Informed Consent Practices Among Emergency Staff for Patients Undergoing Emergency Surgery in the Emergency Surgical Units of Two Tertiary Teaching Hospitals in Uganda: A Qualitative Study

Informed Consent Practices Among Emergency Staff for Patients Undergoing Emergency Surgery in the Emergency Surgical Units of Two Tertiary Teaching Hospitals in Uganda: A Qualitative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Informed Consent Practices Among Emergency Staff for Patients Undergoing Emergency Surgery in the Emergency Surgical Units of Two Tertiary Teaching Hospitals in Uganda: A Qualitative Study Olivia Kituuka, Ian Munabi, Moses Galukande, Adelline Twimukye, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4472834/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Dec, 2025 Read the published version in BMC Medical Ethics → Version 1 posted 13 You are reading this latest preprint version Abstract Background Staff in low resourced emergency units of a low-income country face the challenge of obtaining informed consent for incapacitated patients or their next of kin in a time-constrained situation often in an overcrowded environment. Therefore, we aimed to establish the informed consent practices for emergency surgical care among healthcare professional at two emergency surgical units at two tertiary teaching hospitals in Uganda. Methods In October 2022 – February 2023we conducted key informant interviews in Uganda and purposively selected 16 staff in surgical emergency units at two tertiary teaching hospitals and directly observed the informed consent practices. Data was managed and analyzed inductively using NVivo version 12. Results Six themes emerged from key informant interviews including knowledge and perspectives no informed consent; processes, procedures, and practices regarding informed consent; communication strategies for informed consent; ethical considerations; benefits of informed consent during surgery; and challenges to emergency informed consent. Staff had adequate knowledge about informed consent but faced several challenges during the consent process due to lack of guiding institutional policies. Overall, the informed consent process was inadequate at both institutions with greeting of patients, disclosure of risks and assessment of understanding poorly done. Consent was conducted in a noisy environment at both institutions and there was no privacy in the public hospital. Conclusion Although knowledge about consent practices by emergency staff at both institutions was good, in practice there was inadequate disclosure of risks, inadequate knowledge about the surgical procedure, risks, and benefits. Emergency staff identified the need for procedure specific consent documents which capture the information that is given to the patient and guiding policies on consent for incapacitated patients who have no surrogates. Emergency surgery Informed consent emergency staff Figures Figure 1 Introduction In the surgical emergency room rapid decision-making is required which makes it difficult for the emergency physician to maintain the four Belmont report principles of ethical management of patients autonomy, non – maleficence, beneficence and justice derived from the Hippocratic oath ( 1 – 3 ). The emergency units in hospitals in low-income countries are often overcrowded and do not have the required privacy for adequate informed consent. Adequate informed consent involves informing patients about the surgical procedure, the risks and benefits and alternative treatment options with understanding of this information and documentation of consent by an individual with the capacity to consent. In some emergency surgical conditions, patients’ capacity to provide consent is diminished and sometimes there is no accompanying caregiver, next of kin or surrogate decision maker to urgently provide consent for life-saving treatment. In such a scenario the surgeon may take on the responsibility to decide on care in the patient’s best interest ( 4 ). This is because urgent care is required for life-threatening and life altering surgical conditions. In a teaching hospital, there are trainee surgeons who are often the first to diagnose the emergency surgical condition and carry out the surgery under the supervision of the surgeons. The trainee surgeons and other junior emergency staff seek informed consent from patients, their caregivers or next of kin. This study aimed to establish the informed consent practices for emergency surgical care among healthcare professional at two emergency surgical units at two tertiary teaching hospitals in Uganda. Our findings will contribute to improving the informed consent process for emergency care in low resource settings. We set out to compare informed consent practices among emergency staff in the setting of a public hospital and a private hospital where financial costs are involved. Methods Study design: In October 2022 – February 2023, we conducted a cross sectional qualitative study using key informant interviews, and direct observation of the emergency staff with nurses, intern doctors, surgery residents and surgeons. We used a phenomenological approach to describe the experiences and consent practices of emergency care staff in the emergency surgery setting. We aimed to understand the subjectivity of the consent process from the perspective of the emergency staff. Study setting: The study was conducted in the Accident and Emergency Units at a public National Referral Hospital and a private hospital. Both hospitals were university teaching hospitals based in Kampala, the capital city of a low-income country Uganda. The Accident and Emergency unit is where most emergency surgery is carried out by surgery residents who are supervised by surgeons and work with intern doctors, nurses, and anaesthetists. Training of students both at undergraduate and postgraduate level occurs in these units making the units a reflection of what practices are expected in other health units following completion of training and going to practice all over the country. Sampling methods: We purposively selected 16 participants including nurses, medical officers, surgical residents, and surgeons who work in the emergency departments and were involved in soliciting informed consent process from patients scheduled for emergency surgery. Face to face key informant interviews were conducted with six participants from the private hospital and 10 participants from the public hospital. Emergency staff were also observed as they obtained consent from patients for emergency surgery. Participants at the private hospital were obtained from the head of the emergency unit who provided the telephone contacts of all nurses and doctors working full time within the Accident and Emergency unit. These were then contacted on phone and those who were interested in participating were invited to provide written consent to participation in the study. Participants at the public hospital were selected to get representation of at least 1 doctor from each of the surgical units of Orthopaedics, Neurosurgery, Gastrointestinal surgery, ENT, Cardiothoracic surgery, Urology and from 3 full time nurses attached to the Accident and Emergency Unit. Participants were contacted on phone and written informed consent was obtained from those who expressed interest in participating in the study. Data collection Key informant interviews of the emergency department staff at each of the two tertiary teaching hospitals were conducted in a private staff room within the Accident and Emergency unit of the private hospital and in the department of surgery office for the public hospital. We used an interview guide (Appendix 1) that entailed open-ended questions and flexible probes to investigate perceptions and experiences. The key issues explored were knowledge about elements of informed consent, how informed consent was practiced and their experiences obtaining consent for an incapacitated patient with a surgical emergency, their attitude towards the informed consent process in terms of what they considered adequate, what should be included, what they liked and disliked about the consent process. Key informant interviews were conducted by the author who is a female PhD Bioethics fellow and a surgeon. Direct observation was done by two research assistants, one at each institution. The research assistant at the private hospital was a male third year surgery resident who had completed his rotation in the emergency unit and was conducting his own research in another area in surgery. The research assistant at the public hospital was a female fifth year undergraduate student of Bachelor of Medicine and Surgery who was trained by the author and had been conducting other research under supervision for 2 years. The author and the two research assistants had certification in Responsible Conduct of Research and Good Clinical Practice. Written informed consent was obtained from the participants for the key informant interviews and for audio recordings of the interviews. Interviews were conducted in English in a private room and confidentiality was maintained by avoiding the use of any identifiers like the participant’s name or surgical specialty. Each key informant interview lasted approximately 20–30 minutes. Data saturation was achieved as there were no different issues arising from subsequent interviews following analysis that was done by the author and an independent reviewer after every four interviews. Interviews were audio-recorded with participant consent and transcribed verbatim in English for data analysis. Data collection was from October 2022 to February 2023. Data analysis occurred during the data collection period and continued until June 2023. Direct observation of the emergency staff obtaining informed consent from patients was done without their knowledge and consent. Waiver of consent was obtained for direct observation of the emergency staff to avoid behavior being affected by the participants’ awareness of being observed. However, administrative clearance was obtained from the health institution and the in-charges of the units to observe the emergency staff. Observation was done on four different days of the week and at four different times of the day at each of the two tertiary teaching hospitals to capture any variations in practice according to time of day or day of the week. The in-charge of the emergency unit was informed when any troubling issues were observed for remedial action to be taken. An observation checklist (Appendix II) was used to capture emergency staff practices during the informed consent process, communication, who does the consent, where it is done, when it is done. The checklist was generated from standard key components of the informed consent process and was a modification of the Process and Quality of Informed Consent Instrument (P-QIC) which is a four-point scale (well done, done, done poorly, not done) for 20 items Likert type scoring with a total score of 40–100 for the whole encounter (Cohn, Jia, Smith, Erwin, & Larson, 2011). The checklist was modified to carry out 16 observations under 4 domains Communication skills, Disclosure, Voluntariness and Understanding and separate observations for privacy and confidentiality, presence and documentation of the consent form, duration of the consent process and who administered the consent. Data analysis We conducted an inductive thematic analysis of the data collected from key informant interview with different respondent categories such as nurses, medical officers, surgical residents, and surgeons. The analysis examined meanings, theme and patterns that manifested in particular texts from the interviews. Two independent coders individually read each transcript and identified key concepts to develop a coding framework. The coding framework was based on three transcripts that were manually reviewed and coded to generate the initial set of codes that were crosschecked iteratively between two coders for consensus and to improve reliability. All transcripts were imported into NVivo version 12 software computer-assisted qualitative analysis of data for open coding, management of data. A code book was developed, and the revised codes were grouped into categories and identified themes. Illustrative quotations for each emergent theme were selected for results narration. Participants did not provide feedback on the findings. Each observation had a five-point Likert scale with each response ranging from 1–5 corresponding to the range of poorly done to well done. Modes and medians were used to analyze each observation made from the Likert type scale. An average of each observation done at the four different times was calculated. An average of 2.5 and above showed that an observed activity was well done while a score of less than 2.5 was poorly done. A total score for all the observations out of a maximum of 80 and was converted into a percentage. A percentage score of 50 and above indicated an adequate informed consent process. Separate observations were made for the domains of privacy and confidentiality, documentation of the consent form, duration of the consent process and who administered the consent. These domains were assessed separately according to frequencies of each observation made for each domain. Results Most of the study participants were male and majority were surgery residents for both the key informant interviews and direct observation. There were no surgeons observed or interviewed at the emergency units although they were available for consultation during emergencies. This is summarized in Table 1 below. Table 1 Participant characteristics Key informant interviews Direct observation Public Private Public Private Gender Male 6 4 8 4 Female 4 2 2 2 Total 10 6 10 6 Category Nurse 2 3 2 3 Intern doctor 1 1 2 1 Surgery resident 7 2 6 2 Total 10 6 10 6 We report on the key findings from the key informant interviews and direct observation of the consenting process in the emergency. Direct observation of emergency staff Direct observation of emergency staff was done on four separate days for each study site and at four different times. The domains that were observed are summarized in Table 2 below. Table 2 Domains observed during informed consent for emergency surgery. A Communication skills A1 Greets and shows interest in the patient and or their next of kin A2 Uses language that is easy to understand; avoids medical jargon A3 Introduces themselves to the patient or next of kin B Disclosure B1 Provides information about the clinical diagnosis of the patient B2 Provides information about the treatment options B3 Provides information about the recommended treatment B4 Provides information about the benefits of the treatment B5 Provides possible risks of the surgical procedure B6 Provides information about the treatment goal B7 Provides information about the complications B8 Provides information about the cost of the surgical procedure C Voluntariness C1 Offers the patient or next of kin the opportunity to accept or decline the treatment offered C2 Patient or next of kin given time to decide C3 Decision made without pressure or coercion D Understanding D1 Patient or next of kin asked if they had any questions about the procedure D2 Patient or next of kin asked to re-state what procedure was to be done and the risks and benefits We used a 5-point Likert scale for each observation under the above domains. The Likert scale is best used to measure attitudes, behaviour and personality traits ( 5 ), and was used to assess behaviour of the emergency staff during the informed consent process. The average Lickert scale values for each domain at the 4 different observation times was calculated and represented in the figure below and compared between the two institutions (Fig. 1 ). Further analysis of the different observations under the four domains Using simple language under communication skills and voluntariness domains were the better performed components of the informed consent process (Fig. 1 ) Greeting of patients, information disclosure and assessment of understanding were poorly done. The emergency staff did not introduce themselves to the patients at both institutions except on one occasion at each of the institutions. Worst done at both institutions was disclosure of risks and assessment of understanding by asking them to repeat the procedure to be done, and the risks and benefits as told to them. (Fig. 1 ). The environment was noisy at both institutions with the environment in the public hospital always crowded with no privacy whereas that in the private hospital was not crowded and offered more privacy. Consenting at the private hospital was done by the nurses while at public hospital it was mainly done by the intern doctors and surgical residents. The duration of consent at both institutions was all less than 30 minutes. Key informant interviews Six themes were derived from key informant interviews and these included knowledge and perspectives about informed consent; practices, processes, procedures, and practices regarding informed consent; communication strategies for informed consent; ethical considerations; benefits of informed consent during surgery; and challenges to the consenting process in emergency surgery. (Table 3 ). Table 3 Summary of themes and codes for key informant interviews of emergency staff THEME CODES Knowledge and perspectives on informed consent • Definition of informed consent • Key components of consent documents for surgery Processes, procedures, and practices regarding informed consent. • Persons expected to administer consent and their roles. • Duration of consenting emergency patients • Decision making Disclosure of informed consent • Factors enabling effective communication during informed consent. • Type of information shared during informed consent.