Contributors – Rachell Nguyen
Dave Calubaquib

Imagine a preoperative nurse busy managing a full panel of patients. The clock is ticking, surgical suites are ready, and everyone feels the pressure of time. Suddenly, a patient, gowned and with an intravenous (IV) catheter in place, just moments from being moved in, looks up with a bit of uncertainty in their eyes. They may not fully understand what is about to happen to their body and just want a chance to talk to the physician first. Before the nurse can respond, the charge nurse appears at the curtain: “Why isn’t this patient in the operating room (OR) yet?”

In this scenario, the nurse finds themself in a gray area, caught between their institutional duties and their ethical responsibilities. Should they halt everything, find the surgeon, and respect the patient’s concerns? Or should they continue as is? This is not just a hypothetical situation; it happens daily in hospitals. It reveals a hidden but critical issue: informed consent, a key ethical aspect of clinical care, has been reduced to a mere form to be signed and filed.

A Ritual Without Meaning

In many healthcare settings, consent is treated as a procedural step: a standard form, a signature line, a timestamp, and a checked legal box. The workflow proceeds, and the patient moves forward. While this model effectively safeguards institutions by reducing liability, meeting regulatory standards, and promoting efficiency, it has subtly stripped consent of its deeper ethical significance.

Valid consent is not simply a signature. Ethicists and clinicians recognize that meaningful consent requires four essential elements: disclosure of accurate and adequate information, understanding of what that information means for the individual patient, voluntariness (freedom from coercion), and capacity to make an informed decision (Beauchamp & Childress, 2019). When any of these elements is compromised, consent is ethically hollow, regardless of what the form says.

Autonomy is the quality or state of being self-governing. In health care, patient autonomy is the foundational basis for consent. It reflects a moral commitment to respecting persons as agents of their own lives and bodies (Beauchamp & Childress, 2019). When a patient signs a form they do not fully understand, their autonomy is not protected. It is bypassed.

Consent as a Moral Encounter

What gets lost in the procedural model is the relational dimension of consent. Watson (2008) argued that caring is not just a clinical activity but a moral and relational practice, one that takes the patient’s lived experience, emotional state, and meaning-making seriously. Consent, viewed through this lens, is not the delivery of information. It is a genuine encounter between two people at a moment of vulnerability and trust.

Barbara Carper’s (1978) work on ways of knowing in nursing, later extended by Chinn and Kramer (2018), offers another frame. Nursing knowledge is not only empirical; it is also ethical, personal, and aesthetic. A nurse who stands with a frightened patient and listens is drawing on all of these ways of knowing at once. The nurse who processes a signature without attending to the patient’s confusion is drawing on none of them.

Consent is both permission and participation. It is the patient saying, “I understand what is about to happen, I have had my questions answered, and I choose this.” When that is missing, something ethically essential is missing, even if the paperwork is complete (Faden & Beauchamp, 1986).

The Gray Zone

The preoperative nurse’s dilemma is not just a personal ethical challenge but also stems from a system that links consent to metrics such as throughput and bed turnover. Nurses navigate a structure that predetermines certain choices, rather than simply choosing between right and wrong (Burton et al., 2024).

The tension is real: balancing efficiency with presence, standardization with individuality, and information with understanding. These are not interchangeable. Efficiency at the expense of presence causes patients to sign forms they do not understand. Similarly, standardization that ignores individual needs can overlook patients whose language, literacy, culture, or emotional state requires a personalized approach (Godskesen et al., 2023).

Nurses are uniquely positioned at this intersection. They are usually the last clinician the patient speaks with before a procedure. They are present when confusion, fear, and hesitation surface. And they are also the ones most likely to feel institutional pressure to keep things moving (Burton et al., 2024).

