses as central to safety, little is known about nurses’ perspectives on threats to patient safety in inpatient birth settings. Studies in academic emergency departments, critical care units, and birth settings have demonstrated nurses’ direct role in identifying and correcting patient care errors (Henneman, et al, 2006; Lyndon, 2007; Rothschild et al., 2006), suggesting nurses have important knowledge about potential safety threats. Perinatal nurses participating in a larger study identified inadequate informed consent for common obstetrical procedures and medications as a threat to safety and an ethical dilemma. No other studies were identified addressing problem in perinatal care. The purpose of this analysis was to fully describe the problem from the nurses’ perspective.

Methodology: Grounded theory using open-ended semi-structured interviews with a purposive sample of 12 perinatal registered nurses. The sample and results reported here are from a larger study on collective agency for safety in perinatal care. The dimension “informational ethics,” representing problematic informed consent, was identified during simultaneous data collection and analysis for the larger study, using the constant comparative method, dimensional, and situational analysis. Secondary analysis of the data pertaining to this dimension was conducted after primary data collection. Rigor was maintained through reflexivity, data and analytic triangulation, use of a detailed audit trail, peer analysis, and member checking.

Findings: Perinatal nurses conceptualized thorough informed consent as an important property of safe patient care in response to the question, “What does ‘keeping patients safe’ mean to you?” They expressed concern over the quality of informed consent women were receiving. Nurses described consent as highly variable between different physicians, and frequently lacking full disclosure of the risks associated with common obstetric medications and procedures. Nurses’ responses ranged from “cross-counseling,” where they directly counseled patients differently from physicians, to “ensuring her questions get asked.”

Interpretation/Implications for Nursing Practice & Research: Perinatal nurses were in a difficult bind regarding informed consent. They experienced moral distress related to their ambiguous role in verifying that consent was informed, but not being directly responsible for the consent process itself. This distress could contribute to burnout in perinatal nurses and negatively affect nurses’ agency for safety. The gap between nurses’ perceptions of how much information should be provided about common obstetrical procedures and the amount of information that was being provided to childbearing families represents an opportunity for improving perinatal safety and quality. Further research is needed in diverse settings and from the perspectives of both families and physicians. Assessment of informed consent practices could be a fruitful area for interdisciplinary quality improvement.