• Ethical considerations • Voluntariness • Capacity to consent • Documentation of consent • Handling patients without care takers • Beneficence. • Right to information Benefits of informed consent during surgery • Respect for patient autonomy. • Confidence and protection of emergency staff and health institutions Challenges of emergency informed consent • Inadequate disclosure • Communication challenges • Inadequate documentation of consent • Poor working environment. • Medicolegal • Financial and Time constraints THEME 1: KNOWLEDGE AND PERSPECTIVES ON INFORMED CONSENT • Definition of informed consent All participants were knowledgeable about the definition of informed consent and its related components. They commonly described informed consent as a means to understand and seek permission for surgical procedures and or admission for patients. Consent could be written or verbal for surgery. Participants contended that informed consent entails explanation of specific health condition procedures and benefits to the patient as well as patient’s voluntary decision to undergo a surgical or a medical intervention. “Informed consent first of all is a process which we normally use for patients who need an intervention. It might be a surgical intervention or a medical intervention. We give information preferably written about what the intervention is, the benefits, the risks of the intervention. Sometimes we explain how for the procedure or the condition how it comes about, what brought it and how we can manage it” --KII 12, doctor, Private hospital. • Key components of consent documents for surgery Participants mentioned the key components of an informed consent document for emergency surgery. The major component of an informed consent form mentioned by the majority of participants included details of the patient including name, age, date and time, address and contact. Other components mentioned were the signature of patient, name of surgeon, witness, indication of the surgery, for the patient that is not able to give a written consent for example in view of disability or for a child. “I would want to see the time and date, the place where the patient signs or the attendant signs. I want to see the place where the witness signs or the one has taken the patient through the consent process. I would want clear information about where you document what you have told the patient, clear Information, not what I see. It is better in my view. The document I see in Casualty unit is insufficient because it is giving just the name of the patient, the doctor and the witness” --KII 5, doctor, Public hospital. All the participants stated that the consent document should include potential risks, complications and outcomes about surgery. One participant noted that consent documents should contain a provision to consent for sharing any photography or images taken during a surgical procedure. “They would capture what they are suffering from their diagnosis, benefits of the procedure, complications associated with the procedure, 5. Who is the surgeon who is going to perform the procedure. … Photography during the procedure” --KII 4, doctor, Public hospital. One participant wanted information about surgery procedures and processes, materials to be used and medicines(drugs) supplied during surgery to be included in the consent document. “1. The procedure to be done.needs to be written clearly and boldly and explained to the patient 2. Medicines e.g., analgesics, antibiotics, Sedatives we need to be talked about in the consent. 3. The material to be used for the operation should be mentioned e.g if you are going to use artificial valves or prostheses or grafts” --KII 1, doctor, Public hospital. One participant noted that an option that verbal consent will be obtained should be clearly stated and documented for specified procedures. “The patient can consent verbally for minor procedures e.g., doing vitals and putting a canula they do not give a written consent. We do not need a written consent and they give a verbal consent. Here we do for minor procedures e.g., STS and catheterization” --KII 11, nurse, Private hospital. THEME 2: PROCESSES, PROCEDURES AND PRACTICES OF INFORMED CONSENT. Person expected to administer consent and their roles. Participants from both hospitals stated that surgeons should administer consent because they were experienced and have the capacity to offer accurate information to patient concerning the surgery. This was at both hospitals where consent was sometimes administered by the nurses. “If possible, if the specialist going to do the operation is available or is nearby, we also prefer for them to be involved so that the caretaker or the patient can see the person who is going to perform the surgery, they can also come and give more information. But sometimes they are very busy, and we do it but in case they don’t come the doctors in the department should be the people to administer consent not the nurses because it will be a matter of sign here sign there” --KII 12, nurse, Private hospital. ‘’In my opinion the Surgeon who is going to carry out the procedure is the one supposed to take consent from this patient because they best understand what is going to be done, what is associated with what is likely to be done. They also best understand that if plan A fails then what plan B is available during the surgery. But the nurse may not understand this. The surgeon knows when to carry out the procedure should be the one obtaining the consent’ --KII 3, doctor, Public hospital. For patients who are unconscious and had no caretakers present to give consent, participants from both hospitals stated that the heads of accident and emergency, consultant surgeons, surgical residents managing the patient should consent on behalf of the patient. “There are certain conditions when the patient is not able to consent for themselves then either the medical professional like the head of the hospital can consent for the patient if it is urgently needed” -- KII 11, nurse, Private hospital. • Duration of consenting emergency patients Participants noted that the duration of the consenting process depends on the urgency of the procedure and the patient load. Participants pointed out that the duration of the consenting procedure was shorter for patients requiring emergency surgery and when there was a heavy patient load. “In an emergency when a patient needs a particular procedure… we consent patients in a short period of time depending on the urgency. Therefore, we may not give them adequate time to decide on the procedure, whether they would like it or not, and whether they would ask, what would we have done at another time or not. We usually come and probably talk to the patient and the attendants obviously we explain the diagnosis and what's to be done” --KII 1, doctor, Public hospital. “The cases we get which normally go to theatre are not so many they are mainly head injuries. In a week we might see 5–10 cases which are admitted via theatre…It[consenting] takes a very short time. Different cases e.g. obstructed hernia which doesn’t involve so many things or many risks we take about 5–10 minutes. If they have understood most patients do not want to delay once you have told them it is emergency surgery. We don’t take more than 10 minutes” --KII 12, doctor, Private hospital. • Decision making Participants indicated that they expect patients to make an individual decision but noted that often times family members and other surrogates participate in decision-making. “But it is the patient to sign for himself. If the patient does not consent or in some cases the patient does not want to reveal their condition to the relatives. But if the caretakers are around, we explain to them so that they can also get confidence in case the patient delays in theatre they understand” --KII 11, nurse, Private hospital. “There need to be other people other than the patient involved in the process. it might be the patient's relative or friend. Even if someone is above 18 years there needs to be someone there so that the person can be a witness” --KII 1, doctor, Public hospital. “We explain to the patient, and we normally involve one or two caretakers or family members because we do not want crowding in the emergency area. Sometimes family members also help in the process to help the patient to make a choice because you find that they are the people who are going to pay the money, so we have to involve them. It is always very fast if it is an emergency. At times when they are thinking about the condition of the patient, they don’t internalize what we are telling them” --KII 12, doctor, Private hospital. Participants reported that other people like other family members and caretakers who pay the patient’s medical bills and are not physically present during the consent process, participate and help patients to make a choice based on whether they can afford to cover the costs for surgery. “Occasionally they make phone calls to those who can support them financially to take care of the financial implications of the operation. We do not always have to talk about finances during emergency consent process, but it is an important thing and there is an option of having this emergency procedure done at a place where they can afford” --KII 9, doctor, Private hospital. Participants acknowledged that sometimes there are differences in opinion about the treatment options from different emergency staff and this affects consent because it causes confusion for the patient. “We have gotten them sometimes when the patient has been consented earlier and the patient is stable. We usually base on the primary consent but we explain to the patient. That is something that has to be improved on. Then even among the Ortho team we have different people on call. I could come and give the patient a different treatment plan and I can look at their condition and say that we can push it to tomorrow. When my colleague comes may say that this is urgent and needs to be dealt with immediately. This confuses the patient” --KII 6, doctor, Public hospital. THEME 3: DISCLOSURE OF INFORMED CONSENT Factors enabling effective communication during informed consent. Emergency staff stated that the major communication channel for informed consent is face to face verbal communication where the healthcare worker introduces themselves to the patient and tries to create a rapport with patients or care takers. “I welcome the patient, triage, take vitals and then take them to the place where I will examine her. I tell [the patient] my names and what I am going to do. After they have accepted and seen that surgery needs to be done. Then I bring the consent form and I ask them to help me to fill this form so that we can operate” --KII 10, nurse, Private hospital. “…what I think is first, we create rapport with the subject either the patient or attendant. Rapport involves proper identification of yourself to the patient or attendant and also understanding whether you are dealing with the right patient or attendant managing the patient. And then you try to understand to what level do they know about what is happening to them. Do they know about their condition? You must probe to know what they know then you give them what they should know as per, what you want to do” --KII 5, doctor, Public hospital. The health care workers noted that clear and elaborative explanation to the patient about surgery procedures is given including complications and other treatment options and the implications of their options. “… the health care provider is able to explain in detail to the patient or the one who is coming to receive the service, about their condition, the diagnosis that they have, the intervention that is going to be offered plus the complications that are associated with the intervention that is going to be offered. And then once this is arrived at then the receiver or the patient decides whether they are willing to take up the treatment option or not without being coerced, but after understanding in detail what they have been explained to–K II 4, doctor, Public hospital. Emergency staff reported that sometimes consent is sought via phone calls to next of kin who are not present to aid the patient during the consent process. In certain circumstances the phone call involves consent to avail financial support where surgical services are not free like in the private hospital. “…we try to ensure that we get the consent from the attendants and sometimes we have to get their numbers and call them for them to provide consent” --KII 8, doctor, Private hospital. Occasionally they make phone calls to those who can support them financially to take care of the financial implications of the operation. We do not always have to talk about finances during emergency consent process, but it is an important thing and there is an option of having this emergency procedure done at a place where they can afford–K II 9, doctor, Private hospital. Some participants indicated that they use pictorials and illustrative diagrams to explain the disease condition and the procedure the patient is to undergo. “ Normally what we do, you explain, I use diagrams explain, for instance, after we explain the pathology, basically we told the attendant sign here and the attendant sign, but most of the time we put the data ourselves and also, we write the name of the surgeon ourselves. So, a lot of times the weakness is in us” --KII 7, doctor, Public hospital. Most of the participants noted that the language used during informed consent should be simple to enable patient to understand and that for those who did not understand English, a translation of the consent form to appropriate language like Luganda was used. “We give them[patients] time to read through consent for admission as they sign and if they can’t read you read for them. If they don’t understand English because it is in English, we explain to them what is in that consent knowing what they are signing rather than telling them to sign here, sign there what they don’t know. The other thing is our surgery consent form it has both parts Luganda and English. Someone who does not understand English the Luganda bit works” --KII 11, nurse, Private hospital. Patients or caretakers are given time to ask questions regarding surgery and whether they agree to the procedure. “Providing the patient with information about the examination, investigations, procedure or other treatment prior to doing the same on the patient. Making sure the patient understands the information, giving the patient the room to ask questions and making the patient understand that they have the right to refuse consent or treatment or planned procedure” --KII 9, nurse, Private hospital. Participants pointed out that obtaining consent in the emergency setting requires a multi-disciplinary approach. The surgeons, nurses, anesthesiologists, and other healthcare professional all have a role to play to ensure that patients understand during the consenting process, as illustrated in the following quotes. “Then finally with the help of the nursing staff, the surgeon, the nursing staff and I are all involved in the consent. I find it to be a multidisciplinary consent where the examining clinician seeks consent for examination, investigations and diagnosis and the operation. Then the same is emphasized by the surgeon on review of the patient prior to the surgery” --KII 9, doctor, Private hospital. “We usually come and probably talk to the patient and the attendants obviously we explain the diagnosis and what's to be done. But consent needs to be multidisciplinary. In that point there is a missing link because the doctors talk to the patient, but the anesthesiologist is not there and we have other things missing” --KII 1, doctor, Public hospital. Type of Information shared during informed consent. Participants stated benefits, risks, implications of refusal to consent, and outcome of surgery as the major type of information shared. They argued that sharing of risks of surgery enables patients to make an informed decision regarding surgery. “Then with that you also give them the challenges and the benefits and the complication of your intervention so that they can decide whether to go ahead with the surgery. I think rapport gathering information from the attendants and the patients, providing information about the procedure including risks and benefits and some alternatives if they are there and the complications. Asking them whether they agree to the procedure…They must know because that is the whole idea of informed consent so that they accept knowing the risks. There's no surgery which doesn't have a risk so you must tell them the risk.” --KII 5, doctor, Public hospital. Participants said that they inform patients about the benefits of the proposed surgical procedures and reassure them on potential success of surgery. They also reported that they give patients the opportunity to ask questions to ensure that patients understand. “The kind of information we give depends on the type of operation. We explain to them the procedure, the benefits, if there are any risks, we have to inform them. We reassure them that the operation will go very well, not to worry and will be successful” --KII 10, nurse, Private hospital. “Then you ask for their opinion, and you ask from what you have heard do you accept to have the procedure, or do you have some reservations which you want to communicate and some questions you want clarification on.” --KII 5, doctor, Public hospital. Participants noted that they provide information about alternative treatment options, guidance on the preferred treatment option and the consequences of not consenting to surgery. “…then after that you tell them[patients] about the other alternatives you would have taken and why you have not taken them and why you have chosen that.” --KII 9, doctor, Private hospital. “Then we have to explain to the family the decisions that we think are better for them for the situation they are in. After explaining to them, we give them the possibility, the benefit of the surgery and the risks. At the same time, we tell them if they don’t consent what may happen if they don’t get the surgery” --KII 6, doctor, Public hospital. Participants mentioned that they also discuss the cost associated with the surgery and hospitalization . “First of all being a private hospital we have to explain to them the financial cost. This affects the numbers, for those who can afford its ok. During the informed consent process, we have to tell them about the financial cost, and we send them to the cashier and sometimes involve the social worker to process the bills” KII 8, nurse, Private hospital. THEME 4: ETHICAL CONSIDERATIONS • Voluntariness Participants noted that patients must make voluntary decisions without any coercion or undue influence. “Informed consent is the process of getting voluntary permission from the patient for any procedure that you are going to perform on them. They should not be coerced; you give them all the necessary information. They are a liberty whether to decide to the surgery or not to decide. You give them all the necessary information and they are allowed to decide for the medical intervention or to refuse the medical intervention.” --KII 6, doctor, Public hospital. • Capacity to consent Emergency staff noted that a patient should have the mental capacity to consent and should understand the information shared. Adults aged-18 years and above were eligible to consent for self or with the help of their next of kin. “The patient should have the capacity to consent, should be 18 years and above, information should be given about the procedure, and they understand and giving them room to ask questions and letting them be aware that they have a right to decline to consent” --KII 9, doctor, Private hospital. They acknowledged that some patients do not have the capacity to consent in an emergency setting because they were unconscious, mental disability or were children less than 18 years of age. Emergency staff suggested that the legal capacity of the surrogate decision maker should also be verified in such instances. “…if there is someone consenting on behalf of the patient to do this on my patient state the relationship.” --KII 9, doctor, Private hospital. “What level do they understand this patient? Are they closed relatives? Are they just friends? Are they good Samaritans? Because some decisions vary. What a mother or a wife would sign for their patient is different from what a good Samaritan would sign.” --KII 5, doctor, Public hospital. “Another important part consent is supposed to be given by the patient if they are able. In case a patient is not able to give consent, the person giving consent has an area where he has to put the reason why the real patient was not able to give consent. The patient can be unconscious, patients with disability, maybe a child” --KII 12, doctor, Private hospital. The emergency staff also observed that sometimes attendants are asked to sign for patients even though the patient had the capacity to consent for themselves. “Usually what happens is make the decision to operate, and as the patient is being wheeled into casualty. Basically, as they are changing, usually that is when we do the consent and basically what we do, the majority of times it's not actually the patient