Reclaiming the Moment

Reclaiming consent as a humanistic practice does not require dismantling the operational realities of healthcare. It requires naming the ethical stakes and giving nurses the moral authority and institutional support to act on them. A patient who is confused and hesitant before a procedure is not an obstacle to workflow. That patient is exercising exactly the kind of autonomy that consent is designed to protect. Stopping to address that confusion, even if it delays the case or requires calling the physician, is not a failure of efficiency. It is the practice of nursing at its most ethically grounded (Watson, 2008).

The preoperative nurse in that curtained bay is not just a technician processing a patient for transport. In that moment, they are the guardian of one of health care’s most fundamental values: the right of a person to understand and choose what happens to their own body (Beauchamp & Childress, 2019). The OR can wait. The patient cannot be undone.

Real-World Constraints in Practice

Achieving meaningful informed consent is challenging due to healthcare’s focus on efficiency, patient flow, and documentation (Cainzos & Gonzales-Vinagre, 2014). It becomes harder when patient barriers exist alongside demanding clinical realities. For example, older adults require more time and support during consent. In surgeries such as spine procedures, patients often prioritize independence, avoiding being a burden, and weighing quality of life against long-term outcomes (Newsome et al., 2022).

Health literacy poses a significant obstacle, as many patients struggle to comprehend medical terminology and consent documents, which are often written above their reading level. This situation can result in patients signing forms without fully understanding them (Newsome et al., 2022). Patients might feel too embarrassed to admit confusion, particularly regarding procedures such as robotic surgery or cardiac bypass. Language barriers further hinder the consent process; patients with limited English proficiency often rely on interpreters, but professional services are not always accessible, leading family members to provide incomplete explanations. Additionally, patients tend to avoid asking questions out of fear of being a burden.

Misinformation also affects decision-making. Many patients search online for information before surgery, but unreliable internet sources can create fear and confusion (Newsome et al, 2022). A patient preparing for robotic surgery may misunderstand the robot’s role or develop unnecessary anxiety from inaccurate information. These realities show that informed consent requires more than a signature. It requires patience, clear communication, and a genuine effort to ensure understanding.

Reframing Patient Consent

Informed consent should be viewed as an ongoing process rather than a single event (Cainzos & Gonzales-Vinagre, 2014). Too often, consent is reduced to signing a form shortly before surgery. However, patients facing robotic surgery, spinal procedures, or cardiac bypass may need repeated conversations to fully understand what is happening. Consent must move from information delivery to shared understanding. Simply explaining risks and benefits is not enough if the patient feels afraid or too intimidated to ask questions. Patients may say they understand even when confusion persists (Yusof et al., 2022; Hetzler & Angelos, 2023).

The teach-back method helps improve this process. Instead of asking, “Do you understand?” nurses can ask patients to explain the procedure in their own words. This reveals misunderstandings and creates space for clarification. Using plain language and allowing time for reflection also improves consent. The goal is not just legal protection but ethical engagement. Consent should be co-created with patients, not simply obtained from them.

Implications for Nursing Practice

Nurses are central to ensuring genuine consent because they spend more time with patients and recognize fear and confusion that others might miss. They explain complex procedures in simple terms, such as how robotic surgery enhances surgeons’ precision rather than relying on autonomous machines, reducing fear and building trust. Additionally, nurses facilitate communication among patients, families, surgeons, and anesthesia providers, allowing patients to ask questions they might hesitate to pose to physicians. Sometimes, ethical nursing involves slowing the process for patient clarity, such as asking surgeons to return or delaying OR transport, to protect autonomy. Nursing’s role at the intersection of institutional protocol and human vulnerability makes ensuring meaningful consent a fundamental duty.

Conclusion

The ethical tension between process-based and humanistic approaches to patient consent highlights a major challenge in healthcare. While institutions prioritize workflow, documentation, and legal protection, true informed consent involves understanding, trust, and patient participation. A signed form for procedures such as robotic surgery or neurosurgery may allow treatment but does not ensure that the patient feels informed or respected. Consent should be a human encounter based on dignity, not just paperwork. Viewing consent as an ongoing process enables healthcare providers to shift from compliance to partnership. Using plain language, reflection, and teach-back techniques enhances understanding and supports autonomy. Nurses play a crucial role because they are closest to the patient during vulnerable moments. Our advocacy helps keep consent ethical, not just procedural. A signature may authorize treatment, but only meaningful consent honors patient dignity.

