Consent in the context of health assessment is a process that begins with provision of information regarding the nature and purpose of the intended exam or procedure. Essential components of the process are that the patient is fully informed by the healthcare provider of exam or procedure details; consent is given freely; and the patient is of sound mind to consent. Initial consent may be withdrawn at any point. Thus, the consent process does not end with initial consent but rather at the conclusion of the exam or procedure.¹

Although consent for invasive procedures or treatments has long been standard in healthcare, consent for invasive assessments has been less defined. Trauma-informed care principles highlight the need for consent prior to pelvic exams in practice settings.² These same principles are applicable to educational settings in which the consent process for invasive exams is the most undefined.

An overheard conversation in the clinical setting between students from another discipline led the student author to question the consent process in teaching environments. Discussion with peers and faculty led to an exploration of the history of various teaching methods including the practice of pelvic exams on anesthetized patients. This article explores the consent process for pelvic exams performed by students with surrogate patients in learning environments and actual patients in clinical precepted settings.

Surrogate patients

Use of surrogate patients enables students to develop the essential motor skills to adequately and safely perform physical examinations.³ A systematic approach to the consent process in the context of educational experiences is needed to protect the autonomy of the surrogate and provide practice and reinforcement for students in acquiring consent from patients.⁴ The consenting process with a surrogate patient should mimic obtaining consent in the clinical setting.² Surrogates may go through two consenting procedures: the first when they are hired to allow for a mutual understanding of the role, and the second during each interaction with a student or with each intervention.

The first consent process with surrogate patients should include information about the encounter, student interaction, and the expectations for the student’s consenting process. The surrogate should be educated on the pillars of consent (autonomy, justice, beneficence, and nonmaleficence) and the ethical considerations with each.² This knowledge allows for the surrogate patient to give feedback on the adequacy of the consenting process with the student.³ The second consenting process, occurring with each student interaction, should be viewed as a part of the experience and equally as a point for education. The surrogate patient must be regarded in the same manner as a patient in the clinical practicum setting to allow for the full extent of education for the student and the ethical responsibility to the surrogate patient in respect of their autonomy.⁴ The experience is immensely beneficial, as it provides clarity on the process for obtaining consent for invasive exams.

Clinical practicums

Learning how to perform pelvic exams during the clinical practicum calls into question benefit of the patient while still allowing for needed learning opportunities for future providers.³ A standardized consent process can unite these priorities.

Obtaining consent from patients in the setting of clinical practicums adds to the dynamic of the student’s learning experience while ensuring the patient’s wellbeing and clinical needs are being adequately met.⁴ Consent must first be seen as an indispensable and continual process during any interaction with a patient, but especially during invasive examinations. It must also be understood that consent only applies to a specific intervention, not in a blanket fashion for the entire appointment and can be rescinded at any point.⁵ Consent for the student to be integrated in a patient’s care does not automatically assume consent to perform a pelvic exam.⁵ Each portion of the patient interaction requires specific consent.

The process of obtaining consent should be done by the student whenever possible to allow for transparency. The student introduction and consent process must include the following:

• Share full name and discipline—Example. My name is Jane Doe. I’m a registered nurse and a women’s health nurse practitioner student at XYZ University.
• Provide an explanation of the aspects of care in which they will be involved. Clearly state the collaboration of the student and supervising preceptor/clinician in each aspect of care.⁶ Example: With your consent, I will perform the pelvic exam, then share my findings with my preceptor.
• Ask patients if they have questions. Encourage them with discussion on the importance of their understanding and that questions are welcomed. Example: If at any point during the exam you have questions, please do not hesitate to ask.
• Obtain a clear “yes/no” response for each aspect of care for which the patient agrees to have the student involved. Example: Everything looks normal and healthy on the external part of the exam. May I proceed to the internal part of the exam?
• Remind the patient that consent for student involvement can be removed at any time throughout the exam. They can reverse a yes decision to a no decision at any point in the exam. Reassure them that they are fully in charge of who is involved in their care and to what extent. Example: If at any point you change your mind about allowing the exam, say stop and the exam will end.

This approach ensures the patient is fully informed and has clarity on proposed student engagement.⁶ Each of the mentioned components are essential in respecting autonomy of the patient and complete informed consent.

Conclusion

Patients often describe pelvic exams as high anxiety experiences during which vulnerability is apparent. Learning how to complete proficient pelvic exams is also a source of anxiety for students. There has been great debate over the best way for students to gain the skill. Historically, anesthetized patients and cadavers have been utilized.² Methods of education that include both surrogate patients and patients in clinical practicums along with a standardized consent process can effectively replace these prior practices and the potential ethical dilemmas that can accompany them.³ A thorough consent process leads to a fully transparent environment that respects patient rights and provides meaningful experience for students.⁵ This approach will benefit both patient and student and avoid any misleading practices or gaps in consent.

Emma Metz is a student in the WHNP program at Vanderbilt University in Nashville, Tennessee. Ginny Moore is Associate Professor of Nursing and WHNP Academic Director at Vanderbilt University School of Nursing. The authors have no actual or potential conflicts of interest in relation to the contents of this article.

References

1. Shah P, Thornton I, Turrin D, Hipskind JE. Informed consent. StatPearls [Internet]. Updated August 22, 2020.
2. Tillman S. Consent in pelvic care. J Midwifery Womens Health. 2020;65(6):749-758.
3. Lee D. Don’t examine without me – the role of the patient in learning pelvic exams. Voices in Bioethics. 2020;6(2020):1-11.
4. Bruce L. A pot ignored boils on: sustained calls for explicit consent of intimate medical exams. HEC Forum. 2020;32(2):125- 145.
5. Friesen P. Educational pelvic exams on anesthetized women: why consent matters. Bioethics. 2018;32(5):298-307.
6. Friesen P, Persaud RD, Wilson RF. Legislative alert: the ban on unauthorized pelvic exams. NYSBA Health Law J. 2020;25(1):29-34.