Journal of Interprofessional Care, 2012, 26: 212–218

q 2012 Informa UK, Ltd.

ISSN 1356-1820 print/ISSN 1469-9567 online
DOI: 10.3109/13561820.2011.645171

Patient or physician safety? Physicians’ views of informed consent and

nurses’ roles in an Indonesian setting
Astrid Pratidina Susilo1, Ira Nurmala2, Jan van Dalen3 and Albert Scherpbier4
1
Graduate School of Clinical Pharmacy, Surabaya University, Surabaya, Indonesia, 2Department of Health Promotion and
Behavioral Sciences, School of Public Health, Airlangga University, Surabaya, Indonesia, 3Skills Laboratory, Institute for
Education, Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, The Netherlands, 4Institute
for Education, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands

(Messer, 2004; Whitney, McGuire, & McCullough, 2004)

Informed consent is a reflection of patients’ autonomy in health
decision-making. The main responsibility lies with the doctor.
In practice, the nurses’ contributions matter as well. This paper
presents a case study that explored physicians’ perceptions of
the existing informed consent process, their suggestions for
improvement and their views on the nurses’ roles in this process.
A two-phase approach was conducted. First, six physicians with
different expertise were interviewed. Second, after attending
presentations about informed consent and physician– patient
relationship principles, 32 physicians were asked to complete
an open-ended questionnaire. Data were analyzed by two
independent coders and emerging themes were compared.
The results of the questionnaires and the interviews were
triangulated. Of 32 physicians attending the presentations,
24 (75%) completed the questionnaire. The results indicate that
physicians perceive patients, physicians and the hospital as main
factors influencing the process of informed consent. Physicians’
misinterpretation of informed consent principles,
(mis)perceptions regarding patients and their family, and
deficient hospital policy and support challenge the informed
consent process. Physicians value nurses’ roles, provided nurses
have sufficient clinical knowledge, sound comprehension of
informed consent principles and effective communication skills.
Keywords: Informed consent, interprofessional collaboration,
nurses, physicians, roles, shared decision-making
INTRODUCTION
Informed consent reflects the relationship between health
providers and patients with regard to planned medical
treatments and procedures. Patients are assumed to make a
voluntary decision about their medical treatment after
receiving adequate information from the health providers
concerning the nature of the treatment, its purpose, linked
processes, possible risk of complications, treatment alterna-
tives and prognosis (Messer, 2004; Sims, 2008).
The recommended model of informed consent is based on
principles of shared decision-making (SDM), which are in
alignment with the partnership model of physician – patient
relationship (Whitney et al., 2004). The literature has
revealed several challenges involved in applying SDM in daily
clinical practice. Time constraints, resistance of physicians or
lack of cooperation from patients have been reported as
major barriers (Gravel, Legare, & Graham, 2006; Legare,
Ratte, Gravel, & Graham, 2008; Stevenson, 2003). Although
the majority of these studies were performed in a Western
setting, similar findings were also found in Eastern settings,
such as Malaysia and India (Yousuf, Fauzi, How, Rasool, &
Rehana, 2007) and Indonesia (Claramita, Utarini, Soebono,
van Dalen, & van der Vleuten, 2011). Different strategies
have been proposed to overcome these barriers, such as
improving physicians’ communication skills, empowering
patients and involvement of other health professionals as a
team (Grol & Wensing, 2005; Legare, Ratte, Stacey,
Kryworuchko, Gravel, & Graham, 2010).
According to the Indonesian law, the responsibility for
informed consent lies with the physician. However, this
responsibility can be delegated to other health professionals
involved in patient care (Menteri Kesehatan Republik
Indonesia, 2008). Nurses have a strong influence as they are
continuously present in the wards and become the most
accessible care providers (Robinson, 2001; Sims, 2008).
Nurses often take conventional roles, such as checking the
completeness of informed consent documents (Davies et al.,
2004; Grace & McLaughlin, 2005; Sims, 2008). They could also
take on the role of patient advocate: to voice unspoken

