INFORMED CONSENT: A COMPARATIVE SURVEY OF GREEK AND BRITISH NURSE PRECEPTORS BELIEFS TO INFORMED CONSENT

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1 INFORMED CONSENT: A COMPARATIVE SURVEY OF GREEK AND BRITISH NURSE PRECEPTORS BELIEFS TO INFORMED CONSENT K., Karpouzi 1 RN MPH, C., H. Davos 1 MD, PhD, Research Cardiologist, L., Elliott 2 PhD MA (Hons), Professor 1. Cardiovascular Research Laboratory, Centre of Clinical Research, Foundation of Biomedical Research of The Academy of Athens, Athens, Greece. 2. Center for Integrated Health Care Research and The School of Community Health, Napier University, Edinburgh Abstract: Background: Many cultural, multinational studies have been conducted on the issue of informed consent among health professionals and patients. However, little attention has been given to nurse preceptors and informed consent for patients between Greece and Britain. Method: A comparative survey was conducted with 53 Greek and 60 British nurse preceptors. The Greek sample completed a questionnaire which included eight questions on demographic information of respondents and the remaining were related to the issue of patients rights. The British sample completed a second different questionnaire on informed consent for patients treatment. Three common questions on informed consent and six demographic questions were adopted from the Greek questionnaire and included in the British questionnaire. Results: Both British and Greek nurses agreed that the patient s consent should be obtained when referring on to other health professionals. However, most of the British nurses believed that the nurse should look for alternative treatments when a patient does not accept a specific treatment, which is against their religious beliefs. On the other hand, most of the Greek nurses believed that the nurse in a same situation should change the patient s mind through information, advice. 22% of the nurses (n=11) agreed that relatives could be informed without patient s consent compared to 77% (n=41) of the Greek nurses. Conclusion: Cultural differences were seen in the beliefs of British compared to Greek nurse preceptors on informed consent for patients treatment. Keywords: informed consent, nurse preceptors, Britain, Greece. Background T he ethical roots of informed consent have developed through the centuries, but most importantly, the legal aspects have been recognised worldwide since the Nuremberg trials and the formulation of the Nuremberg Code, in 1946 (Brazell 1997). The Nuremberg Code was the first formal declaration, which marked the end of an era where human rights were non-existent due to the atrocities of the World War II, by setting new rules for the protection of human rights in the research field. Since then many declarations of human rights have been signed and in the 1970 s in United States the movement of patients rights became apparent. Europe followed in the 1990 s with most ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 1 - of 12

2 countries establishing national laws on patients rights and signing relevant conventions (Council of Europe 1997). Greece was the first country in Europe, which enacted legislation on patients rights, in 1992 (Law 2071 of 6/ , Merakou & Tragakes 1999). Britain has incorporated the 1950 Declaration of Human rights by establishing the Human Rights Act, in However, in Britain patients rights are still mostly embodied in codes of Professional bodies (Guidelines for Professional Practice 1996, McHale et al. 2001). Despite the fact that similar legislation is set on patients rights across Europe, several research studies have showed the existence of many cultural differences in the everyday practice of these rights among health professionals of different countries. The different cultural background of each country affects significantly the lives of their citizens. As culture affects all the aspects of a human life, it could not affect less health professions and nursing profession. A recent comparative study conducted between Finland, Spain, Greece, Germany and Scotland on nurses and elderly patients perceptions of autonomy, privacy and informed consent in the nursing care of the elderly showed differences across these countries (Leino-Kilpi et al. 2003). Irrespectively of the different cultural attitudes of health professionals, an equal recognition of patients rights in the practice of health professionals across Europe is not only essential for the quality of care provided to patients but also for the quality of education on ethics provided to health profession students which ultimately, affects the care and the recognition of patients rights by future health professionals. Thus, it is important to examine how culture specifically affects the practice of nursespreceptors, who are responsible for the education of student nurses in the clinical areas, and how they perceive patients rights and informed consent. Literature review Informed consent is the willing agreement or refusal by an individual to undergo treatment (Brett 1998). It refers to the provision of information to an individual about a specific treatment, and then the opportunity is given to that individual to accept or reject that treatment (Trudeau 1993). More specifically, fully informed consent is