themselves, even when they have capacity, so the majority of times it is attendants who give consent on behalf of patients” --KII 7, doctor, Public hospital. • Documentation of consent There are two types of consent forms at the private hospital which were termed general/admission and emergency consent forms. Emergency staff noted that the doctor should sign the consent form to confirm that they have explained to the patient and a nurse then signs as the witness. One participant reported that what the doctor explained to the patient should be documented as proof of what was discussed. Patients who are unable to sign should use a thumb print instead of a signature. “So, we have high risk consent forms both medical and surgical, then we have the general consent forms. What we do first is to get the right condition for the right patient and if we think the patient needs surgery so we categorize does this patient need emergency surgery or is its urgent surgery or can this patient be worked up we wait and then plan for the surgery (electives). That’s what we do. If it’s an emergency, we have emergency consent forms” --KII 12, doctor, Private hospital. was done for. “… they will not be able to hold a pen to sign, but they will allow you to get a thumb print. So, you get a pen and shade the thumb and then they put it there.” --KII 2, doctor, Public hospital. “Unfortunately, all that I say is not written down. If there is a way in which me the provider can be helped to write it down. Let's say they leave a space where you say Dr… this is what you have explained to the patient in 3 or 4 lines. I have explained that this will happen, this will happen, this will be good. I think that would be beneficial for that informed process.” --KII 2, doctor, Public hospital. For some minor procedures, emergency staff obtained verbal consent, and this is not documented. “The patient can consent verbally for minor procedures e.g. doing vitals and putting a canula they do not give a written consent. We do not need a written consent and they give a verbal consent.” --KII 11, nurse, Private hospital “As for us nurses the doctor explains to the patient then I also reinforce and re-explain to the patient. Then I make the patient sign…... The doctor may have to sign because they are the ones who explain to the patient what is going to be done. I go through again with the patient and then I sign as a witness” --KII 11, nurse, Private hospital. Some emergency staff reported that patients who required more than one type of surgery were operated upon based on the consent obtained by one surgical team. “Most times when we are called in those patients have already undergone certain procedures. When the first team on board calls us we go forward to explain to the patient. But we tell them what we are going to do, although our assumption is the first team got consent and this is an emergency” --KII 2, doctor, Public hospital. “ Handling patients without care takers In the public hospital one participant noted that if a patient was unconscious without a caretaker the consent is waivered by the medical team. The head of the emergency unit, surgical resident on duty, the consultant on duty and administrator counter signed for patients without care takers. “We have a number of unknowns who come to the ward and a number of times they need surgery but there is no one to consent for them. So usually in those instances especially for the unknowns, we have counter signing by head of the Accident and Emergency unit with the Administrator for the unit if they are available. But in the night, it is a little bit of a challenge. And so most of the time in the night, it's the SHO or any of the surgeons who is available who takes the consent form this patient if they need that emergency surgery. For the minors there is no clear policy so it will depend on the will now of the parents who bring these patients here. I think the good observation, I think also need to create a policy about that” --KII 3, doctor, Public hospital. One participant from the private hospital stated that medical workers do not perform surgeries on patients without caretakers but referred them to the public hospital to avoid liability. “We sometimes refer patient who cannot consent or refuse to consent and therefore the liability and repercussions of refusing surgery goes to someone else. We refer them to the national referral hospital so that we do not take up this liability” --KII 9, doctor, Private hospital. Beneficence. Emergency staff determined the benefit of surgery to patient before seeking informed consent. This was to avoid doing more harm than good. “That means we have to explain to the patient or the attendant their diagnosis and after the diagnosis, then we can talk about getting informed consent because sometimes there might be no need for some procedures to be done if the patient is too sick or won’t benefit. So that's an important thing. Then after that we look at the procedure itself. Is it doing better than harm? Those are important facts that need to be balanced. In the conversation.” --KII 1, doctor, Public hospital. • Right to information Patient had a legal right to information during consent. “…you do not just go and work on a patient something which they haven’t understood. You see people here coming and saying they have removed my kidney when they did something else. If you have informed the patient what you are going to do and you have explained to them if you are going to remove an organ you tell them so that they do not complain later because it has legal issues. It is even the patients right to know what is going on to their lives and what one is going to do” --KII 11, nurse, Private hospital. THEME 5: BENEFITS OF INFORMED CONSENT • Respect for patient autonomy Majority of participants stated that informed consent was beneficial to emergency staff and mainly patients. Most participants said the informed consent for surgical care is patient-centered and is a sign of respect. They added that informed consent gives patients the opportunity to make choices concerning their clinical care. “In this day and age consent is very paramount because. It gives a patient liberty to choose. The health care system the drive is now more patient-centered than physician-centered” --KII 1, doctor, Public hospital. • Confidence and protection of emergency staff and health institutions Emergency staff felt that informed consent gave them protection and peace of mind because there was transparency in the care offered to the patient. They also reported that informed consent protected the institution from legal implication by patients or care takers. Emergency staff acknowledged that informed consent helped in building rapport and trust with the patients who were grateful when doctors explained to them or caretakers about the disease condition, diagnosis, intervention, and complications. “I think it is important because it can be a medicolegal issue. I have seen some cases where people have sued and there are lawsuits where a procedure was performed and there were complications and the patients’ attendants take them to court. One of the things that can save them is if the patient or the attendant had signed and understood that they were going to have a procedure and the complications that could happen…Informed consent is important because by the time everyone signs one has understood. It helps everyone to know what exactly is going to be done. I think it protects us and the patient” --KII 8, doctor, Private hospital. THEME 6: CHALLENGES TO INFORMED CONSENT FOR EMERGENCY SURGERY • Inadequate disclosure Emergency staff noted that a major challenge was inadequate disclosure of information to patients because of knowledge gaps, and lack of time for surgeons during the consent process to discuss the whole surgery process in detail. Emergency staff at the public hospital admitted that information provided to the patients was inadequate because of inadequate knowledge about the surgery by the healthcare worker who is obtaining consent from the patient. Sometimes the surgeons left the consent process to nurses or junior doctors who lacked adequate information. “Sometimes we as medical personnel are not able to know all the outcomes of the procedure. If something else happens which we have not told them the surgeons need to tell them since I am the medical officer and I might not know all the risks” --KII 8, doctor, Private hospital. “Most of the time the consent is more or less left to the nursing team who also don't have sufficient knowledge to explain to the patient and so it leaves a big gap of understanding for the patients. But now because most of the patients we have are vulnerable they have no option but to sign what has been presented to them” --KII 3, doctor, Public hospital. Some participants in the private hospital reported poor understanding by the healthcare providers of some principles of informed consent like respect for the patient’s autonomy. “There is no doubt that many times we make informed consent without going back to the principles of it. We need to take time as professionals to read more widely on informed consent, get its underlying principles e.g. respect for human dignity and their bodies, knowing that it can result in legal liabilities if not considered. We need to refresh our knowledge on informed consent” --KII 9, doctor, Private hospital. • Communication challenges Participants expressed communication challenges in the form of fear of communicating risks, language barrier and time constraints to communicate adequately. Emergency staff stated there was fear for some medical workers to describe to patients about the risks of surgery. “When you are seeking consent from patients you are afraid that describing risks will stop the patients from giving consent. So, a lot of times, we actually either don't give all the risks or give a few or don't play them up” --KII 7, doctor, Public hospital. Language barrier was coupled with complex medical jargon which was difficult to simplify or translate into a form which patients would understand. “Sometimes we use words that are in medical terms e.g. herniorrhaphy even after explaining to the patient and they have understood, it is hard to put these terms in the patient’s own language that they have understood.” --KII 12, doctor, Private hospital “What I don't like about it is that we rush it. We don't communicate to the patients well. I also don't like that sometimes it's very hard to communicate the problem. I think we don't do it as well as we should. It is rushed” --KII 2, doctor, Public hospital. One participant in the public hospital said it was difficult for emergency staff to explain to patients about procedures with high risk of morbidity or mortality. “The other one is at an individual level I don’t find it very comfortable to consent someone for a procedure when it is not going to be beneficial or that may result in permanent disability specifically. I would request someone else to do it” --KII 6, doctor, Public hospital. Emergency staff reported communication challenges due to poor patient understanding due to illiteracy and poor comprehension of complex medical terms resulted in limited understanding during the consent process. “I think some of our patients they do not understand what's going to be done. And I think it's based on a number of things. Maybe their level of education because even if you explain to them, they may not comprehend and know what will be done. It is challenging that way” --KII 1, doctor, Public hospital. Some family members signed informed consent rapidly without understanding what was to be done. According to emergency staff, patients in an emergency setting sometimes consented under the pressure of the emergency. “…even when you tell them sign here it is always very fast without even reading. For some who can read we tell them to first read through. The moment you tell them surgery they ask you how much, sign here, where can we sign like whatever you are explaining they are not understanding because they are afraid of the patient” --KII 12, doctor, Private hospital. “In casualty patients are desperate, panicking even the attendants and they accept anything. ……The attendants think that their right to informed consent is taken away…so anxious, so panicky such that they think they are being totally helped and that they don’t have rights for a decision” --KII 5, doctor, Public hospital. Poor working environment. Some participants in the public hospital noted that the environment lacked privacy and was crowded making it hard for doctors to discuss and obtain consent from patients for surgery. Some participants in the public hospital reported that high patient volumes contributed to the overcrowding and hindered the consent process. “It [emergency area] is a marketplace at the moment. It is not a good place where you can give consent. There is no privacy. The whole environment is not patient friendly and not only that but not even doctor friendly” --KII 6, doctor, Public hospital. It was noted that the absence of guiding protocols for consent in difficult emergency situations made the consent process challenging for the emergency staff. “Maybe they should put somewhere that if the patient is not able, I can consent for them. It should be there with some information about when this should be done and the circumstances when this occurs should be outlined” --KII 10, nurse, Private hospital. Some participants mainly from the public hospital said there were limited specialists and social workers to support the consent process. “There might be some things which are lacking at that point, like support services make it difficult for us. You look at the patient and you probably say that you need a social worker is lacking.” --KII 1, doctor, Public hospital • Inadequate documentation of consent Some participants in the public hospital stated that the consent document was insufficient and did not capture what was done during the consent process and at times blanket consent was obtained. Inadequacies in the consent form e.g., lack of procedure - specific consent forms, missing details were also reported by emergency staff in the public hospital. “It's a blanket consent for which nothing is written to record what has been told to the patient.” --KII 2, doctor, Public hospital. “it [consent document] doesn’t specify all the details that are necessary for a patient to make a decision. The consent forms we use don't provide that opportunity or space for such details to be provided.” --KII 5, doctor, Public hospital. • Medicolegal challenges Emergency staff at the private hospital expressed fear of being sued by patients or their care takers if they did not obtain consent from the patients. “It is of utmost importance to respect patient’s dignity and their bodies; it has legal consequences resulting in litigation if a patient had a procedure done without their consent. There is a legal liability that can arise from not obtaining informed consent” --KII 9, doctor, Private hospital. The emergency staff faced challenges with patients who declined to consent because they were to undergo high risk procedures, could not meet the financial costs of the surgery, or disagreed with the proposed care. “Mostly here they involve as many people to explain to the patient. When the patient and they tell them the risks and the benefits and if they still refuse then we just refer the patient to other people. Another reason why patients refuse is because of financial implications. Those are the things that cause us problems” –KII- 11, nurse, Private hospital. Emergency staff noted that it is difficult to obtain valid informed consent for incapacitated patients without care takers or those whose next of kin is below 18 years and is not legally able to provide consent for the patient... “The challenge is that sometimes they are not 18 as next of kin. The process is now stuck. The patient is apparently not understanding what you have said, and they've come with a son or daughter who may be 15 or 16.” --KII 2, doctor, Public hospital • Financial and time constraints Lack of finances to pay for surgical services, drugs and equipment affect decision making in the consent process according to emergency staff at both institutions. “The challenges we get is that we are a private institution and the finances involved. Sometimes we are stuck, and it is an emergency and they do not have money and they want life, it loses meaning when they cannot proceed because of finances, even if they have understood and signed the consent forms. That is a challenge, and our hands are tied” --KII 12, doctor, Private hospital. “You might want to do something very urgently and it is an emergency to help the patient ……and there are some shortages in the hospital. Its one of the biggest challenges and you thinking of consenting a patient and yet they have nothing to use and they can’t buy the requirements.” --KII 6, doctor, Public hospital. Emergency staff at the public hospital noted that there was inadequate time for consenting in an emergency which affected patient understanding. “I think the biggest challenge is we rush the process.” --KII 7, doctor, Public hospital. Discussion Informed consent in an emergency setting has constraints of time and urgency of treatment which may be potentially life changing and may have uncertain outcomes. These challenges are increased for h a patient who might not have the capacity to provide the consent ( 4 ). During surgical emergencies, it might not always be possible to obtain informed consent from patients because the consent process could delay patients from receiving life-saving interventions. Obtaining informed consent may also be impossible in situations where patients have no capacity to understand or when their rights to consent have been waived( 6 – 8 ). Emergency staff should endeavor to obtain informed consent with adequate disclosure of the risks and alternative treatment options. This study described the experiences of emergency staff seeking consent for patients due to undergo emergency surgery. Their knowledge, attitudes and their practice of the informed consent process highlighted the challenges faced with surgical emergency informed consent in a resource limited setting. Knowledge and attitudes Emergency staff were well informed about informed consent, and this was demonstrated in their response to what the key elements of informed consent were. They indicated that informed consent is beneficial to them and protects in case of litigation. They acknowledged the challenges of limited time, inadequate information about the surgical procedure and the reluctance to disclose risk. As in other studies, emergency staff appreciate the importance of informed consent and have a positive attitude towards its practice. This was also reflected when all the emergency staff took their patients or their surrogates through the informed consent process although there were some gaps in information disclosure. Gaps between knowledge and what is practiced in an emergency setting where there are time constraints and no consensus on how much information should be disclosed have been described in other studies ( 9 – 11 ). Disclosure of consent in communication Emergency staff found it a challenge communicating the risks of the surgery to patient because they feared that patients would decline the surgical procedure. Communicating risk requires adequate knowledge of the procedure and good communication skills to facilitate understanding by the patient. Consent forms often do not have information about