Quotes in this paper were translated into English, following the intention of the original Indonesian quotes as closely as possible.
Correspondence: Astrid Pratidina Susilo, Graduate School of Clinical Pharmacy, Surabaya University, Jalan Raya Kalirungkut, Surabaya 60293,
Indonesia. E-mail: pratidina@yahoo.com
Received 23 January 2011; revised 13 September 2011; accepted 25 November 2011

212

concerns of patients and become mediators (Vaartio, Leino-
Kilpi, Salantera, & Suominen, 2006). Their involvement is
considered beneficial to patients and supportive of physicians
(Davies et al., 2004; Windle, Mamaril, & Fossum, 2008).
Nurses’ actions, however, are affected by their
relationship with physicians. Parish (1997) argued that any
recommendations made by nurses tend to be communicated
indirectly, and thus appear as though formulated by
physicians. Within an equal physician – nurse relationship,
nurses are able to perform the role of patient advocate.
However, in settings where the relationship is on a less equal
footing, for example, in Indonesia, nurses are struggling to
gain professional recognition. They are trying to shift from a
position of subservience to physicians to a position in which
they can act as independent professionals (Sciortino, 1995).
METHODS
A case study was conducted based on Yin (2003) to explore
two areas: (1) physicians’ perceptions of the existing
informed consent process and (2) physicians’ perceptions
of nurses’ roles in this process. The study was undertaken
over two phases. The first phase undertook semistructured
interviews with a purposeful sample of physicians. The
second phase served to explore the validity of the findings
from the first phase with a larger group of physicians.
Our study was conducted in an Indonesian private
hospital with around 300 beds and a bed occupancy rate of
around 80%. The hospital was located in a city with
approximately three million inhabitants. Approximately 50
physicians were employed by the hospital and 150 consultant
physicians in private practice also practiced in the hospital.
Data collection
Data for the study were gathered over two iterative phases.
In the first phase of the study, six physicians were interviewed
in the Indonesian language by APS, using a semistructured
interview format. The interviews addressed two main topics:
first, perceptions of physicians about the existing informed
consent process, and second, perceptions of physicians about
the nurses’ role in this process. We selected a general surgeon,
a pediatrician, an obstetrician, an internist, a general
practitioner and a dentist as initial sample. We purposively
chose physicians from these six disciplines because they
represented basic medical service in Indonesia. Participants
gave written consent. The interviews were recorded and notes
were taken.
In the second phase, we challenged the findings from the
first phase by collecting information from participants who
attended presentations of “ideal” principles of informed
consent. Fifty physicians and dentists who were registered in
the hospital and worked in outpatient and inpatient settings
were invited to attend a forum. Thirty-two attended the
meeting, 24 (75%) completed the questionnaires. The first
presentation was held by an expert in Indonesian medicolegal
matters and dealt with the legal aspects of informed consent.
The second presentation was held by an expert in
communication training (JvD) and dealt with the general
q 2012 Informa UK, Ltd.
PATIENT OR PHYSICIAN SAFETY? 213
principles of SDM. The presentations were followed by a
group discussion.
Finally, participants were told that the hospital manage-
ment (1) took the challenges of developing a sound informed
consent process seriously and (2) was aware that successful
implementation of such a process was only possible with
the help of all stakeholders. Therefore, an appeal was made
to the physicians to put forward their suggestions as to
how the process and procedures around informed consent
in the hospital could be improved. With this approach, we
attempted to stimulate physicians to reflect on their own
practice of informed consent.
After receiving the information mentioned above,
participants were asked to complete an open-ended
questionnaire consisting of four questions that explored
their perceptions of factors that promoted and inhibited the
informed consent process, as well as factors that might
improve the informed consent process.
Nurses were explicitly not mentioned in the questions to
open other ideas for improvement and to see if and how
physicians would mention the role of the nurse. Participation
was voluntary and the participants were told that they could
leave the form blank if they declined to participate.
Participants answered in Indonesian.
Analysis and synthesis
The verbatim transcripts were made in Indonesian and
analyzed by APS and IN who are Indonesian native speakers.
We conducted a constant comparative approach to identify
emerging themes. The analysis of the questionnaires was
undertaken independently from the interviews. We started
with the open coding independently, developed the coding
categories and applied the categories to all data. This process
was followed by discussions among APS and IN until a
consensus was reached. In the later phase of the analysis,
interviews and questionnaires were triangulated by compar-
ing the emerging themes from the interviews with the
analysis of the questionnaire data.
Ethics
Permission for the study was granted by the hospital
board of directors. No physical risk was identified. To ensure
confidentiality, questionnaires were number coded and
interview transcripts were anonymized.
RESULTS
The themes and issues that emerged from the analysis of the
interviews and questionnaires were similar and comparable
(see Table I).
Physicians’ perceptions of the existing informed consent
process
Participants agreed that informed consent is important to
providing safe care, and that improvement of the current
process was possible. The current practice was seen to be
influenced by factors related to the hospital, physicians and
patients. These are now discussed.
214 A.P. SUSILO ET AL .