the awareness of the outcomes of the suggested action, when the patient understands the possibility of reasonable risks, and has made a choice from all possible alternatives which are available to them (Brett 1998). Three elements form the basis of informed consent. The first states that informed consent must be voluntary. The second that it must be specific and the third that it must come from a competent person such as an adult of a sound mind. The patients must know precisely what they are consenting to, when the exact nature of the treatment has been determined (Wallace 1995). Informed consent has been well examined and addressed in several studies. Each of the studies examined the issue of informed consent from different perspectives. Many multinational and cultural studies have been conducted on the issue of informed consent. A multinational study, which included patients and nurses working in acute hospitals from Finland, Japan, Norway and the USA, examined the nurses and patients attitudes towards consumerism in health care. The patients from the USA, Finland and Japan believed more than nurses that patients should have access to their medical records, to the provision of information about their treatment, their nursing care and the respective risks these might entail. Additionally, more than one third of patients from all countries believed in their right to information about decisions that nurses take for them. More than one third of the American, Japanese and Norwegian patients and most nurses from all countries believed in the patients right of collaboration with nurses in nursing care decision making (Kim et al. 1993). A comparative survey between Britain and the United States examined the nurses and doctors attitudes to ethical issues at the end of life. More British nurses compared to US nurses believed that conflicts arise between staff about the adequacy of the informed consent process. More US nurses compared to British nurses stated that many patients prefer to let others to decide on what treatment is best for them. British nurses were also more satisfied with patients involvement in practice compared to their US ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 2 - of 12

3 counterparts (Dickenson 1999). An international comparative study between Finland, Spain, Greece, Germany and Scotland examined nurses and patients perceptions on autonomy, privacy and informed consent in relation to nursing interventions. Differences were seen in all five countries between staff and patients perceptions of autonomy, privacy and informed consent (Leino-Kilpi et al.2003, Schopp et al. 2003, Leino-Kilpi et al. 2003, Suhonen et al. 2003). Other studies involve as subjects, patients of different ethnic groups. A study of 800 patients; 200 Korean-American, 200 Mexican-American, 200 African-American, and 200 white European-American explored their attitudes towards autonomy in medical decision-making. Cultural differences were observed in the attitudes of the provision of information between the different ethnic groups of patients (Blackhall et al. 1995). A study of 31 cancer patients; 9 Chinese, 12 Latino and 10 Anglo-Americans on issues of informed consent showed that cultural factors affect the informed consent process (Barnes 1998). The studies that conducted in Greece are mostly focused on the issue of truth telling of cancer diagnosis and even though some of these are not directly related to the issue of informed consent, they are reflecting on the way health professionals behave in their everyday practice on similar issues. These studies examine the doctors views, the patients views and the public views on the truth telling issue. Most doctors usually do not disclose the cancer diagnosis to their patients and even if they do, they avoid disclosing the whole truth or their patient s prognosis. Patients felt that they needed more information to be disclosed to them (Sarfatis & Papachristodoulou 1972, Hellenic Anticancer Society 1978, Hellenic Anticancer Society 1988, Manos & Christakis 1981, Lavrentiadis et al. 1988, Dosios et al.1986, Mystakidou et al. 1996, Dalla-Vorgia et al.1992, Iconomou et al. 2002). Two studies, which formed two separate PhD theses, examined the first; the knowledge of 600 non-cancer patients of the 1992 Greek patients rights law. Most patients (84.3%, n=600) were unaware of the law on patients rights. (Merakou 1998, Merakou et al.2001). The second published PhD thesis examined informed consent from the doctors, nurses and cancer patients point of view. Most cancer patients (63%, n=100) want to be given the whole truth about their treatment. The nurses who had some education on ethics provided more truth to their patients compared to the nurses who did not have such education (x 2 =0,027, p=0,87, df=1). The doctors also who had some education in ethics provided more truth to their patients compared to those who did not (x 2 =11,492,p=0,001, df=1) (Giannopoulou 1992). A more recent study examined the attitudes of 148 nurses on truthful communication with cancer patients. Most nurses believed that only some patients have a right to be told of their cancer diagnosis and prognosis and that the truth is revealed to patients relatives. Nurses also stated that they faced problems in their