Ethical issues to be considered when involving patients in teaching can be summarised as the ‘three Cs’: consent, choice and confidentiality. The main message emerging from policy documents, good practice and the research literature is that simply assuming that patients will be involved in teaching and learning without making this explicit through systems, conversations and practice is no longer enough.
Law and professional ethics and guidance documents enshrine the principle of informed consent. This aims to protect those involved in clinical care, particularly when invasive procedures are involved. The lines are more blurred around patients ‘consenting’ to involvement in teaching and learning. It is good practice to inform patients (ideally through written information sent in advance) that learners may be involved in their clinical care; obtaining consent should be ‘a continuous process that begins with the first contact the service has with the patient’ (Howe and Anderson, 2003, p. 327).
How can clinical teachers facilitate patient choice in participating in teaching and learning when learners need to learn from patients and practise procedures within the ‘turbulent here and now of care delivery’ (Hardy and Stanton, 2007)?
Informing patients and seeking agreement should be done without the learner being present, then confirmed in the presence of learners. Building in ‘moment-to-moment’ opportunities for patients to ‘say no’ to specific tasks that might be carried out by learners is another way of empowering patients and acknowledging their needs. For example, a midwife might be supervising a student midwife in examining a woman in early labour, and keep checking throughout delivery (particularly if the situation deteriorates or the woman is in pain) that it is still OK for the learner to continue to examine her. This continual checking, if done in the right way, ensures both patient choice and consent.
Lack of personal power and space and the more urgent need for treatment means that the type of attention that needs to be paid in the hospital context is different to that needed in primary care, where there is a more intimate relationship, more privacy and a more personal setting.
Practical steps that help to maintain confidentiality include:
- providing enough information to patients so they can assess and understand the boundaries of confidentiality
- reassuring the patient and involving them in discussions
- remembering that curtains around a bed or cubicle and open doors do not ensure silence
- finding more private spaces and giving time to discuss intimate or distressing issues
- discussing issues of confidentiality actively with learners as part of the preparation and debrief
- obtaining permission for the use of images, sound recordings and extracts from case notes which should never identify a patient.
As we have said before, it is very easy for patients to become disempowered, objectified and institutionalised, particularly in hospital settings. Clinical teachers are key role models for their learners: keeping the ‘three Cs’ in mind for both you and your learners ensures that these are seen as fundamental pillars of good healthcare, not as options.