Table 1. Emergent themes and issues from interviews and There should be a clear separation which cases can be
questionnaires. explained by nurses and which by physicians.
Interview Questionnaire [Questionnaire 8]
1. Physicians’ perceptions of the existing
informed consent process I notice that she [nurse] does not have enough knowledge
Hospital-related factors
to explain about the risk. [DR 3, interview]
Clarity of informed consent-related policy V V
Procedures V V Supporting facilities. Participants noted that they needed
Monitoring and sanction – V
Delegation V V
rooms where they could have a confidential conversation
Supporting facilities V V with patients and family members. It was suggested that
Private places V V measures should be taken to facilitate the provision of
Information aids (leaflet, video) V V information to patients, for example, by means of
Physician-related factors audiovisual aids to explain medical procedures or providing
Time-related issues V V
Unmatched schedule V V
hospital staff with training to communicate with patients
Workload V V over their informed consent:
Perception of working V –
Financial concern V V
This [providing facilities to support information transfer
Concern of legal suit V V to patients] can be integrated in one must-do step in
Quality of interprofessional relationships V V medical procedures [so that] patients are taken to a special
Patient-related factors place where physicians explain the treatment. The hospital
Patient’s ability to understand V V could provide video, projector, laptop or computer. The
Patient’s perception of risk V V
Involvement of family member V V
Medical Committee could set up a team to determine what
Information from other parties V V is to be included in the video. [DR6, interview]
2. Physicians’ perceptions of nurses’ roles Also, it was noted that information about the cost of
in informed consent process treatment was not always available. This lack of information
Desired roles of nurses V V
Nurses’ roles that merit consideration V V was seen as problematic, as it was crucial to patients and their
Needed competence of nurses V V family members to make a decision about their care:
Ninety per cent of the questions [asked by patient and
Hospital-related factors
their families] are about costs. Patients ask more questions
Clarity of informed consent-related policy. There were calls
about costs than about risks. [DR4, interview]
from the participants for a clear hospital policy on informed
consent to guide practice. The participants raised a number
of areas in which clarification for informed consent was Physician-related factors
needed as indicated in the following data extracts: Time-related issues. Time constraint was identified by
Do cosmetic procedures need informed consent? participants as an important barrier to adequate provision of
[Questionnaire 1] information. Physicians, it was noted, were very busy and it was
difficult to synchronize their schedules and those of patients.
The hospital should determine the list of procedures for This often resulted in them encountering difficulties in trying
to arrange a discussion with a patient and family members.
which informed consent is needed. [Questionnaire 24]
Within the context of the hospital, “work” was considered
Some participants recommended that there needed to to be performing medical procedures. In contrast, however,
be revision of hospital policy on informed consent. Indeed, providing patients with information was not considered to be
it was unclear to many participants what they were expected a part of this process:
to explain to patients, as this was not explicitly stated in We practice together in one big room. Patients come in
the current informed consent form. It was also felt that turns to different physicians. I feel uncomfortable talking
monitoring, evaluation and sanctions in cases of non- with patients when my colleagues are busy working. I seem
compliance should be integrated into any revised policy. to remember that one time we tried to make a
Participants also asked for clear hospital regulations that commitment, like, “We should explain more to
explained the legal consequences of delegating informed patients!” However, someone said, “No [ . . . ] we are
consent to others. It was noted that when the information busy and there are many patients.” [DR2, interview]
necessary for informed consent was not provided by the
physician who was actually treating the patient, the quality of Financial concerns. A number of participants noted that some
the information may suffer: of their colleagues were concerned about a financial issue
when patients may refuse treatment, for example, when
If I am told to obtain informed consent from a patient of information on the risk of complications concerned them.
another specialist and explain the treatment to that Indeed, for one participant, the related financial concern,
patient, will I be held responsible if there is a malpractice combined with time pressures, hindered them spending
suit?[DR4, interview] more time on providing information:
Journal of Interprofessional Care