communication with patients (Georgaki et al. 2002). Few studies, which conducted in Greece, involve the nursing profession and the informed consent issue (Lemonidou et al. 2002, Lemonidou et al.2003). Fewer are multinational, cultural studies (Leino-Kilpi et al. 2003). The study Aim The current paper presents a comparative survey of the Greek and British nurses preceptors beliefs to informed consent. It intends to show the differences in the perceptions of Greek and British nurses to informed consent. Design a) Greek questionnaire The Greek self-administered questionnaire was developed for another study, which was related to the beliefs of nurses on patients rights. The questions selected for the development of this questionnaire were based mainly on article 47, The patients rights in hospital of the Greek law 2071/1992 and on a review of the literature on patients rights. The rationale for the development of this questionnaire was to examine nurses attitudes to patients rights and to assess their knowledge about Greek law on patients rights. The Greek questionnaire included thirty-four closed questions, from which eight ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 3 - of 12

4 provided demographic information on respondents. The remaining questions contained statements on issues such as confidentiality, informed consent, and religious beliefs of patients, euthanasia and autonomy, to which the respondent was asked to agree or disagree by ticking a box 1 for Yes or 2 for No (Dimitriadou et al.1998). Only three questions about informed consent and six demographic questions were chosen and analysed from the Greek questionnaire, as only these three were comparable with questions included in the British questionnaire because of the way of the construction of the Greek questionnaire. The first of the three questions on informed consent presented a scenario about a patient who denies treatment because of their religious beliefs. Respondents were asked to choose one of three alternative courses of action. The first asked if nurses would change the patients mind through information and/or advice. The second asked if they would look for alternative treatments, and the third, if they would allow discharge of the patient without the hospital taking responsibility for it. An affirmative response to each option question was coded as follows; 1, 2 or 3 respectively. This question was chosen because it could reflect on the religious beliefs of the respondents. The second question asked if the consent of the patient was required before nurses liaised with other health professionals. Respondents were asked to tick a box for Yes, coded with 1, or a box for No, coded with 2. This specific question was chosen as this shows how respondents could behave on one of the tasks of the nursing practice in relation to informed consent. The last question on informed consent asked if the relatives of the patient should be informed about patient s condition without the patient s consent. Again the respondents were asked to tick a box for Yes coded with 1, or to tick a box for No, coded with 2. This question was also chosen to show the kind of relationship respondents established with patient s relatives. Finally, the six common demographic questions, provided information about the sex, age, years of working experience, the place where nurses lived during their adolescence, their religious status and the type of clinical area in which they presently worked i.e. a surgical or a medical ward. b) British questionnaire The British questionnaire included twenty-four close-ended questions; of which the common demographic questions adopted from the Greek questionnaire were included. The informed consent questions included a statement and the respondents were asked to say how far they agreed or disagreed with the statement, using a four-point Likert scale, ranging from strongly disagree to strongly agree. The responses were coded 1 for strongly disagree, 2 for disagree, 3 for agree and 4 for strongly agree. Data collection a) Greek sample The respondents were nurses-preceptors who worked in surgical and medical wards in hospitals, in a city in Northern Greece and who also worked on a part time basis, in the Department of Nursing. Nurse-preceptors are responsible for most of the clinical based teaching of student nurses and therefore occupy a key position in the Greek, (and for that matter, UK) nurse education system. In order to identify the nurses-preceptors, a list of their names was provided by the Department of Nursing. The total number of Greek nurse-preceptors was fifty-three. The questionnaires were administered in anonymous envelopes to the fifty-three nurses at a one-day seminar for nursespreceptors, which were held in May 1998 in the Department of Nursing. b) British sample The respondents were nurses-preceptors who worked in a large university teaching hospital, in Scotland, UK in The Senior Charge nurses in each surgical and medical ward were contacted and asked to supply a list of nurse-preceptors working in their clinical area. The total number of nurses-preceptors identified was ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 4 - of 12