risks and the emergency staff often have challenges with communicating the risks ( 12 ). Verbal communication is sometimes combined with the use of visual aids in form of diagrams, videos, and brochures for elective surgery which may not be possible in an emergency setting where time is inadequate ( 13 ). However, some emergency staff reported that they used diagrams to communicate and explain surgical procedures which aided understanding for the patient although this was not observed. Disclosure during informed consent involves the benefits, risks, and possible complications of the procedure. Emergency staff challenges in communicating risk as reported in the interviews and as observed, were also noted in other studies( 14 , 15 ). The information provided should be done using simplified language which is easy for the patient to understand. In this study emergency staff noted that there was a challenge of adequate disclosure affected by language barrier, literacy level of the patient, time constraints and knowing how much information to give the patient as have been similarly found in other studies ( 14 ). The volume of information provided in an emergency setting should be limited to main complications and risks which encompass what should be understood and would guide meaningful discussion during the consent process ( 16 ). The emergency staff therefore need to identify the procedure specific critical information that should be disclosed to the patient within a limited time in an emergency. Understanding Emergency staff reported that during a surgical emergency, patients or their surrogate sometimes do not take time to understand the information provided because of the limited time needed to get the care needed for the patient. This perception by the emergency staff probably contributed to the observation that staff did not take time to ask if the patient or next of kin had understood the information given. has been is This finding is consistent with other scholars who noted challenges of confirming understanding of information provided during an emergency. ( 17 , 18 ). Studies have looked at assessment of understanding using teach-back method by physicians to improve patient understanding and health literacy although this has not been studied in an emergency setting ( 19 ). Participants suggested the use of visual aids to help improve understanding of the patients and studies have shown that aids like videos, brochures and diagrams are useful in improving patient understanding during the consent process ( 13 , 20 ). Administration and documentation of informed consent Our findings suggest that administration of consent is done by different people including nurses, junior doctors, and surgeons. In this study the nurses and junior doctors had challenges of adequate disclosure of information about the surgical procedures because they had inadequate knowledge about it. They preferred the surgeon to administer the consent. They also acknowledged the challenges of the surgeon having limited time to administer consent in a high-volume emergency unit. Emergency staff at both institutions noted that the consent form was inadequate and lacked a provision for documenting the information provided by the healthcare worker. Similar studies on doctors’ practices during surgical informed consent have shown information on the complications of surgery that have been discussed by the surgeon are often not documented in the consent form ( 10 , 21 , 22 ). In this study emergency staff felt protected by documentation of consent as has been noted in other studies ( 9 , 23 ). Timfote et al propose the use of 3 principles: equality, utility and justice when obtaining informed consent for emergency surgery ( 24 ). Equality is when all individuals have equal life worth and should receive equal treatment, utility refers to using limited resources for the greater good for the greatest number of individuals, while justice refers to prioritizing care according to the greatest emergency. Informed consent might not be obtained when a patient is in a clearly life or death situation and such situations need to be well documented ( 24 ). Challenges Challenges encountered by emergency staff in this study included communication of risks, fear of litigation, inadequate knowledge about the surgical procedures, inadequate time for consent and lack of guidelines for emergency consent. These challenges have been highlighted in other studies for consent for elective and emergency surgery ( 15 , 25 , 26 ). Surgeons also find it challenging to make rapid and deliberate decisions in acute and emergency surgery settings especially when they are alone and this affects their ethical judgement which is required when providing informed consent( 27 ). Lack of privacy during the consent process was observed in the public hospital which affects communication during the consent process. The public hospital is overcrowded unlike the private hospital emergency unit, and this contributes to lack of privacy. Overcrowding in emergency units results in inadequate privacy during the informed consent process for both the emergency staff and the patients. Conclusion Knowledge about consent practices by emergency staff is good but there is little time for adequate disclosure coupled with inadequate knowledge by nurses about the surgical procedure, risks, and benefits. Surgeons should be the ones administering consent. Consent documents need to be more procedure specific and should capture the information that is given to the patient during informed consent. Emergency staff at both institutions have challenges communicating the risks of surgery. Lack of guiding policies on consent for incapacitated patients who have no surrogates results in fear of litigation for the emergency staff. The environment in the public hospital where there are high patient volumes is not conducive and there is lack of privacy during the consent process. When emergency care is not free, emergency staff discuss financial implications of surgical care during the informed consent process. Declarations Ethics approval and consent to participate. Ethical approval to conduct the study was obtained from the School of Biomedical Sciences Research Ethics Committee of Makerere University College of Health Sciences (SBSREC – 831) Administrative clearance was obtained from the Research Ethics committee of both the private and public hospitals. All participants provided written informed consent to participate in the study for the key informant interviews. Informed consent was waived for the direct observation of the emergency staff, but administrative clearance was obtained from the heads of the Accident and Emergency Units at both the public and the private hospitals. Consent for publication. Not applicable Availability of data and materials The datasets used and /or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Research reported in this publication and funding for data collection, data analysis and manuscript writing were supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW010892 through the Makerere University International Bioethics Research Training Program. Authors’ contributions OK designed the study, coded transcribed interviews, analyzed the data, drafted the manuscript. IM designed the study, reviewed, and edited the manuscript. EM designed the study, coded the transcribed interviews, reviewed, and edited the manuscript. AT coded the transcribed interviews, reviewed and edited the manuscript. MG reviewed and edited the manuscript. All authors read and approved the final manuscript. Acknowledgements We acknowledge the support of Prof. Nelson Sewankambo who provided oversight of this research, the research assistants who conducted the interviews and the direct observations and the emergency staff and administration of the two health institutions where this research was conducted. References Beauchamp TL. Methods and principles in biomedical ethics. J Med Ethics. 2003;29:6. Childress TLBJF. Principles of Biomedical Ethics. 2013:495. Aacharya RP, Gastmans C, Denier Y. Emergency department triage: an ethical analysis. BMC Emerg Med. 2011;11(1):16. Muskens IS, Gupta S, Robertson FC, Moojen WA, Kolias AG, Peul WC, et al. When Time Is Critical, Is Informed Consent Less So? A Discussion of Patient Autonomy in Emergency Neurosurgery. World Neurosurg. 2019;125:e336–40. Boone HN Jr, Boone DA. Analyzing likert data. J Ext. 2012;50(2):48. Boisaubin EV, Dresser R. Informed consent in emergency care: illusion and reform. 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Supplementary Files AppendixIKeyinformantinterviewsquestionguidefinal.docx AppendixIIOBSERVATIONALCHECKLIST.docx Cite Share Download PDF Status: Published Journal Publication published 17 Dec, 2025 Read the published version in BMC Medical Ethics → Version 1 posted Editorial decision: Revision requested 02 Aug, 2024 Reviews received at journal 02 Aug, 2024 Reviewers agreed at journal 29 Jul, 2024 Reviewers agreed at journal 28 Jul, 2024 Reviewers agreed at journal 19 Jul, 2024 Reviews received at journal 16 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers agreed at journal 16 Jul, 2024 Reviewers invited by journal 16 Jul, 2024 Editor invited by journal 06 Jun, 2024 Editor assigned by journal 06 Jun, 2024 Submission checks completed at journal 06 Jun, 2024 First submitted to journal 24 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Uganda","correspondingAuthor":false,"prefix":"","firstName":"Erisa","middleName":"","lastName":"Mwaka","suffix":""}],"badges":[],"createdAt":"2024-05-24 13:39:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4472834/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4472834/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12910-025-01337-8","type":"published","date":"2025-12-17T15:58:18+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":59051201,"identity":"b9691563-d2b7-4113-b0e7-a8e5260a8c76","added_by":"auto","created_at":"2024-06-25 20:02:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":8758,"visible":true,"origin":"","legend":"\u003cp\u003eComparison of average Likert scales of observations of informed consent process at public versus private hospital\u003c/p\u003e","description":"","filename":"Onlinedrawingimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-4472834/v1/94197753ec68b371ec76d066.png"},{"id":98815056,"identity":"3906795c-9bb8-40e1-a24a-6abda9796cd3","added_by":"auto","created_at":"2025-12-22 16:13:19","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1309279,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4472834/v1/9988835b-ba4a-48a6-a719-00f791290ce1.pdf"},{"id":59052017,"identity":"62e4d835-92e2-436d-8211-6ba7779efdf2","added_by":"auto","created_at":"2024-06-25 20:10:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16687,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixIKeyinformantinterviewsquestionguidefinal.docx","url":"https://assets-eu.researchsquare.com/files/rs-4472834/v1/158f2afd11bc4634a3c9ddc4.docx"},{"id":59051203,"identity":"15d16529-ec46-4ca8-a7f0-6ed4bc2d1187","added_by":"auto","created_at":"2024-06-25 20:02:56","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":21580,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixIIOBSERVATIONALCHECKLIST.docx","url":"https://assets-eu.researchsquare.com/files/rs-4472834/v1/10a78445095e97d18ca62ddb.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eInformed Consent Practices Among Emergency Staff for Patients Undergoing Emergency Surgery in the Emergency Surgical Units of Two Tertiary Teaching Hospitals in Uganda: A Qualitative Study\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the surgical emergency room rapid decision-making is required which makes it difficult for the emergency physician to maintain the four Belmont report principles of ethical management of patients autonomy, non \u0026ndash; maleficence, beneficence and justice derived from the Hippocratic oath (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The emergency units in hospitals in low-income countries are often overcrowded and do not have the required privacy for adequate informed consent. Adequate informed consent involves informing patients about the surgical procedure, the risks and benefits and alternative treatment options with understanding of this information and documentation of consent by an individual with the capacity to consent. In some emergency surgical conditions, patients\u0026rsquo; capacity to provide consent is diminished and sometimes there is no accompanying caregiver, next of kin or surrogate decision maker to urgently provide consent for life-saving treatment. In such a scenario the surgeon may take on the responsibility to decide on care in the patient\u0026rsquo;s best interest (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This is because urgent care is required for life-threatening and life altering surgical conditions. In a teaching hospital, there are trainee surgeons who are often the first to diagnose the emergency surgical condition and carry out the surgery under the supervision of the surgeons. The trainee surgeons and other junior emergency staff seek informed consent from patients, their caregivers or next of kin. This study aimed to establish the informed consent practices for emergency surgical care among healthcare professional at two emergency surgical units at two tertiary teaching hospitals in Uganda. Our findings will contribute to improving the informed consent process for emergency care in low resource settings. We set out to compare informed consent practices among emergency staff in the setting of a public hospital and a private hospital where financial costs are involved.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design:\u003c/h2\u003e \u003cp\u003eIn October 2022 \u0026ndash; February 2023, we conducted a cross sectional qualitative study using key informant interviews, and direct observation of the emergency staff with nurses, intern doctors, surgery residents and surgeons. We used a phenomenological approach to describe the experiences and consent practices of emergency care staff in the emergency surgery setting. We aimed to understand the subjectivity of the consent process from the perspective of the emergency staff.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy setting:\u003c/h2\u003e \u003cp\u003eThe study was conducted in the Accident and Emergency Units at a public National Referral Hospital and a private hospital. Both hospitals were university teaching hospitals based in Kampala, the capital city of a low-income country Uganda. The Accident and Emergency unit is where most emergency surgery is carried out by surgery residents who are supervised by surgeons and work with intern doctors, nurses, and anaesthetists. Training of students both at undergraduate and postgraduate level occurs in these units making the units a reflection of what practices are expected in other health units following completion of training and going to practice all over the country.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSampling methods:\u003c/h2\u003e \u003cp\u003e We purposively selected 16 participants including nurses, medical officers, surgical residents, and surgeons who work in the emergency departments and were involved in soliciting informed consent process from patients scheduled for emergency surgery. Face to face key informant interviews were conducted with six participants from the private hospital and 10 participants from the public hospital. Emergency staff were also observed as they obtained consent from patients for emergency surgery. Participants at the private hospital were obtained from the head of the emergency unit who provided the telephone contacts of all nurses and doctors working full time within the Accident and Emergency unit. These were then contacted on phone and those who were interested in participating were invited to provide written consent to participation in the study. Participants at the public hospital were selected to get representation of at least 1 doctor from each of the surgical units of Orthopaedics, Neurosurgery, Gastrointestinal surgery, ENT, Cardiothoracic surgery, Urology and from 3 full time nurses attached to the Accident and Emergency Unit. Participants were contacted on phone and written informed consent was obtained from those who expressed interest in participating in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eKey informant interviews of the emergency department staff at each of the two tertiary teaching hospitals were conducted in a private staff room within the Accident and Emergency unit of the private hospital and in the department of surgery office for the public hospital. We used an interview guide (Appendix 1) that entailed open-ended questions and flexible probes to investigate perceptions and experiences. The key issues explored were knowledge about elements of informed consent, how informed consent was practiced and their experiences obtaining consent for an incapacitated patient with a surgical emergency, their attitude towards the informed consent process in terms of what they considered adequate, what should be included, what they liked and disliked about the consent process. Key informant interviews were conducted by the author who is a female PhD Bioethics fellow and a surgeon. Direct observation was done by two research assistants, one at each institution. The research assistant at the private hospital was a male third year surgery resident who had completed his rotation in the emergency unit and was conducting his own research in another area in surgery. The research assistant at the public hospital was a female fifth year undergraduate student of Bachelor of Medicine and Surgery who was trained by the author and had been conducting other research under supervision for 2 years. The author and the two research assistants had certification in Responsible Conduct of Research and Good Clinical Practice. Written informed consent was obtained from the participants for the key informant interviews and for audio recordings of the interviews. Interviews were conducted in English in a private room and confidentiality was maintained by avoiding the use of any identifiers like the participant\u0026rsquo;s name or surgical specialty. Each key informant interview lasted approximately 20\u0026ndash;30 minutes. Data saturation was achieved as there were no different issues arising from subsequent interviews following analysis that was done by the author and an independent reviewer after every four interviews. Interviews were audio-recorded with participant consent and transcribed verbatim in English for data analysis. Data collection was from October 2022 to February 2023. Data analysis occurred during the data collection period and continued until June 2023.