The important article from Keen, Thoele, Fite, and Lancaster raises serious concerns for nurses and for nursing. Refusal of nursing care by competent patients is a thoughtful topic focusing on a real problem in the profession.
The conflict between nursing care (which may require consent) and nursing procedures (which do need consent) is critical. However, the terms "care" and "procedure and treatment" are used almost interchangeably in the article but perhaps are very different. What is nursing care? What are nursing procedures? What are nursing treatments, and how do these differ from procedures? I am not sure I know the finite differences, but I do believe that differences exist. As stated in the authors' review of the literature, the case law in England allows competent patient refusal of "procedures"1 but not of basic nursing care. It seems that a logical distinction between basic nursing care and nursing procedures is needed.
I went back and reviewed Notes on Nursing: What It Is, and What It Is Not, by Florence Nightingale. Nightingale wrote: "It [nursing] ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet-all at the least expense of vital power to the patient."2(p6) Many nursing theorists have studied her words and teachings and proposed new frameworks for the practice of nursing, often stressing one of Nightingale's themes over others.
In 2015, collaborators developing a text, Care in Healthcare: Reflections on Theory and Practice, developed the following definition of care: "Care in healthcare is a set of relational actions that take place in an institutional context and aim to maintain, improve or restore well-being."3(p3)* Overtime, the basic tenets of nursing care have remained consistent. Nursing care appears to comprise those activities that assist people in restoring health or preventing disease accomplished by promoting health and wellness and managing diseases, by providing hygiene and proper diet, and by supporting a safe environment.
Then what are nursing procedures? The treatment of pressure injuries might be considered a nursing procedure or treatment. If pressure injury management is ordered by the physician, is it now a medical treatment?
A thread throughout the paper on Competent Patient Refusal of Nursing Care is implied consent versus the need for explicit consent for care. Does a nurse need explicit consent to turn a patient? Does the nurse need consent for procedures and treatment, but not care? Medical treatments that require consent require written consent. Is this the next step for nursing? Will policies be developed in healthcare settings (for hospitalized patients and home care patients) to guide nurses? Are there liability and legal implications of refusal of treatment? For example, if refusal for turning and repositioning for individuals at risk for pressure sores results in tissue damage, what happens?
So, is turning and positioning a patient every 2 hours basic care, or is it a procedure? Is cleaning a patient with incontinence nursing care or a nursing procedure. Since a nursing procedure implies the need for consent, we need to differentiate carefully between the concepts of care and procedures. Nightingale would have defined both as nursing care, and she would have done so with the understanding that providing patients power and a role in the decision-making process was part of nursing care.
I also believe that nurses do seek informed consent to provide care. It is just implied, not explicit. And perhaps the key question to determine is: what procedures or treatments do nurses perform that require consent and should that consent be in writing? If so, then policies and guidelines can be developed to guide the consent process and thus define the rights of refusal by competent patients. I assert that institutional policies or professional nursing guidelines are urgently needed to help both nurses and competent patient deal with the critical question of declining nursing care, including education for nurses in negotiation and shared accountability related to the decisions of refusal of care.
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