5 sixty-six, of which sixty were traced and contacted individually by the author in August The nurses were asked to complete and to return their questionnaires to the author in three days. A significant number of nurses did so in that period of time and in all other cases extension of a few more days was provided. Ethical considerations Approval for this study was requested by the Head of the Nursing Department in Greece and by the Associate Director of Nursing of the NHS Trust Hospital, in order the questionnaires to be submitted to nurse-preceptors. Ethical approval by the local ethics committee was not requested for this study, as it did not involve patients, as research subjects. The purpose of the study was explained to all participants; it was also made clear that anonymity would be maintained. Both Greek and British nurses were requested to sign the consent forms and asked to return their questionnaires. Data entry and analysis Data entry The data from both the questionnaires were entered directly into SPSS for windows/version 8.0 for analysis. Analysis Statistical tests Frequencies were calculated for all questions in each questionnaire. Cross tabulations and Pearson s chi-square tests were carried out to test the differences between the beliefs of British and Greek nurses on informed consent and their demographic characteristics. The p-value of <0.01 was considered to be statistically significant. A logistic regression was carried out to determine if there was any association between the demographic variables in the Greek and UK samples and responses given to all three-attitude questions. A second logistic regression was carried out to determine whether responses to a particularly controversial question; whether relatives should be given patient information without consent, could be explained by sample characteristics and/or responses to the other two attitude questions. A third logistic regression was carried out to determine whether the dependent variable country was influenced by the responses given to the scenario question with the three options about the acceptance of a treatment by a patient which is against his/her religious beliefs. A further analysis using nominal regression of the above question and having considered the responses given to all the three options again influencing the dependent variable country was conducted. The responses to the common informed consent and demographic questions were recoded for these regressions. For example, the dependent dichotomous variables consisted of disagree with new code 1 for the combined strongly disagree and disagree and agree with new code 2 for the combined strongly agree and agree. A new dependent dichotomous variable was constructed, called country and consisted of two parts, Britain code 1 and Greece code 2. Again p value <0.01 and p value<0.05 were used. Results The response rate of the Greek nurses was almost 93% (n=49), while, the response rate of the British nurses was 76% (n=50). Socio-demographic characteristics of Greek and British nurses The majority of the respondents in both the Greek (94%, n=45) and British (94%, n=45) samples were women. ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 5 - of 12

6 The largest single group (38%, n=18) of the British nurses were aged between years, while, (71%, n=34) of the Greek nurses were aged 41 years and over. (x 2 =18.918, df=2, p<0.01) British nurses (42%, n=21) had from one to ten years of working experience, whereas, Greek nurses (46%, n=22) had from eleven to twenty years of working experience. (x 2 =8.412, df=2,p<0.01). As far as the place of living during their adolescence is concerned, (45%, n=21) of the British nurses lived in a town, whereas, (37%, n=18) of the Greek nurses lived in a village. Moreover, (59%, n=27) of the British nurses defined themselves as not religious, compared with (19%, n=9) of the Greek nurses. (x 2 =15.110, df=1,p<0.01). Finally, half of the British (50%, n=24) and almost half of the Greek (51%, n=24) nurses had been working in medical wards. (Table 1) Table 1 Socio-demographic characteristics of Greek and British nurses Nurses: British Greek n=50 n=49 Sex: Male Female Years of working experience: over Age: over Place of living in adolescence: Town Village City Religious status: Yes No Place of working: Medical ward Surgical ward * Chi-square tests p<0.01 6% (n=3) 94% (n=45) 42% (n=21)* 29% (n=14) 27% (n=13) n=47 34% (n=16) 38% (n=18)* 28% (n=13) n=47 45% (n=21) 21% (n=10) 34% (n=16) n=46 41% (n=19) 59% (n=27)* 50% (n=24) 50% (n=24) 6% (n=3) 94% (n=45) 17% (n=8) 46% (n=22) 37% (n=18) 6% (n=3) 23% (n=11) 71% (n=34) 35% (n=17) 37% (n=18) 27% (n=13) 81% (n=39) 19% (n=9) n=47 51% (n=24) 49% (n=23) Comparison of Greek and UK attitudes Significant differences in nurses attitudes Most of the British nurses (85%, n=40) believed that the nurse should look for alternative treatments when a patient does not accept a specific treatment as it is against their religious beliefs. On the other hand, most of the Greek nurses (49%, n=26) believed that the nurse in a same situation should change the patient s mind through information and / or advice (x 2 =22.219, df=2, p<0.01). Both British (67%, n=33) and Greek (53%, n=28) nurses agreed that the patient s consent should be obtained when referring on to other health professionals. The Pearson chi-square test (x 2 =. 844 df=1) showed no association of the combined question between Britain and Greece. British nurses (22%, n=11) agreed that relatives can be informed without patient s consent compared with (77%, n= 41) of Greek nurses (x 2 =39.544, df=1, p<0.01). (Table 2) ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 6 - of 12