\u003c/p\u003e \u003cp\u003eDirect observation of the emergency staff obtaining informed consent from patients was done without their knowledge and consent. Waiver of consent was obtained for direct observation of the emergency staff to avoid behavior being affected by the participants\u0026rsquo; awareness of being observed. However, administrative clearance was obtained from the health institution and the in-charges of the units to observe the emergency staff. Observation was done on four different days of the week and at four different times of the day at each of the two tertiary teaching hospitals to capture any variations in practice according to time of day or day of the week. The in-charge of the emergency unit was informed when any troubling issues were observed for remedial action to be taken. An observation checklist (Appendix II) was used to capture emergency staff practices during the informed consent process, communication, who does the consent, where it is done, when it is done. The checklist was generated from standard key components of the informed consent process and was a modification of the Process and Quality of Informed Consent Instrument (P-QIC) which is a four-point scale (well done, done, done poorly, not done) for 20 items Likert type scoring with a total score of 40\u0026ndash;100 for the whole encounter (Cohn, Jia, Smith, Erwin, \u0026amp; Larson, 2011). The checklist was modified to carry out 16 observations under 4 domains Communication skills, Disclosure, Voluntariness and Understanding and separate observations for privacy and confidentiality, presence and documentation of the consent form, duration of the consent process and who administered the consent.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe conducted an inductive thematic analysis of the data collected from key informant interview with different respondent categories such as nurses, medical officers, surgical residents, and surgeons. The analysis examined meanings, theme and patterns that manifested in particular texts from the interviews. Two independent coders individually read each transcript and identified key concepts to develop a coding framework. The coding framework was based on three transcripts that were manually reviewed and coded to generate the initial set of codes that were crosschecked iteratively between two coders for consensus and to improve reliability. All transcripts were imported into NVivo version 12 software computer-assisted qualitative analysis of data for open coding, management of data. A code book was developed, and the revised codes were grouped into categories and identified themes. Illustrative quotations for each emergent theme were selected for results narration. Participants did not provide feedback on the findings.\u003c/p\u003e \u003cp\u003eEach observation had a five-point Likert scale with each response ranging from 1\u0026ndash;5 corresponding to the range of poorly done to well done. Modes and medians were used to analyze each observation made from the Likert type scale. An average of each observation done at the four different times was calculated. An average of 2.5 and above showed that an observed activity was well done while a score of less than 2.5 was poorly done. A total score for all the observations out of a maximum of 80 and was converted into a percentage. A percentage score of 50 and above indicated an adequate informed consent process. Separate observations were made for the domains of privacy and confidentiality, documentation of the consent form, duration of the consent process and who administered the consent. These domains were assessed separately according to frequencies of each observation made for each domain.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMost of the study participants were male and majority were surgery residents for both the key informant interviews and direct observation. There were no surgeons observed or interviewed at the emergency units although they were available for consultation during emergencies. This is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eKey informant interviews\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eDirect observation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePublic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNurse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntern doctor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSurgery resident\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTotal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e10\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe report on the key findings from the key informant interviews and direct observation of the consenting process in the emergency.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eDirect observation of emergency staff\u003c/h2\u003e \u003cp\u003eDirect observation of emergency staff was done on four separate days for each study site and at four different times. The domains that were observed are summarized in Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDomains observed during informed consent for emergency surgery.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunication skills\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGreets and shows interest in the patient and or their next of kin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUses language that is easy to understand; avoids medical jargon\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eA3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntroduces themselves to the patient or next of kin\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eB\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisclosure\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the clinical diagnosis of the patient\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the treatment options\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the recommended treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the benefits of the treatment\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides possible risks of the surgical procedure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the treatment goal\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProvides information about the cost of the surgical procedure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eVoluntariness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOffers the patient or next of kin the opportunity to accept or decline the treatment offered\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient or next of kin given time to decide\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDecision made without pressure or coercion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eUnderstanding\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient or next of kin asked if they had any questions about the procedure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eD2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePatient or next of kin asked to re-state what procedure was to be done and the risks and benefits\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWe used a 5-point Likert scale for each observation under the above domains. The Likert scale is best used to measure attitudes, behaviour and personality traits (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), and was used to assess behaviour of the emergency staff during the informed consent process. The average Lickert scale values for each domain at the 4 different observation times was calculated and represented in the figure below and compared between the two institutions (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Further analysis of the different observations under the four domains Using simple language under communication skills and voluntariness domains were the better performed components of the informed consent process (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) Greeting of patients, information disclosure and assessment of understanding were poorly done. The emergency staff did not introduce themselves to the patients at both institutions except on one occasion at each of the institutions. Worst done at both institutions was disclosure of risks and assessment of understanding by asking them to repeat the procedure to be done, and the risks and benefits as told to them. (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe environment was noisy at both institutions with the environment in the public hospital always crowded with no privacy whereas that in the private hospital was not crowded and offered more privacy. Consenting at the private hospital was done by the nurses while at public hospital it was mainly done by the intern doctors and surgical residents. The duration of consent at both institutions was all less than 30 minutes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eKey informant interviews\u003c/h2\u003e \u003cp\u003eSix themes were derived from key informant interviews and these included knowledge and perspectives about informed consent; practices, processes, procedures, and practices regarding informed consent; communication strategies for informed consent; ethical considerations; benefits of informed consent during surgery; and challenges to the consenting process in emergency surgery. (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of themes and codes for key informant interviews of emergency staff\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTHEME\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCODES\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eKnowledge and perspectives on informed consent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Definition of informed consent\u003c/p\u003e \u003cp\u003e\u0026bull; Key components of consent documents for surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProcesses, procedures, and practices regarding informed consent.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Persons expected to administer consent and their roles.\u003c/p\u003e \u003cp\u003e\u0026bull; Duration of consenting emergency patients\u003c/p\u003e \u003cp\u003e\u0026bull; Decision making\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisclosure of informed consent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Factors enabling effective communication during informed consent.\u003c/p\u003e \u003cp\u003e\u0026bull; Type of information shared during informed consent.\u0026bull;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthical considerations\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Voluntariness\u003c/p\u003e \u003cp\u003e\u0026bull; Capacity to consent\u003c/p\u003e \u003cp\u003e\u0026bull; Documentation of consent\u003c/p\u003e \u003cp\u003e\u0026bull; Handling patients without care takers\u003c/p\u003e \u003cp\u003e\u0026bull; Beneficence.\u003c/p\u003e \u003cp\u003e\u0026bull; Right to information\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBenefits of informed consent during surgery\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Respect for patient autonomy.\u003c/p\u003e \u003cp\u003e\u0026bull; Confidence and protection of emergency staff and health institutions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChallenges of emergency informed consent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026bull; Inadequate disclosure\u003c/p\u003e \u003cp\u003e\u0026bull; Communication challenges\u003c/p\u003e \u003cp\u003e\u0026bull; Inadequate documentation of consent\u003c/p\u003e \u003cp\u003e\u0026bull; Poor working environment.\u003c/p\u003e \u003cp\u003e\u0026bull; Medicolegal\u003c/p\u003e \u003cp\u003e\u0026bull; Financial and Time constraints\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eTHEME 1: KNOWLEDGE AND PERSPECTIVES ON INFORMED CONSENT\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; Definition of informed consent\u003c/h2\u003e \u003cp\u003e All participants were knowledgeable about the definition of informed consent and its related components. They commonly described informed consent as a means to understand and seek permission for surgical procedures and or admission for patients. Consent could be written or verbal for surgery. Participants contended that informed consent entails explanation of specific health condition procedures and benefits to the patient as well as patient\u0026rsquo;s voluntary decision to undergo a surgical or a medical intervention.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Informed consent first of all is a process which we normally use for patients who need an intervention. It might be a surgical intervention or a medical intervention. We give information preferably written about what the intervention is, the benefits, the risks of the intervention. Sometimes we explain how for the procedure or the condition how it comes about, what brought it and how we can manage it\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Key components of consent documents for surgery\u003c/h2\u003e \u003cp\u003e Participants mentioned the key components of an informed consent document for emergency surgery. The major component of an informed consent form mentioned by the majority of participants included details of the patient including name, age, date and time, address and contact. Other components mentioned were the signature of patient, name of surgeon, witness, indication of the surgery, for the patient that is not able to give a written consent for example in view of disability or for a child.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I would want to see the time and date, the place where the patient signs or the attendant signs. I want to see the place where the witness signs or the one has taken the patient through the consent process. I would want clear information about where you document what you have told the patient, clear Information, not what I see. It is better in my view. The document I see in Casualty unit is insufficient because it is giving just the name of the patient, the doctor and the witness\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e All the participants stated that the consent document should include potential risks, complications and outcomes about surgery. One participant noted that consent documents should contain a provision to consent for sharing any photography or images taken during a surgical procedure.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;They would capture what they are suffering from their diagnosis, benefits of the procedure, complications associated with the procedure, 5. Who is the surgeon who is going to perform the procedure. \u0026hellip; Photography during the procedure\u0026rdquo;\u003c/em\u003e --KII 4, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e One participant wanted information about surgery procedures and processes, materials to be used and medicines(drugs) supplied during surgery to be included in the consent document.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;1. The procedure to be done.needs to be written clearly and boldly and explained to the patient 2. Medicines e.g., analgesics, antibiotics, Sedatives we need to be talked about in the consent. 3. The material to be used for the operation should be mentioned e.g if you are going to use artificial valves or prostheses or grafts\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e One participant noted that an option that verbal consent will be obtained should be clearly stated and documented for specified procedures.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The patient can consent verbally for minor procedures e.g., doing vitals and putting a canula they do not give a written consent. We do not need a written consent and they give a verbal consent. Here we do for minor procedures e.g., STS and catheterization\u0026rdquo;\u003c/em\u003e --KII 11, nurse, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTHEME 2: PROCESSES, PROCEDURES AND PRACTICES OF INFORMED CONSENT.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePerson expected to administer consent and their roles.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants from both hospitals stated that surgeons should administer consent because they were experienced and have the capacity to offer accurate information to patient concerning the surgery. This was at both hospitals where consent was sometimes administered by the nurses.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If possible, if the specialist going to do the operation is available or is nearby, we also prefer for them to be involved so that the caretaker or the patient can see the person who is going to perform the surgery, they can also come and give more information. But sometimes they are very busy, and we do it but in case they don\u0026rsquo;t come the doctors in the department should be the people to administer consent not the nurses because it will be a matter of sign here sign there\u0026rdquo;\u003c/em\u003e --KII 12, nurse, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;\u0026rsquo;In my opinion the Surgeon who is going to carry out the procedure is the one supposed to take consent from this patient because they best understand what is going to be done, what is associated with what is likely to be done. They also best understand that if plan A fails then what plan B is available during the surgery. But the nurse may not understand this. The surgeon knows when to carry out the procedure should be the one obtaining the consent\u0026rsquo;\u003c/em\u003e--KII 3, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eFor patients who are unconscious and had no caretakers present to give consent, participants from both hospitals stated that the heads of accident and emergency, consultant surgeons, surgical residents managing the patient should consent on behalf of the patient.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There are certain conditions when the patient is not able to consent for themselves then either the medical professional like the head of the hospital can consent for the patient if it is urgently needed\u0026rdquo;\u003c/em\u003e --\u003cem\u003eKII 11, nurse, Private hospital.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Duration of consenting emergency patients\u003c/h2\u003e \u003cp\u003e Participants noted that the duration of the consenting process depends on the urgency of the procedure and the patient load. Participants pointed out that the duration of the consenting procedure was shorter for patients requiring emergency surgery and when there was a heavy patient load.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In an emergency when a patient needs a particular procedure\u0026hellip; we consent patients in a short period of time depending on the urgency. Therefore, we may not give them adequate time to decide on the procedure, whether they would like it or not, and whether they would ask, what would we have done at another time or not. We usually come and probably talk to the patient and the attendants obviously we explain the diagnosis and what's to be done\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The cases we get which normally go to theatre are not so many they are mainly head injuries. In a week we might see 5\u0026ndash;10 cases which are admitted via theatre\u0026hellip;It[consenting] takes a very short time. Different cases e.g. obstructed hernia which doesn\u0026rsquo;t involve so many things or many risks we take about 5\u0026ndash;10 minutes. If they have understood most patients do not want to delay once you have told them it is emergency surgery. We don\u0026rsquo;t take more than 10 minutes\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Decision making\u003c/h2\u003e \u003cp\u003eParticipants indicated that they expect patients to make an individual decision but noted that often times family members and other surrogates participate in decision-making.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;But it is the patient to sign for himself. If the patient does not consent or in some cases the patient does not want to reveal their condition to the relatives. But if the caretakers are around, we explain to them so that they can also get confidence in case the patient delays in theatre they understand\u0026rdquo;\u003c/em\u003e --KII 11, nurse, Private hospital.