Sources

Beauchamp, T. L., & Childress, J. F. (2019). Principles of biomedical ethics (8th ed.). Oxford University Press.

Burton, C. W., Jenkins, D. K., Chan, G. K., Zellner, K. L., & Zalta, A. K. (2024). A mixed methods study of moral distress among frontline nurses during the COVID-19 pandemic. Psychological Trauma: Theory, Research, Practice, and Policy, 16(4), 568–575. https://doi.org/10.1037/tra0001493

Cainzos, M. A., & González-Vinagre, S. (2014). Informed consent in surgery. World Journal of Surgery, 38(7), 1587–1593. https://doi.org/10.1007/s00268-014-2585-0      

Carper, B. A. (1978). Fundamental patterns of knowing in nursing. Advances in Nursing Science, 1(1), 13–23. https://doi.org/10.1097/00012272-197810000-00004

Chinn, P. L., & Kramer, M. K. (2018). Knowledge development in nursing: Theory and process (10th ed.). Elsevier.

Faden, R. R., & Beauchamp, T. L. (1986). A history and theory of informed consent. Oxford University Press.

Godskesen, T., Björk, J., & Juth, N. (2023). Challenges regarding informed consent in recruitment to clinical research: A qualitative study of clinical research nurses’ experiences. Trials, 24(1), 801. https://doi.org/10.1186/s13063-023-07844-6

Hetzler, P. T., & Angelos, P. (2023). Surgical decision-making and informed consent: The dynamic role of the risk/benefit discussion. Annals of Surgery, 278(3), e468-e469. https://doi.org/10.1097/SLA.0000000000005911      

Newsome, F., McDonnell, J. M., Macken, M., Clesham, K., Morris, S., Cunniffe, G., & Butler, J. S. (2022). Barriers to consent in spine surgery. The Spine Journal, 22(7), 1073–1078. https://doi.org/10.1016/j.spinee.2022.03.003 

Watson, J. (2008). Nursing: The philosophy and science of caring (Rev. ed.). University Press of Colorado.

Yusof, M. Y. P. M., Teo, C. H., & Ng, C. J. (2022). Electronic informed consent criteria for research ethics review: a scoping review. BMC Medical Ethics, 23(1), 1-11. https://doi.org/10.1186/s12910-022-00849-x          

About the Contributors

Rachell Nguyen

Greetings! I am a nursing professional development specialist and a board-certified family nurse practitioner with 20 years of clinical experience in various healthcare settings, including academic medical centers, community clinics, and specialty practices. My professional focus is on evidence-based practice (EBP), research, nursing practice, nurse empowerment and advocacy, and the management of chronic diseases, particularly diabetes, in underserved populations. I teach and facilitate system-wide nursing programs on EBP, research, and practice. My academic background includes a Doctor of nursing practice and ongoing Doctor of Philosophy studies in nursing. I am dedicated to advancing nursing practice through clinical inquiry, mentorship, empowerment, and interdisciplinary collaboration.

Dave Calubaquib

I’m Dave Calubaquib, a dedicated perioperative nurse with a diverse background. My career has afforded me the opportunity to work across various countries, including the Philippines, Singapore, and the US, which has significantly enhanced my expertise, skills, and positive outlook. I am now pursuing a PhD to further deepen my ability to generate and apply research effectively and integrate the research into practice. My professional goal is to make meaningful contributions to research, evidence-based practice, and safety within the perioperative field. I aim to improve team communication, operational efficiency, equity, enhanced recovery after surgery (ERAS), and organ procurement processes, ultimately driving positive outcomes for our patients and advancing the quality of care we provide.