7 Table 2 UK and Greek nurses attitudes to informed consent Questions 14 Refusal of treatment by a patient as it is against their religious beliefs. The nurse should: a) Change patient s mind through information or advice b) Look for alternative treatments c) Allow the discharge of the patient without the hospital taking the responsibility for it? Greek sample n=49 (n= number of nurses agreeing) n=26 (49%)* n=21 (40%) * n=2 (11%)* UK sample (n= number of nurses agreeing) n=4 (9%)* n=40 (85%) * n=4 (6%)* 15 Patient consent for referral to other health professionals is provided. n=28 (53%) n=33 (67%) 16 Relatives can be informed without patient s consent n=41 (77%) * n=11 (22%) * * Chi-square test p<0.01 Logistic regressions The above responses were examined in relation to socio-demographic characteristics using a logistic regression where the dependent variable was country, i.e. Britain and Greece. This logistic regression (exp. B: 18.7, 95% CI: ) confirmed that Greek nurses were less likely to agree to seek patient s consent before informing relatives of their condition. Greek nurses were also older (exp. B: 3.3, 95% CI: 1.4-8) and defined themselves as religious (exp. B: 0.28, 95% CI: ), compared with British nurses. A second logistic regression was performed with dependent dichotomous variable being the question about informing relatives without patients consent, and independent variables the other attitudinal questions, and the demographic data including the variable country i.e. Britain and Greece. Again Greek nurses were more likely to agree that relatives could be informed about the patient s condition without their consent compared with British nurses (exp. B: 22.7, 95% CI: ). No other independent variables were included in the equation. A third logistic regression was performed with dependent dichotomous variable being country and independent variable the question which presented the scenario about a patient, who denies treatment due to his/her religious beliefs and the three options that the respondents had to choose. No statistical significance was found. (Exp. B: 0.182, CI: ). A further nominal regression of the above question showed a statistically significant difference with p<0.05 (exp. B: 5.494, 95% CI: ). Discussion Culture played an important role in the responses nurse preceptors gave about the patients informed consent issue. Cultural differences were found between the attitudes of Greek and British nurses to informed consent and in the socio-demographic characteristics of the two samples. Socio-demographic characteristics of Greek and British nurses ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 7 - of 12

8 The age difference of the (younger) British compared to the (older) Greek nurses may be explained by the fact that British nurses can become preceptors having one year of working experience, whereas, Greek nurses can become preceptors after five years of working experience. This may also explain why Greek nurses had more years of working experience compared to British nurses. Most of the Greek nurses defined themselves as religious compared to the British nurses. This may reflect the observed age difference but is more likely to be explained by cultural differences between Greece and Britain, which affected the responses Greek nurses gave to the questions. This is also consistent with the results of another study on the attitudes of Greeks to the truth telling issue. Most religious people replied negatively on the truth disclosure of diagnosis to a patient, who is dying (Dalla- Vorgia et al. 1992). Greek and UK attitudes on informed consent The results showed that British and Greek nurses agreed only on the provision of informed consent to the patient prior to their referral to other health professionals. Religion, as a cultural factor seems to affect Greek nurses preceptors in the non practice of informed consent to patients. A larger number of Greek nurses would try to change a patient s mind if they refused treatment on religious grounds. These differences may reflect the greater role of religion in Greek society and that the patient care in Greek hospitals is mainly based on a paternalistic model, where the doctor or the nurse knows best and the patients autonomy is undermined. This finding is supported by the findings of a comparative study of surgical nurses perceptions on patients autonomy, where Scottish nurses advocated patients autonomy more (mean=4.22, SD=0.47, n=253) compared to Greek nurses (mean=3.34, SD=0.72, n=209) (Suhomen et al. 2003). The results of another published part of the same study showed how British nurses respected patients autonomy and they asked for patients consent for six nursing interventions more frequently than the nurses of Germany, Finland, Spain and Greece (Schopp et al. 2003). The respect of patients autonomy by British nurses seen in this study is a fact experienced by most nurses in other studies (May 1993, Kee 1995, Aveyard 2003, Aveyard 2005). Another