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;There need to be other people other than the patient involved in the process. it might be the patient's relative or friend. Even if someone is above 18 years there needs to be someone there so that the person can be a witness\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We explain to the patient, and we normally involve one or two caretakers or family members because we do not want crowding in the emergency area. Sometimes family members also help in the process to help the patient to make a choice because you find that they are the people who are going to pay the money, so we have to involve them. It is always very fast if it is an emergency. At times when they are thinking about the condition of the patient, they don\u0026rsquo;t internalize what we are telling them\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e Participants reported that other people like other family members and caretakers who pay the patient\u0026rsquo;s medical bills and are not physically present during the consent process, participate and help patients to make a choice based on whether they can afford to cover the costs for surgery.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Occasionally they make phone calls to those who can support them financially to take care of the financial implications of the operation. We do not always have to talk about finances during emergency consent process, but it is an important thing and there is an option of having this emergency procedure done at a place where they can afford\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e Participants acknowledged that sometimes there are differences in opinion about the treatment options from different emergency staff and this affects consent because it causes confusion for the patient.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We have gotten them sometimes when the patient has been consented earlier and the patient is stable. We usually base on the primary consent but we explain to the patient. That is something that has to be improved on. Then even among the Ortho team we have different people on call. I could come and give the patient a different treatment plan and I can look at their condition and say that we can push it to tomorrow. When my colleague comes may say that this is urgent and needs to be dealt with immediately. This confuses the patient\u0026rdquo;\u003c/em\u003e --KII 6, doctor, Public hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eTHEME 3: DISCLOSURE OF INFORMED CONSENT\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eFactors enabling effective communication during informed consent.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003e Emergency staff stated that the major communication channel for informed consent is face to face verbal communication where the healthcare worker introduces themselves to the patient and tries to create a rapport with patients or care takers.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I welcome the patient, triage, take vitals and then take them to the place where I will examine her. I tell [the patient] my names and what I am going to do. After they have accepted and seen that surgery needs to be done. Then I bring the consent form and I ask them to help me to fill this form so that we can operate\u0026rdquo;\u003c/em\u003e --KII 10, nurse, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;what I think is first, we create rapport with the subject either the patient or attendant. Rapport involves proper identification of yourself to the patient or attendant and also understanding whether you are dealing with the right patient or attendant managing the patient. And then you try to understand to what level do they know about what is happening to them. Do they know about their condition? You must probe to know what they know then you give them what they should know as per, what you want to do\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eThe health care workers noted that clear and elaborative explanation to the patient about surgery procedures is given including complications and other treatment options and the implications of their options.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; the health care provider is able to explain in detail to the patient or the one who is coming to receive the service, about their condition, the diagnosis that they have, the intervention that is going to be offered plus the complications that are associated with the intervention that is going to be offered. And then once this is arrived at then the receiver or the patient decides whether they are willing to take up the treatment option or not without being coerced, but after understanding in detail what they have been explained to\u0026ndash;K\u003c/em\u003eII 4, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eEmergency staff reported that sometimes consent is sought via phone calls to next of kin who are not present to aid the patient during the consent process. In certain circumstances the phone call involves consent to avail financial support where surgical services are not free like in the private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;we try to ensure that we get the consent from the attendants and sometimes we have to get their numbers and call them for them to provide consent\u0026rdquo;\u003c/em\u003e --KII 8, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003eOccasionally they make phone calls to those who can support them financially to take care of the financial implications of the operation. We do not always have to talk about finances during emergency consent process, but it is an important thing and there is an option of having this emergency procedure done at a place where they can afford\u0026ndash;K\u003c/em\u003eII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003eSome participants indicated that they use pictorials and illustrative diagrams to explain the disease condition and the procedure the patient is to undergo.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eNormally what we do, you explain, I use diagrams explain, for instance, after we explain the pathology, basically we told the attendant sign here and the attendant sign, but most of the time we put the data ourselves and also, we write the name of the surgeon ourselves. So, a lot of times the weakness is in us\u0026rdquo;\u003c/em\u003e --KII 7, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e Most of the participants noted that the language used during informed consent should be simple to enable patient to understand and that for those who did not understand English, a translation of the consent form to appropriate language like Luganda was used.\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;We give them[patients] time to read through consent for admission as they sign and if they can\u0026rsquo;t read you read for them. If they don\u0026rsquo;t understand English because it is in English, we explain to them what is in that consent knowing what they are signing rather than telling them to sign here, sign there what they don\u0026rsquo;t know. The other thing is our surgery consent form it has both parts Luganda and English. Someone who does not understand English the Luganda bit works\u0026rdquo;\u003c/em\u003e --KII 11, nurse, Private hospital.\u003c/p\u003e \u003cp\u003ePatients or caretakers are given time to ask questions regarding surgery and whether they agree to the procedure.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Providing the patient with information about the examination, investigations, procedure or other treatment prior to doing the same on the patient. Making sure the patient understands the information, giving the patient the room to ask questions and making the patient understand that they have the right to refuse consent or treatment or planned procedure\u0026rdquo;\u003c/em\u003e --KII 9, nurse, Private hospital.\u003c/p\u003e \u003cp\u003eParticipants pointed out that obtaining consent in the emergency setting requires a multi-disciplinary approach. The surgeons, nurses, anesthesiologists, and other healthcare professional all have a role to play to ensure that patients understand during the consenting process, as illustrated in the following quotes.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Then finally with the help of the nursing staff, the surgeon, the nursing staff and I are all involved in the consent. I find it to be a multidisciplinary consent where the examining clinician seeks consent for examination, investigations and diagnosis and the operation. Then the same is emphasized by the surgeon on review of the patient prior to the surgery\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We usually come and probably talk to the patient and the attendants obviously we explain the diagnosis and what's to be done. But consent needs to be multidisciplinary. In that point there is a missing link because the doctors talk to the patient, but the anesthesiologist is not there and we have other things missing\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eType of Information shared during informed consent.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eParticipants stated benefits, risks, implications of refusal to consent, and outcome of surgery as the major type of information shared. They argued that sharing of risks of surgery enables patients to make an informed decision regarding surgery.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Then with that you also give them the challenges and the benefits and the complication of your intervention so that they can decide whether to go ahead with the surgery. I think rapport gathering information from the attendants and the patients, providing information about the procedure including risks and benefits and some alternatives if they are there and the complications. Asking them whether they agree to the procedure\u0026hellip;They must know because that is the whole idea of informed consent so that they accept knowing the risks. There's no surgery which doesn't have a risk so you must tell them the risk.\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eParticipants said that they inform patients about the benefits of the proposed surgical procedures and reassure them on potential success of surgery. They also reported that they give patients the opportunity to ask questions to ensure that patients understand.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The kind of information we give depends on the type of operation. We explain to them the procedure, the benefits, if there are any risks, we have to inform them. We reassure them that the operation will go very well, not to worry and will be successful\u0026rdquo;\u003c/em\u003e --KII 10, nurse, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Then you ask for their opinion, and you ask from what you have heard do you accept to have the procedure, or do you have some reservations which you want to communicate and some questions you want clarification on.\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eParticipants noted that they provide information about alternative treatment options, guidance on the preferred treatment option and the consequences of not consenting to surgery.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;then after that you tell them[patients] about the other alternatives you would have taken and why you have not taken them and why you have chosen that.\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Then we have to explain to the family the decisions that we think are better for them for the situation they are in. After explaining to them, we give them the possibility, the benefit of the surgery and the risks. At the same time, we tell them if they don\u0026rsquo;t consent what may happen if they don\u0026rsquo;t get the surgery\u0026rdquo;\u003c/em\u003e --KII 6, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003eParticipants mentioned that they also discuss the cost associated with the surgery and hospitalization\u003c/em\u003e. \u003cem\u003e\u0026ldquo;First of all being a private hospital we have to explain to them the financial cost. This affects the numbers, for those who can afford its ok. During the informed consent process, we have to tell them about the financial cost, and we send them to the cashier and sometimes involve the social worker to process the bills\u0026rdquo;\u003c/em\u003e KII 8, nurse, Private hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eTHEME 4: ETHICAL CONSIDERATIONS\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; Voluntariness\u003c/h2\u003e \u003cp\u003eParticipants noted that patients must make voluntary decisions without any coercion or undue influence.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Informed consent is the process of getting voluntary permission from the patient for any procedure that you are going to perform on them. They should not be coerced; you give them all the necessary information. They are a liberty whether to decide to the surgery or not to decide. You give them all the necessary information and they are allowed to decide for the medical intervention or to refuse the medical intervention.\u0026rdquo;\u003c/em\u003e --KII 6, doctor, Public hospital.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Capacity to consent\u003c/h2\u003e \u003cp\u003eEmergency staff noted that a patient should have the mental capacity to consent and should understand the information shared. Adults aged-18 years and above were eligible to consent for self or with the help of their next of kin.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The patient should have the capacity to consent, should be 18 years and above, information should be given about the procedure, and they understand and giving them room to ask questions and letting them be aware that they have a right to decline to consent\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003eThey acknowledged that some patients do not have the capacity to consent in an emergency setting because they were unconscious, mental disability or were children less than 18 years of age. Emergency staff suggested that the legal capacity of the surrogate decision maker should also be verified in such instances.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;if there is someone consenting on behalf of the patient to do this on my patient state the relationship.\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;What level do they understand this patient? Are they closed relatives? Are they just friends? Are they good Samaritans? Because some decisions vary. What a mother or a wife would sign for their patient is different from what a good Samaritan would sign.\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Another important part consent is supposed to be given by the patient if they are able. In case a patient is not able to give consent, the person giving consent has an area where he has to put the reason why the real patient was not able to give consent. The patient can be unconscious, patients with disability, maybe a child\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003c/p\u003e \u003cp\u003eThe emergency staff also observed that sometimes attendants are asked to sign for patients even though the patient had the capacity to consent for themselves.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Usually what happens is make the decision to operate, and as the patient is being wheeled into casualty. Basically, as they are changing, usually that is when we do the consent and basically what we do, the majority of times it's not actually the patient themselves, even when they have capacity, so the majority of times it is attendants who give consent on behalf of patients\u0026rdquo;\u003c/em\u003e --KII 7, doctor, Public hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Documentation of consent\u003c/h2\u003e \u003cp\u003eThere are two types of consent forms at the private hospital which were termed general/admission and emergency consent forms. Emergency staff noted that the doctor should sign the consent form to confirm that they have explained to the patient and a nurse then signs as the witness. One participant reported that what the doctor explained to the patient should be documented as proof of what was discussed. Patients who are unable to sign should use a thumb print instead of a signature.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;So, we have high risk consent forms both medical and surgical, then we have the general consent forms. What we do first is to get the right condition for the right patient and if we think the patient needs surgery so we categorize does this patient need emergency surgery or is its urgent surgery or can this patient be worked up we wait and then plan for the surgery (electives). That\u0026rsquo;s what we do. If it\u0026rsquo;s an emergency, we have emergency consent forms\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003ewas done for.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip; they will not be able to hold a pen to sign, but they will allow you to get a thumb print. So, you get a pen and shade the thumb and then they put it there.\u0026rdquo;\u003c/em\u003e --KII 2, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Unfortunately, all that I say is not written down. If there is a way in which me the provider can be helped to write it down. Let's say they leave a space where you say Dr\u0026hellip; this is what you have explained to the patient in 3 or 4 lines. I have explained that this will happen, this will happen, this will be good. I think that would be beneficial for that informed process.\u0026rdquo;\u003c/em\u003e --KII 2, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eFor some minor procedures, emergency staff obtained verbal consent, and this is not documented.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The patient can consent verbally for minor procedures e.g. doing vitals and putting a canula they do not give a written consent. We do not need a written consent and they give a verbal consent.\u0026rdquo;\u003c/em\u003e --KII 11, nurse, Private hospital\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;As for us nurses the doctor explains to the patient then I also reinforce and re-explain to the patient. Then I make the patient sign\u0026hellip;... The doctor may have to sign because they are the ones who explain to the patient what is going to be done. I go through again with the patient and then I sign as a witness\u0026rdquo;\u003c/em\u003e --KII 11, nurse, Private hospital.\u003c/p\u003e \u003cp\u003eSome emergency staff reported that patients who required more than one type of surgery were operated upon based on the consent obtained by one surgical team.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most times when we are called in those patients have already undergone certain procedures. When the first team on board calls us we go forward to explain to the patient. But we tell them what we are going to do, although our assumption is the first team got consent and this is an emergency\u0026rdquo;\u003c/em\u003e --KII 2, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u003c/em\u003e \u003cb\u003eHandling patients without care takers\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the public hospital one participant noted that if a patient was unconscious without a caretaker the consent is waivered by the medical team. The head of the emergency unit, surgical resident on duty, the consultant on duty and administrator counter signed for patients without care takers.