Ethical Guidelines: Involving Patients in Clinical Teaching

Introduction

An effective health care system needs a continuing supply of qualified staff. An essential requirement for training health professionals is access to practical experience that is well planned and properly supervised.

Good quality practical experience for students is based on a 4-way partnership between the patient who agrees to be part of the teaching/learning process; teaching staff; other qualified staff; and the student.

In this partnership, the paramount consideration must always be the welfare and interests of the patient. The present Guidelines address the issue of how to ensure such an ethical focus when patient/student interaction is organised primarily for teaching purposes.

In some situations, different ethical codes or guidelines apply, e.g.:

When qualified personnel (e.g. doctor, nurse, physiotherapist, etc) are seeing patients for the purpose of their own continuing education, the normal ethical obligations appropriate to their own professional responsibilities will apply.
When students are involved with patients as providers of care, their supervision is the responsibility of the senior qualified professional involved, and the latter are therefore responsible for ensuring that the provision of care meets appropriate ethical standards.

All fully qualified staff, and not just teaching staff, have an obligation to facilitate the teaching of students in their own and related disciplines, and share a common responsibility to ensure adherence to the Guidelines.

Guidelines

1. Patients' Rights

Every patient has the right to decide whether he or she wishes to agree to an interview, examination or other specific procedure carried out by a student, and to withdraw from the teaching situation at any stage. Patients have the right to have a support person present. These rights should be brought to the attention of all patients who are asked to become involved in a teaching situation.

2. Right to Refuse

Every patient must receive a clear prior assurance that refusal to participate in teaching or withdrawing from teaching will not jeopardise his or her care in any way.

3. Students to seek consent

Students must seek the agreement of patients allocated to them to be interviewed and examined, or to be the subject of specific learning procedures, and must explain clearly what is involved.

4. Teachers to seek consent for group teaching

Teachers must ask a patient's permission to involve him or her in group teaching or clinical demonstration sessions and explain precisely what will be involved and how many students will be present.

5. Situations needing special care

Teachers must exercise special care when there may be difficulties for patients in understanding what is proposed, or in making their own views known. Patients who may have such difficulties include:

Children
For children under 16, consent must be sought by an appropriate means from a parent or a guardian. Children who can understand what is involved should participate in the decision.
Those from a different cultural background to the teacher or student
Cultural differences in decision making should be respected. This process may include involvement of family members.
Those not proficient in English
Patients must have an adequate prior understanding of what is proposed; the involvement of family members or a recognised interpreter may be necessary, before, during, or after the teaching, as the patient chooses.
Those disabled by confusion, an altered state of consciousness, mental incompetence, speech understanding difficulties, or hearing problems.
Agreement should be sought from another person who can speak for the patient, e.g. family member or close friend.

6. Involvement not to be unreasonable

Physical examination or specific procedures must not be repeated unreasonably on any one patient, and must not produce or prolong significantly any distress or pain.

7. Support for particular procedures

The patient's right to have a support person present requires particular emphasis during intimate examinations such as rectal and vaginal examinations.

8. Written consent for procedures under anaesthetic

Students must obtain written consent before premedication for any procedure or examination to be performed by them while the patient is under general anaesthesia or sedation.

9. Observing in Theatre

Student must obtain the patient's verbal consent to observe procedures in theatre.

10. Identity of students to be known

Patients have a right to know the name and professional status of any person who wishes to interview and/or examine them, or carry out any specific treatment or investigation procedures. Students must wear name badges and introduce themselves to their patients.

11. Students to respect confidentiality

Students are responsible for ensuring that personal information acquired by them about their patients remains confidential.

12. Teachers to provide supervision

Teachers responsible for clinical teaching must provide effective supervision of their students and ensure adherence to these guidelines.