If I spent long time with one patient, I could only finish ten
patients per day. I should finish 50 patients. It means that
one patient should pay five times the cost. It should be like
that. I’m sorry that I think economically. [DR4, interview]
Concern of legal suits. Physicians were aware of the
importance of informed consent as a protection of both
patients and themselves. They indicated the importance of
helping patients understand the purpose and the expected
outcomes of a medical treatment. However, some empha-
sized informed consent, as a legal requirement, mostly
protect themselves against legal suits. This was especially the
case in the light of patients’ increasing awareness of their
rights; and as a result of the rapidly growing stream of
medical information that was becoming accessible to the
general public:
Both patients and physicians need legal assurance.
[Questionnaire 11]
The community nowadays gets information more easily
from the mass media. We need to be more careful to
perform a procedure or treatment. [Questionnaire 6]
Informed consent is important for the protection of our
[physicians’] career. [DR5, interview]
This concern about liability helped ensure that physicians
paid attention and update their knowledge on informed
consent practice.
Quality of interprofessional relationships. Interprofessional
relationships and communication between physicians and
other health professionals were factors with a strong impact
on informed consent. Patients were mostly treated by
multiple specialists, who may have held conflicting medical
views concerning the medical treatment. Consequently,
different physicians often gave conflicting information to
one patient:
Several physicians are taking care of a patient. Who is the
leader? [Questionnaire 18]
Physicians hold different views. A conflict may occur.
A third person is needed. Whoever he or she is, at least
someone who is able to explain. [DR4, interview]
Patient-related factors
Patients’ ability to understand. Discussing medical treatment
with patients was considered as a challenging task that
required tailor-made approaches for different types of
patients. Some participants indicated that it was difficult
for many patients to understand the information they
received and to use it in order to make a well-considered
decision. Patients often found themselves in an emotional
state of mind, for instance, in an emergency situation, and
were not able to make a well-considered decision. Academic
and language gaps between physicians and patients were also
mentioned.
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PATIENT OR PHYSICIAN SAFETY? 215
Despite the increasing availability of medical information,
many patients were still considered to be less educated,
ignorant of their rights or unable to understand the
physician’s explanation. It was also noted that some patients
did not ask for information as they had complete trust in the
physician to make the right decision for them:
Patients sometimes panic; although they do not
understand, they just sign the informed consent form.
[Questionnaire 24]
The language of the patients is not the same as that of
physicians. Patients sometimes do not understand. [DR 6,
interview]
Many patients do not understand informed consent.
Moreover, they are afraid of information about medical
procedures. [Questionnaire 2]
Patients’ perception of risk. Contrasting opinions were raised
concerning the advisability to inform patients about risks
and possible complications of medical treatment. On one
hand, participants argued that patients should be told the
whole truth, as long as the physician’s practice was evidence-
based and guided by sound clinical reasoning. On the other
hand, participants reasoned that disclosure of risk could
detrimentally affect the patient, and that information should
therefore be tailored to individual patients at the physician’s
discretion:
If you mention every risk, patients will run away, do not
dare to undergo the treatment. Thus, it will be more
dangerous to the patients. [DR3, interview]
I always communicate risks, even the smallest ones. Local
anesthesia, for example, may cause an allergic reaction or
bleeding. Patients should be told about that. [DR1, interview]
Involvement of family members. Although participants
recognized the importance of involving family members,
this was also regarded as a challenge for them. In general, it
was noted that it takes physicians extra time and effort to
satisfy all family members, as often many people were
involved, all of whom demanded different forms of
information. It was also pointed out that problems could
occur when family members expressed conflicting opinions
about the patient or when the available family member
communicating with the clinician was not to be a capable
decision-maker.
Information from other parties. It was stressed by a number of