\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;We have a number of unknowns who come to the ward and a number of times they need surgery but there is no one to consent for them. So usually in those instances especially for the unknowns, we have counter signing by head of the Accident and Emergency unit with the Administrator for the unit if they are available. But in the night, it is a little bit of a challenge. And so most of the time in the night, it's the SHO or any of the surgeons who is available who takes the consent form this patient if they need that emergency surgery. For the minors there is no clear policy so it will depend on the will now of the parents who bring these patients here. I think the good observation, I think also need to create a policy about that\u0026rdquo;\u003c/em\u003e --KII 3, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eOne participant from the private hospital stated that medical workers do not perform surgeries on patients without caretakers but referred them to the public hospital to avoid liability.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We sometimes refer patient who cannot consent or refuse to consent and therefore the liability and repercussions of refusing surgery goes to someone else. We refer them to the national referral hospital so that we do not take up this liability\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBeneficence.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eEmergency staff determined the benefit of surgery to patient before seeking informed consent. This was to avoid doing more harm than good.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;That means we have to explain to the patient or the attendant their diagnosis and after the diagnosis, then we can talk about getting informed consent because sometimes there might be no need for some procedures to be done if the patient is too sick or won\u0026rsquo;t benefit. So that's an important thing. Then after that we look at the procedure itself. Is it doing better than harm? Those are important facts that need to be balanced. In the conversation.\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Right to information\u003c/h2\u003e \u003cp\u003e Patient had a legal right to information during consent.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;you do not just go and work on a patient something which they haven\u0026rsquo;t understood. You see people here coming and saying they have removed my kidney when they did something else. If you have informed the patient what you are going to do and you have explained to them if you are going to remove an organ you tell them so that they do not complain later because it has legal issues. It is even the patients right to know what is going on to their lives and what one is going to do\u0026rdquo;\u003c/em\u003e --KII 11, nurse, Private hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eTHEME 5: BENEFITS OF INFORMED CONSENT\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; Respect for patient autonomy\u003c/h2\u003e \u003cp\u003e Majority of participants stated that informed consent was beneficial to emergency staff and mainly patients. Most participants said the informed consent for surgical care is patient-centered and is a sign of respect. They added that informed consent gives patients the opportunity to make choices concerning their clinical care.\u003c/p\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;In this day and age consent is very paramount because. It gives a patient liberty to choose. The health care system the drive is now more patient-centered than physician-centered\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Confidence and protection of emergency staff and health institutions\u003c/h2\u003e \u003cp\u003eEmergency staff felt that informed consent gave them protection and peace of mind because there was transparency in the care offered to the patient. They also reported that informed consent protected the institution from legal implication by patients or care takers. Emergency staff acknowledged that informed consent helped in building rapport and trust with the patients who were grateful when doctors explained to them or caretakers about the disease condition, diagnosis, intervention, and complications.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think it is important because it can be a medicolegal issue. I have seen some cases where people have sued and there are lawsuits where a procedure was performed and there were complications and the patients\u0026rsquo; attendants take them to court. One of the things that can save them is if the patient or the attendant had signed and understood that they were going to have a procedure and the complications that could happen\u0026hellip;Informed consent is important because by the time everyone signs one has understood. It helps everyone to know what exactly is going to be done. I think it protects us and the patient\u0026rdquo;\u003c/em\u003e --KII 8, doctor, Private hospital.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eTHEME 6: CHALLENGES TO INFORMED CONSENT FOR EMERGENCY SURGERY\u003c/h2\u003e \u003cdiv id=\"Sec26\" class=\"Section4\"\u003e \u003ch2\u003e\u0026bull; Inadequate disclosure\u003c/h2\u003e \u003cp\u003eEmergency staff noted that a major challenge was inadequate disclosure of information to patients because of knowledge gaps, and lack of time for surgeons during the consent process to discuss the whole surgery process in detail. Emergency staff at the public hospital admitted that information provided to the patients was inadequate because of inadequate knowledge about the surgery by the healthcare worker who is obtaining consent from the patient. Sometimes the surgeons left the consent process to nurses or junior doctors who lacked adequate information.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes we as medical personnel are not able to know all the outcomes of the procedure. If something else happens which we have not told them the surgeons need to tell them since I am the medical officer and I might not know all the risks\u0026rdquo;\u003c/em\u003e --KII 8, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Most of the time the consent is more or less left to the nursing team who also don't have sufficient knowledge to explain to the patient and so it leaves a big gap of understanding for the patients. But now because most of the patients we have are vulnerable they have no option but to sign what has been presented to them\u0026rdquo;\u003c/em\u003e --KII 3, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eSome participants in the private hospital reported poor understanding by the healthcare providers of some principles of informed consent like respect for the patient\u0026rsquo;s autonomy.\u003c/p\u003e \u003cp\u003e\u003cem\u003e \u0026ldquo;There is no doubt that many times we make informed consent without going back to the principles of it. We need to take time as professionals to read more widely on informed consent, get its underlying principles e.g. respect for human dignity and their bodies, knowing that it can result in legal liabilities if not considered. We need to refresh our knowledge on informed consent\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section3\"\u003e \u003ch2\u003e\u0026bull; Communication challenges\u003c/h2\u003e \u003cp\u003e Participants expressed communication challenges in the form of fear of communicating risks, language barrier and time constraints to communicate adequately. Emergency staff stated there was fear for some medical workers to describe to patients about the risks of surgery.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When you are seeking consent from patients you are afraid that describing risks will stop the patients from giving consent. So, a lot of times, we actually either don't give all the risks or give a few or don't play them up\u0026rdquo;\u003c/em\u003e --KII 7, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eLanguage barrier was coupled with complex medical jargon which was difficult to simplify or translate into a form which patients would understand.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Sometimes we use words that are in medical terms e.g. herniorrhaphy even after explaining to the patient and they have understood, it is hard to put these terms in the patient\u0026rsquo;s own language that they have understood.\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;What I don't like about it is that we rush it. We don't communicate to the patients well. I also don't like that sometimes it's very hard to communicate the problem. I think we don't do it as well as we should. It is rushed\u0026rdquo;\u003c/em\u003e --KII 2, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eOne participant in the public hospital said it was difficult for emergency staff to explain to patients about procedures with high risk of morbidity or mortality.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The other one is at an individual level I don\u0026rsquo;t find it very comfortable to consent someone for a procedure when it is not going to be beneficial or that may result in permanent disability specifically. I would request someone else to do it\u0026rdquo;\u003c/em\u003e --KII 6, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eEmergency staff reported communication challenges due to poor patient understanding due to illiteracy and poor comprehension of complex medical terms resulted in limited understanding during the consent process.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think some of our patients they do not understand what's going to be done. And I think it's based on a number of things. Maybe their level of education because even if you explain to them, they may not comprehend and know what will be done. It is challenging that way\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e Some family members signed informed consent rapidly without understanding what was to be done. According to emergency staff, patients in an emergency setting sometimes consented under the pressure of the emergency.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;even when you tell them sign here it is always very fast without even reading. For some who can read we tell them to first read through. The moment you tell them surgery they ask you how much, sign here, where can we sign like whatever you are explaining they are not understanding because they are afraid of the patient\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;In casualty patients are desperate, panicking even the attendants and they accept anything. \u0026hellip;\u0026hellip;The attendants think that their right to informed consent is taken away\u0026hellip;so anxious, so panicky such that they think they are being totally helped and that they don\u0026rsquo;t have rights for a decision\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003ePoor working environment.\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eSome participants in the public hospital noted that the environment lacked privacy and was crowded making it hard for doctors to discuss and obtain consent from patients for surgery. Some participants in the public hospital reported that high patient volumes contributed to the overcrowding and hindered the consent process.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It [emergency area] is a marketplace at the moment. It is not a good place where you can give consent. There is no privacy. The whole environment is not patient friendly and not only that but not even doctor friendly\u0026rdquo;\u003c/em\u003e --KII 6, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eIt was noted that the absence of guiding protocols for consent in difficult emergency situations made the consent process challenging for the emergency staff.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Maybe they should put somewhere that if the patient is not able, I can consent for them. It should be there with some information about when this should be done and the circumstances when this occurs should be outlined\u0026rdquo;\u003c/em\u003e --KII 10, nurse, Private hospital.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Some participants mainly from the public hospital said there were limited specialists and social workers to support the consent process.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There might be some things which are lacking at that point, like support services make it difficult for us. You look at the patient and you probably say that you need a social worker is lacking.\u0026rdquo;\u003c/em\u003e --KII 1, doctor, Public hospital\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Inadequate documentation of consent\u003c/h2\u003e \u003cp\u003eSome participants in the public hospital stated that the consent document was insufficient and did not capture what was done during the consent process and at times blanket consent was obtained. Inadequacies in the consent form e.g., lack of procedure - specific consent forms, missing details were also reported by emergency staff in the public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It's a blanket consent for which nothing is written to record what has been told to the patient.\u0026rdquo;\u003c/em\u003e --KII 2, doctor, Public hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;it [consent document] doesn\u0026rsquo;t specify all the details that are necessary for a patient to make a decision. The consent forms we use don't provide that opportunity or space for such details to be provided.\u0026rdquo;\u003c/em\u003e --KII 5, doctor, Public hospital.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003e\u0026bull; Medicolegal challenges\u003c/h2\u003e \u003cp\u003eEmergency staff at the private hospital expressed fear of being sued by patients or their care takers if they did not obtain consent from the patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It is of utmost importance to respect patient\u0026rsquo;s dignity and their bodies; it has legal consequences resulting in litigation if a patient had a procedure done without their consent. There is a legal liability that can arise from not obtaining informed consent\u0026rdquo;\u003c/em\u003e --KII 9, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e The emergency staff faced challenges with patients who declined to consent because they were to undergo high risk procedures, could not meet the financial costs of the surgery, or disagreed with the proposed care.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Mostly here they involve as many people to explain to the patient. When the patient and they tell them the risks and the benefits and if they still refuse then we just refer the patient to other people. Another reason why patients refuse is because of financial implications. Those are the things that cause us problems\u0026rdquo;\u003c/em\u003e \u0026ndash;KII- 11, nurse, Private hospital.\u003c/p\u003e \u003cp\u003eEmergency staff noted that it is difficult to obtain valid informed consent for incapacitated patients without care takers or those whose next of kin is below 18 years and is not legally able to provide consent for the patient...\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The challenge is that sometimes they are not 18 as next of kin. The process is now stuck. The patient is apparently not understanding what you have said, and they've come with a son or daughter who may be 15 or 16.\u0026rdquo;\u003c/em\u003e --KII 2, doctor, Public hospital\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e• Financial and time constraints\u003c/h3\u003e\n\u003cp\u003e Lack of finances to pay for surgical services, drugs and equipment affect decision making in the consent process according to emergency staff at both institutions.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The challenges we get is that we are a private institution and the finances involved. Sometimes we are stuck, and it is an emergency and they do not have money and they want life, it loses meaning when they cannot proceed because of finances, even if they have understood and signed the consent forms. That is a challenge, and our hands are tied\u0026rdquo;\u003c/em\u003e --KII 12, doctor, Private hospital.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You might want to do something very urgently and it is an emergency to help the patient \u0026hellip;\u0026hellip;and there are some shortages in the hospital. Its one of the biggest challenges and you thinking of consenting a patient and yet they have nothing to use and they can\u0026rsquo;t buy the requirements.\u0026rdquo;\u003c/em\u003e --KII 6, doctor, Public hospital.\u003c/p\u003e \u003cp\u003eEmergency staff at the public hospital noted that there was inadequate time for consenting in an emergency which affected patient understanding.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I think the biggest challenge is we rush the process.\u0026rdquo;\u003c/em\u003e --KII 7, doctor, Public hospital.\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003e \u003cstrong\u003eInformed consent\u003c/strong\u003e \u003cp\u003ein an emergency setting has constraints of time and urgency of treatment which may be potentially life changing and may have uncertain outcomes. These challenges are increased for h a patient who might not have the capacity to provide the consent (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). During surgical emergencies, it might not always be possible to obtain informed consent from patients because the consent process could delay patients from receiving life-saving interventions. Obtaining informed consent may also be impossible in situations where patients have no capacity to understand or when their rights to consent have been waived(\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Emergency staff should endeavor to obtain informed consent with adequate disclosure of the risks and alternative treatment options. This study described the experiences of emergency staff seeking consent for patients due to undergo emergency surgery. Their knowledge, attitudes and their practice of the informed consent process highlighted the challenges faced with surgical emergency informed consent in a resource limited setting.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and attitudes\u003c/h2\u003e \u003cp\u003eEmergency staff were well informed about informed consent, and this was demonstrated in their response to what the key elements of informed consent were. They indicated that informed consent is beneficial to them and protects in case of litigation. They acknowledged the challenges of limited time, inadequate information about the surgical procedure and the reluctance to disclose risk. As in other studies, emergency staff appreciate the importance of informed consent and have a positive attitude towards its practice. This was also reflected when all the emergency staff took their patients or their surrogates through the informed consent process although there were some gaps in information disclosure. Gaps between knowledge and what is practiced in an emergency setting where there are time constraints and no consensus on how much information should be disclosed have been described in other studies (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003eDisclosure of consent in communication\u003c/h2\u003e \u003cp\u003eEmergency staff found it a challenge communicating the risks of the surgery to patient because they feared that patients would decline the surgical procedure. Communicating risk requires adequate knowledge of the procedure and good communication skills to facilitate understanding by the patient. Consent forms often do not have information about risks and the emergency staff often have challenges with communicating the risks (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Verbal communication is sometimes combined with the use of visual aids in form of diagrams, videos, and brochures for elective surgery which may not be possible in an emergency setting where time is inadequate (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, some emergency staff reported that they used diagrams to communicate and explain surgical procedures which aided understanding for the patient although this was not observed.