cultural factor is the degree of the relatives involvement in the patient care. It seems that relatives in Greece take a leading role in the decisions of the care of their patients. Thus, a difference was observed concerning the provision of information to the relatives of a patient. It seems that British nurses respect the autonomy and the decisions of their patients, whereas, Greek nurses believe that relatives should be informed even without patients consent. It is more common in Greece for the relatives of the patients to get involved in the care of their patients and for relatives to request that information is withheld from the patient. The results of another study showed that 33% of relatives were informed on their patients behalf and about 48% (n=600) of patients had confidence in their doctors to decide for them (Merakou et al. 2001). In addition, it is supported by the results of the current multinational study, which showed that patients, who had relatives by their side and took care of them (55.59%), believed that their consent was rarely requested compared to patients, who had no relatives present (21.38%) (OR 2.35, 95% CI , p=0.0136) (Schopp et al. 2003). Another Greek study showed that 55% (n=82) of Greek nurses believed that the truth about cancer sometimes should be disclosed to relatives, but not to patients (Georgaki et al. 2002). The result is also supported by three other Greek studies regarding patients satisfaction with nursing services (Merkouris et al. 1999, Dimitriadou et al. 1991) and relatives involvement in the patients care.one of them showed that 61% (n=800) of the hospital patients considered the presence of a relative a necessity and 50% had at least one relative or other to take care of them (Merkouris et al. 1999). The results of the second study showed that 57% (n=35) of the patients who were satisfied by ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 8 - of 12

9 the nursing care, 69% (n=24) were assisted by others, such as relatives (Dimitriadou et al.1991).two explanations were given by the authors; the staff shortage of nurses in Greek hospitals and the close relationships with their relatives that Greek families maintain (Merkouris et al. 1999). The third study showed that 44.3% (n=1995) of family members, who were present at hospital, helped their patients in the fulfillment of their personal needs and in their need of communication (Bellou-Milona et al. 2002). Although, the above studies are primarily concerned with the issue of patient satisfaction and the measurement of relatives involvement in patients care, they perhaps offer an explanation of why Greek nurses are more likely to inform relatives without patients consent. It is possible that Greek nurses do so because they assume that patients and their relatives freely share information, as relatives are always present in hospitals and sometimes patients are incompetent to do so for themselves. However, an alternative explanation is that nurses share a view held in wider Greek society as in most Southern European countries, that blissful ignorance of one s predicament might be in a patient s best interests. Finally, the interesting and in a way problematic perception of the right of informed consent by nurses, especially the Greek nurses in this study could be confirmed by further research where the application of informed consent in the everyday nursing practice would be examined in more depth. The examination also of other health professionals attitudes on informed consent and patients point of view about informed consent would also provide a useful insight into the shared or different ethical values held by each. Method of investigation: Questionnaires versus interviews The current survey was conducted by the use of a structured questionnaire, which was handed personally to the nurses. This survey method was preferred to the conduct of interviews, as it was cheaper, and less time-consuming. Most of the nurses were traced and most completed the questionnaire. In addition, the problems associated with a low response rate, including the nature of the subjects profession and lack of time for interviews, were avoided. Difficulties in the chosen method of investigation Although, the response rate of the British nurses was high; problems in tracing some nurses were not completely avoided. More specifically, these included the absence of some nurses from their work, and the lack of time and comparatively long time period between distributing and returning the questionnaires. On the other hand, the administration and the collection of the Greek questionnaire during that seminar day might have led to the higher response rate, in that all or nearly all nurses-preceptors would be present. Study limitations Problems were experienced due to the design of the study. The British sample included only nurse preceptors in order to be compatible with the Greek sample. It was also limited to medical and surgical wards. The sample size was also small. The method of investigation was restricted to the submission of questionnaires. The comparison was also limited to the three common questions on informed ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 9 - of 12

