In response to the experience, Dr. Merrill emphasized that, "As a physician talking to colleagues, I had the best information possible under the circumstances. But it wasn't the same as my hernia repair. The experience brought home to me the realization that the progress of medicine has made informed consent impossible -- even for me" (Merrill 1999: 190). Rationale of Study

Taken together, the foregoing issues indicate that there is an ongoing need for an assessment of knowledge levels of informed consent among perioperative nurses and operating department practitioners. Perioperative nurses and operating department practitioners, though, are frequently subjected to an enormous amount of stress in a fast-moving and hectic environment, diminishing their ability to provide the level of informed consent counseling that patients need and deserve. According to Salas, Bowers and Eden, "All individuals are susceptible to what is known as human performance limitations. Many health care workers fail to recognize that their abilities may be limited, particularly when they are fatigued, unwell, or otherwise stressed" (2001: 268). These issues are particularly pronounced among anesthesiologists, surgeons, anesthetic nurses, and surgical nurses (Salas et al. 2001). Therefore, by identifying current areas of deficiency in the understanding of informed consent requirements and responsibilities among perioperative nurses and ODPs, timely interventions can be formulated to address these issues so that they will be better prepared to provide their patients with the type of informed consent counseling they need, even during periods of stress and fatigue.

Overview of Study

This proposed study will use a five-chapter format to achieve the research purpose above stated. Chapter one will be used to introduce the issues under consideration, as well as a statement of the problem, the purpose, importance and rationale of the study. Chapter two of the proposed study delivers a critical review of the relevant and peer-reviewed literature concerning informed consent requirements and the specific legal and ethical responsibilities of healthcare providers, including nursing staff. Chapter three will be used to more fully describe the study's methodology, including a description of the study approach, the data-gathering method, the database of study consulted, and the subjects to be used in the study. Chapter four will consist of an analysis of the secondary and primary data developed during the research process and chapter five will present the study's findings, including a summary of the research and recommendations.

Definition of Key Terms

NHS: National Health Service

Operating room practitioner: According to Corbett (2009), "Operating room practitioners are a highly professional group, working behind the doors of an environment that is unfamiliar to the public. It is also new to some nursing colleagues who have never before been exposed to the three main areas of patient care: the anaesthetic room, operating room and recovery" (2009: 37).

Perioperative nurse: A perioperative nurse (or in some settings, also called an operating room nurse), is a member of the surgical team who is responsible for providing care to patients prior to, during and following the completion of their surgical procedures (Novotny, Lippman, Sanders & Fitzpatrick 2003).

CHAPTER 2: REVIEW of RELATED LITERATURE

Chapter Introduction

This chapter provides an overview of informed consent and why it is important in any healthcare setting, followed by a discussion concerning various cultural factors that should be taken into account during the informed consent counseling process. Finally, a review of the informed consent requirements for nurses and operating room practitioners in the United Kingdom is followed by a brief summary of the chapter.

Informed Consent Overview

Nurses have always been involved in obtaining informed consent from clients undergoing diagnostic tests and various interventions. Involvement of nurses in obtaining informed consent from subjects for research protocols/studies is more recent. There are no obvious differences in the legal standards for obtaining informed consent for the purpose of therapy/treatment or research; however, the character of consent provided for therapy differs...

Clients are offered therapy/treatment when there is substantial evidence that they will benefit directly; however, clients are solicited to participate in research studies that may not directly affect their well-being (Lee & Thomas-Lawson 2001).
According to Tobin, the informed consent required in order to provide any type of medical treatment, including surgery, and the process is comprised of three key components as follows:

1. Communication of necessary information which includes three essential elements: (a) the risks of the proposed treatment, (c) viable alternative treatments, and (c) likely outcomes in the absence of treatment;

2. Comprehension of that information by the patient; and,

3. Subsequent consent to treatment (2008: 111).

Although every patient and treatment setting is unique, these elements are common to all informed consent procedures administered by the perioperative nurse (Tobin 2008). In addition, Lachman emphasizes that, "Legally, informed consent is a requirement, unless there are extremely specific circumstances, especially if the person meets competency requirements" (2006: 37). In other words, if people are competent, they have an inalienable and fundamental right to make decisions about their medical treatment, violations of which can carry severe consequences for the healthcare provider. According to Siegel, "Medical ethics and tort law enshrine patient autonomy at the heart of the informed consent dialogue" (2008: 1694). This means that the healthcare provider must ensure that persuasion is not used as a means of coercing a patient to agree to a surgical procedure even if all evidence-based practices indicates that such intervention is needed and may spell the difference between life and death. Rather, Siegel maintains that for the perioperative nurse, "The goal of informed consent counseling is not to intervene in a patient's understanding of her own self-interest, her family's interest or the appropriate balance between them (e.g. whether to risk cardiovascular surgery that might improve quality of life but poses a threat to longevity or whether to undergo chemotherapy that might increase longevity but reduce quality of life). Instead, a professional seeks to provide the patient information about possible benefits and risks of various courses of treatment that would enable the patient to make the medical decisions that -- in her judgment -- best serve her own self-interest and the interests of others dependent upon her" (2008: 1695).

Perioperative nurses and OPDs are just human, of course, and may unknowingly and unintentionally present a compelling argument in favor of a given intervention to the point where the patient's preferences are overridden in favor of the intervention favored by the healthcare providers and the treatment team. In this regard, King and Moulton (2006) note that this tendency can be problematic in a significant percentage of cases: "Around one-third of all medical decisions should depend largely on the values and preferences of the patient, rather than the norms of physician practice. Patient preferences for information disclosure, risk taking, quality of life outcomes and tolerance of side effects differ greatly amongst the patient population, yet variations in treatment decisions often do not reflect differences in patient choice" (2006: 429). Moreover, withholding important information concerning potential alternatives, including doing nothing at all, are contrary to the tenets of informed consent. As Calloway points out, "In cases where patient lifestyle, personal preferences and values are indicative of the most appropriate treatment choice, [clinicians] are not in the best position to make treatment decisions and should not limit disclosure of alternatives" (2006: 429).

There are some sound reasons for the informed consent requirements as well that may or may not be required to be reduced to writing, but which must nevertheless be clearly communicated between practitioner and patient. In this regard, Cobb notes that, "Disclosing information relating to patient treatment enables the patient to knowingly consent to - or to reject - the treatment that the healthcare provider is proposing. The informed consent paradigm should not be solely relegated to a simple form, although written confirmation to the patient to memorialize the process is always advisable" (2005: 330). The foregoing requirements and considerations are fairly straightforward and can be used as a useful framework in which the informed consent process is applied and for what purposes, but there are some other factors involved in the patient-clinician relationship that may affect the informed consent counseling process, and these issues are discussed further below.

Cultural Issues and Informed Consent

Although legally and ethically required, there are some important cross-cultural issues involved in the delivery of informed consent protocols that can affect the perioperative nurse-patient relationship based on fundamentally different worldviews. In her recent study, "The Effect of Culture on Beliefs Related to Autonomy and Informed Consent," Calloway reports that, Our personal world has become a global one and the impact of various cultures causes us to reflect on many previously held beliefs related to autonomy and informed consent within a multicultural framework" (2009: 69). In an increasingly multicultural society such as exists in the United Kingdom today, these are particularly important issues for perioperative nurses and OPDs practicing in National Health Service facilities where a wide range of cultures are represented. It is therefore important for clinicians to understand how these…