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDisclosure\u003c/strong\u003e \u003cp\u003eduring informed consent involves the benefits, risks, and possible complications of the procedure. Emergency staff challenges in communicating risk as reported in the interviews and as observed, were also noted in other studies(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The information provided should be done using simplified language which is easy for the patient to understand. In this study emergency staff noted that there was a challenge of adequate disclosure affected by language barrier, literacy level of the patient, time constraints and knowing how much information to give the patient as have been similarly found in other studies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The volume of information provided in an emergency setting should be limited to main complications and risks which encompass what should be understood and would guide meaningful discussion during the consent process (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The emergency staff therefore need to identify the procedure specific critical information that should be disclosed to the patient within a limited time in an emergency.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003eUnderstanding\u003c/h2\u003e \u003cp\u003eEmergency staff reported that during a surgical emergency, patients or their surrogate sometimes do not take time to understand the information provided because of the limited time needed to get the care needed for the patient. This perception by the emergency staff probably contributed to the observation that staff did not take time to ask if the patient or next of kin had understood the information given. has been is This finding is consistent with other scholars who noted challenges of confirming understanding of information provided during an emergency. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Studies have looked at assessment of understanding using teach-back method by physicians to improve patient understanding and health literacy although this has not been studied in an emergency setting (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Participants suggested the use of visual aids to help improve understanding of the patients and studies have shown that aids like videos, brochures and diagrams are useful in improving patient understanding during the consent process (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eAdministration and documentation of informed consent\u003c/h3\u003e\n\u003cp\u003eOur findings suggest that administration of consent is done by different people including nurses, junior doctors, and surgeons. In this study the nurses and junior doctors had challenges of adequate disclosure of information about the surgical procedures because they had inadequate knowledge about it. They preferred the surgeon to administer the consent. They also acknowledged the challenges of the surgeon having limited time to administer consent in a high-volume emergency unit. Emergency staff at both institutions noted that the consent form was inadequate and lacked a provision for documenting the information provided by the healthcare worker. Similar studies on doctors\u0026rsquo; practices during surgical informed consent have shown information on the complications of surgery that have been discussed by the surgeon are often not documented in the consent form (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). In this study emergency staff felt protected by documentation of consent as has been noted in other studies (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Timfote et al propose the use of 3 principles: equality, utility and justice when obtaining informed consent for emergency surgery (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Equality is when all individuals have equal life worth and should receive equal treatment, utility refers to using limited resources for the greater good for the greatest number of individuals, while justice refers to prioritizing care according to the greatest emergency. Informed consent might not be obtained when a patient is in a clearly life or death situation and such situations need to be well documented (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eChallenges\u003c/h3\u003e\n\u003cp\u003e Challenges encountered by emergency staff in this study included communication of risks, fear of litigation, inadequate knowledge about the surgical procedures, inadequate time for consent and lack of guidelines for emergency consent. These challenges have been highlighted in other studies for consent for elective and emergency surgery (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Surgeons also find it challenging to make rapid and deliberate decisions in acute and emergency surgery settings especially when they are alone and this affects their ethical judgement which is required when providing informed consent(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Lack of privacy during the consent process was observed in the public hospital which affects communication during the consent process. The public hospital is overcrowded unlike the private hospital emergency unit, and this contributes to lack of privacy. Overcrowding in emergency units results in inadequate privacy during the informed consent process for both the emergency staff and the patients.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eKnowledge about consent practices by emergency staff is good but there is little time for adequate disclosure coupled with inadequate knowledge by nurses about the surgical procedure, risks, and benefits. Surgeons should be the ones administering consent. Consent documents need to be more procedure specific and should capture the information that is given to the patient during informed consent. Emergency staff at both institutions have challenges communicating the risks of surgery. Lack of guiding policies on consent for incapacitated patients who have no surrogates results in fear of litigation for the emergency staff. The environment in the public hospital where there are high patient volumes is not conducive and there is lack of privacy during the consent process. When emergency care is not free, emergency staff discuss financial implications of surgical care during the informed consent process.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval to conduct the study was obtained from the School of Biomedical Sciences Research Ethics Committee of Makerere University College of Health Sciences (SBSREC \u0026ndash; 831) Administrative clearance was obtained from the Research Ethics committee of both the private and public hospitals. All participants provided written informed consent to participate in the study for the key informant interviews. Informed consent was waived for the direct observation of the emergency staff, but administrative clearance was obtained from the heads of the Accident and Emergency Units at both the public and the private hospitals.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication.\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and /or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication and funding for data collection, data analysis and manuscript writing were supported by the Fogarty International Center of the National Institutes of Health under Award Number D43TW010892 through the Makerere University International Bioethics Research Training Program.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAuthors\u0026rsquo; contributions\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eOK designed the study, coded transcribed interviews, analyzed the data, drafted the manuscript.\u003c/p\u003e\n\u003cp\u003eIM designed the study, reviewed, and edited the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEM designed the study, coded the transcribed interviews, reviewed, and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eAT coded the transcribed interviews, reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eMG reviewed and edited the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAcknowledgements\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eWe acknowledge the support of Prof. Nelson Sewankambo who provided oversight of this research, the research assistants who conducted the interviews and the direct observations and the emergency staff and administration of the two health institutions where this research was conducted.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBeauchamp TL. Methods and principles in biomedical ethics. J Med Ethics. 2003;29:6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChildress TLBJF. Principles of Biomedical Ethics. 2013:495.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAacharya RP, Gastmans C, Denier Y. Emergency department triage: an ethical analysis. BMC Emerg Med. 2011;11(1):16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuskens IS, Gupta S, Robertson FC, Moojen WA, Kolias AG, Peul WC, et al. When Time Is Critical, Is Informed Consent Less So? A Discussion of Patient Autonomy in Emergency Neurosurgery. World Neurosurg. 2019;125:e336\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoone HN Jr, Boone DA. Analyzing likert data. J Ext. 2012;50(2):48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoisaubin EV, Dresser R. Informed consent in emergency care: illusion and reform. Ann Emerg Med. 1987;16(1):62\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO'Neill O. Some limits of informed consent. J Med Ethics. 2003;29(1):4\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePaduraru M, Saad A, Pawelec K. Emergency surgery on mentally impaired patients: standard in consenting. J Mind Med Sci. 2018;5(1):16\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrady C. Enduring and emerging challenges of informed consent. N Engl J Med. 2015;372(9):855\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHanson M, Pitt D. Informed consent for surgery: risk discussion and documentation. Can J Surg. 2017;60(1):69\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKannan S, Seo J, Riggs KR, Geller G, Boss EF, Berger ZD. Surgeons\u0026rsquo; views on shared decision-making. J patient-centered Res reviews. 2020;7(1):8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin Y-K, Liu K-T, Chen C-W, Lee W-C, Lin C-J, Shi L, et al. How to effectively obtain informed consent in trauma patients: a systematic review. BMC Med Ethics. 2019;20(1):1\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNwomeh BC, Hayes J, Caniano DA, Upperman JS, Kelleher KJ. A parental educational intervention to facilitate informed consent for emergency operations in children. J Surg Res. 2009;152(2):258\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChima SC. Evaluating the quality of informed consent and contemporary clinical practices by medical doctors in South Africa: An empirical study. BMC Med Ethics. 2013;14(1):S3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConvie LJ, Carson E, McCusker D, McCain RS, McKinley N, Campbell WJ, et al. The patient and clinician experience of informed consent for surgery: a systematic review of the qualitative evidence. BMC Med Ethics. 2020;21(1):58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJones JW, McCullough LB, Richman BW. A Comprehensive Primer of Surgical Informed Consent. Surg Clin North Am. 2007;87(4):903\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKinnersley P, Phillips K, Savage K, Kelly MJ, Farrell E, Morgan B et al. Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. Cochrane Database Syst Reviews. 2013(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFink AS, Prochazka AV, Henderson WG, Bartenfeld D, Nyirenda C, Webb A, et al. Predictors of comprehension during surgical informed consent. J Am Coll Surg. 2010;210(6):919\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSeely KD, Higgs JA, Nigh A. Utilizing the teach-back method to improve surgical informed consent and shared decision-making: a review. Patient Saf Surg. 2022;16(1):12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMeredyth NA, de Melo-Martin I. (Under) valuing surgical informed consent. J Am Coll Surg. 2020;230(2):257\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBernat JL, Peterson LM. Patient-centered informed consent in surgical practice. Arch Surg. 2006;141(1):86\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall DE, Hanusa BH, Fine MJ, Arnold RM. Do surgeons and patients discuss what they document on consent forms? J Surg Res. 2015;197(1):67\u0026ndash;77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDavoudi N, Nayeri ND, Zokaei MS, Fazeli N. Challenges of Obtaining Informed Consent in Emergency Ward: A Qualitative Study in One Iranian Hospital. Open Nurs J. 2017;11:263\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTimofte D, Ionescu L, Danila R, Livadariu RM, Barbu ST, Stoica L, THE PRINCIPLE OF INFORMED CONSENT IN EMERGENCY SURGERY\u0026ndash;EQUIVOCAL SITUATION IN MAKING LIFE-SAVING DECISIONS. Revista Romana de Bioetica. 2015;13(2):279\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChima S. Evaluating Knowledge, Practice, and Barriers to Informed Consent Among Professional and Staff Nurses in South Africa: An Empirical Study. Can J Bioethics/Revue canadienne de bio\u0026eacute;thique. 2022;5(2):44\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWood F, Martin SM, Carson-Stevens A, Elwyn G, Precious E, Kinnersley P. Doctors\u0026rsquo; perspectives of informed consent for non‐emergency surgical procedures: a qualitative interview study. Health Expect. 2016;19(3):751\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTorjuul K, Nordam A, S\u0026oslash;rlie V. Ethical challenges in surgery as narrated by practicing surgeons. BMC Med Ethics. 2005;6(1):2.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Emergency surgery, Informed consent, emergency staff","lastPublishedDoi":"10.21203/rs.3.rs-4472834/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4472834/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStaff in low resourced emergency units of a low-income country face the challenge of obtaining informed consent for incapacitated patients or their next of kin in a time-constrained situation often in an overcrowded environment. Therefore, we aimed to establish the informed consent practices for emergency surgical care among healthcare professional at two emergency surgical units at two tertiary teaching hospitals in Uganda.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eIn October 2022 \u0026ndash; February 2023we conducted key informant interviews in Uganda and purposively selected 16 staff in surgical emergency units at two tertiary teaching hospitals and directly observed the informed consent practices. Data was managed and analyzed inductively using NVivo version 12.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix themes emerged from key informant interviews including knowledge and perspectives no informed consent; processes, procedures, and practices regarding informed consent; communication strategies for informed consent; ethical considerations; benefits of informed consent during surgery; and challenges to emergency informed consent. Staff had adequate knowledge about informed consent but faced several challenges during the consent process due to lack of guiding institutional policies. Overall, the informed consent process was inadequate at both institutions with greeting of patients, disclosure of risks and assessment of understanding poorly done. Consent was conducted in a noisy environment at both institutions and there was no privacy in the public hospital.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAlthough knowledge about consent practices by emergency staff at both institutions was good, in practice there was inadequate disclosure of risks, inadequate knowledge about the surgical procedure, risks, and benefits. Emergency staff identified the need for procedure specific consent documents which capture the information that is given to the patient and guiding policies on consent for incapacitated patients who have no surrogates.\u003c/p\u003e","manuscriptTitle":"Informed Consent Practices Among Emergency Staff for Patients Undergoing Emergency Surgery in the Emergency Surgical Units of Two Tertiary Teaching Hospitals in Uganda: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-25 20:02:51","doi":"10.21203/rs.3.rs-4472834/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-02T11:27:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-02T09:52:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196578436335595262327160306423673783750","date":"2024-07-29T12:55:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"313467185813746592746244161418809762043","date":"2024-07-29T01:39:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"29028191447147813040228618045418537310","date":"2024-07-19T10:52:28+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-16T22:39:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"60070686242826316965942654726184421811","date":"2024-07-16T21:16:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"120647566354697033696123064373356319648","date":"2024-07-16T20:58:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-07-16T17:32:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-06T06:54:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-06T05:58:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-06T05:58:26+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Medical Ethics","date":"2024-05-24T13:37:38+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-medical-ethics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"meth","sideBox":"Learn more about [BMC Medical Ethics](http://bmcmedethics.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/meth/default.aspx","title":"BMC Medical Ethics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"860cd94e-4466-4748-af4c-703d051d71fd","owner":[],"postedDate":"June 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T16:09:11+00:00","versionOfRecord":{"articleIdentity":"rs-4472834","link":"https://doi.org/10.1186/s12910-025-01337-8","journal":{"identity":"bmc-medical-ethics","isVorOnly":false,"title":"BMC Medical Ethics"},"publishedOn":"2025-12-17 15:58:18","publishedOnDateReadable":"December 17th, 2025"},"versionCreatedAt":"2024-06-25 20:02:51","video":"","vorDoi":"10.1186/s12910-025-01337-8","vorDoiUrl":"https://doi.org/10.1186/s12910-025-01337-8","workflowStages":[]},"version":"v1","identity":"rs-4472834","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4472834","identity":"rs-4472834","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}