10 consent and to the six common demographic questions because of the construction of the Greek questionnaire. Finally, more in-depth investigation of the subject of informed consent was not permitted. Conclusion The study shows that culture determines the way nurses behave in their practice in both countries. The cultural differences between Greece and Britain are reflected on the different perceptions of informed consent that nurses hold. These different perceptions might affect the way nurses provide their care to the patients. There might appear problems in the nursing care of patients when these are not recognised as individual entities, who have their own rights, which must be respected. The findings also of the study raise some important issues about the nursing education. These issues concern mainly the education and training of future nurses by nurse-preceptors. The education of student nurses especially in the clinical areas could be deficit and problematic when patients rights are not recognised by nurse preceptors, these rights could not be realised and recognised by student nurses. Consequently, student nurses would not be possible to practice patients rights in their future nursing career. Furthermore, as nurses are the main patient s advocates, it is essential for them to act accordingly, safeguarding and protecting patients rights to informed consent. This will also help them to enhance the relationship with their patients and to improve the quality of the nursing care they provide. Finally, for the better realisation of patients rights by health professionals and for the delivery of a highquality care to patients, the following bullet points are recommended: An evaluation of the provision of continuing training for nurses across Europe, especially, when this concerns nurse-preceptors who are responsible for the supervision of student nurses in the clinical areas should be established. The training and information should consider the cultural context of each country, for example awareness of socio-cultural aspects, which could influence the interpretation, and implementation of legislation and guidelines in each country. References Aveyard H. (2003) The patient who is unable to consent to nursing care. International Journal of Nursing Studies 40, Aveyard H. (2005) Informed Consent Prior to Nursing Care Procedures. Nursing Ethics 12(1), Barnes D. M., Davis A.J., Moran T., Portillo C. J. & Koenig B.A. (1998) Informed consent in a multicultural cancer patient population: Implications for nursing practice. Nursing Ethics 5(5), Bellou-Milona P., Iordanou P., Kyriakidou H., Andrea S., Evagelou H. & Konstandou H. (2002) Family members involvement in their hospitalized patients care. ICUS and Nursing Web Journal 12, Blackhall L. J., Murphy S. T., Frank G., Michel V. & Azen S. (1995) Ethnicity and attitudes toward patient autonomy. JAMA 274(10), Brazell N. E. (1997) The significance and application of informed consent. AORN Journal 65(2), Brett S. M. (1998) Informed consent-ethics and the elderly. British Journal of Theatre Nursing 8(7), Council of Europe (1997) Convention for the Protection of Human Rights and Dignity of the Human Being With Regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. European Journal of Health Law 7(4), ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 10 - of 12

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12 Merakou K. & Tragakes E. (1999) Development of patients rights legislation. European Journal of Health Law 6, Merakou K., Dalla-Vorgia P., Garanis-Papadatos T. & Kourea-Kremastinou J. (2001) Satisfying patients rights: A hospital patient survey, Nursing Ethics 8(6), Merkouris A., Yfantopoulos J., Lanara V. & Lemonidou C. (1999) Developing an instrument to measure patient satisfaction with nursing care in Greece. Journal of Nursing Management 7(2), Mystakidou K., Liossi C., Vlachos L. & Papadimitriou J. (1996) Disclosure of diagnostic information to cancer patients in Greece. Palliative Medicine 10, Sarfatis D. & Papachristodoulou G. (1972) Research on attitudes and behaviour of the public towards cancer. Public Hellenic Anticancer Society, Athens (in Greek). Schopp A., Valimaki M., Leino-Kilpi H., Dassen T., Gasull M., Lemonidou C., Scott P.A., Arndt M. & Kaljonen A. (2003) Perceptions of informed consent in the care of elderly people in five European Countries, Nursing Ethics 10(1), Suhonen R., Valimaki M., Dassen T., Gasull M., Lemonidou C., Scott P. A., Kaljonen A., Arndt M. & Leino- Kilpi H. (2003) Patient s autonomy in surgical care: a comparison of nurses perceptions in five European countries. International Nursing Review 50, Taylor K. M. & Kelner M. (1987) Informed consent: the physicians perspective, Social Science & Medicine 24(2), Trudeau M.E. (1993) Informed consent: the patients right to decide. Journal of Psychological Nursing 31(6), Vincent J.L. (1998) Information in the ICU: are we being honest with our patients? The results of a European questionnaire. Intensive Care Medicine 24, Wallace M. (1995) Health Care and the Law. In A Guide for Nurses (2 nd edition), Law Book Corporation, Sydney. Corresponding Author Konstantinia Karpouzi, Foundation For Biomedical Research of the Academy of Athens, Soranou Efesiou 4, Athens. Tel: , Fax: ICUS NURS WEB J ISSUE 24 September- December 2005 (NURSING.GR) Page 12 - of 12