participants that patients and family members often trusted
information about care issues from neighbors or relatives in
their environment more than the information they received
from the physicians. Along with patients’ personal beliefs and
previous experiences, it was noted that this additional
element also played a role in the patients’ decision-making.
216 A.P. SUSILO ET AL .
Physicians’ perceptions of nurses’ roles in informed consent
As discussed above, participants were asked about nurses’
roles in informed consent during the interviews while there
was no specific explicit question on that issue in the
questionnaire. Nevertheless, nurses’ involvement in informed
consent was spontaneously mentioned in 12 of the 24
questionnaires. In general, participants noted that physicians
had only limited time to talk to patients and family, while
nurses were more accessible to them. Different perceptions
regarding nurses’ roles emerged. These different roles are
discussed below.
Desired roles of nurses
On the whole, participants valued nurses’ involvement in
coordinating meetings between physicians, patient and family
members. This arrangement was regarded as an efficient
information process that could be ensured to the patient and
family members. Nurses played a central role in ensuring that
the informed consent form was completed accurately. It was also
considered important to have a nurse witnessing the informed
consent process:
I can explain and ask for consent, but I cannot stay with the
patient when they are filling in the form, [ . . . ] Nurses can
watch them. Later when patients have completed and signed
the form, I will come back and sign it. [DR6, interview]
In addition, participants praised nurses’ efforts to
help patients find information, for example, by contacting
the administration unit for information about the cost of
their care.
Nurses’ roles which merit consideration
Although some participants saw partnership with nurses as
an ideal form of physician –nurse relationship, others were
more critical, stating that nurses often lacked expertise on the
patient’s clinical condition. Junior nurses were also criticized
for using personal experience rather than referring to
scientific resources, or seeking the input of a senior clinical
colleague:
When a young nurse is not sure of a particular subject, s/he
should ask a senior nurse or the physicians. Tell the
patient, “I will ask to the physician later” or something like
that. Do not give an absolute answer. [DR 6, interview]
Some participants urged the necessity of carefully defining
which information a nurse was allowed to provide. For
example, it was stressed that information provided by the
nurse should not contradict the explanation of the physician;
as such information could have a negative impact on the
patient’s decision-making process.
When nurses have a personal opinion, they should discuss
it with the physicians [ . . . ] Differences of opinion should
not be communicated [to the patient]. [DR6, interview]
Nurses’ roles as patient advocates, which include
encouraging patients to undergo treatment, checking if
they had understood the information explained to them
before giving consent or supporting patients in asking
questions, were viewed in different ways. Some participants
appreciated it when nurses reminded them to explain key
information or informed them about the patients’ unspoken
concerns, arguing that nurses should be more active and
assertive on behalf of the patient. In contrast, other
participants preferred nurses to take a neutral position and
not to interfere with the decision-making process. The main
concern was that nurses’ influence could result in patients’
withdrawal from planned treatment.
Needed competence of nurses
To improve the contribution of nurses in the informed
consent process, different suggestions were offered. For
example, it was suggested that courses on communication
skills and improvements in understanding of the legal aspects
and principles of informed consent could be provided.
A model of the influencing factors related to informed
consent
To develop thinking about the issues linked to informed
consent, the findings from interviews and questionnaire have
been synthesized into a model (see Figure 1).
This model indicates the two worlds of professionals and
patients. In the professionals’ world, physicians’ involvement
in the informed consent process is related to the roles of the
nurses and the clarity of hospital policy. Patients’ involve-
ment in the informed consent process is additionally
influenced by their family, who serve as patients’
environment.
DISCUSSION
As indicated above, physicians were not always fully aware of
the law surrounding the use of informed consent before
medical treatments or procedures (Menteri Kesehatan
Republik Indonesia, 2008). The term informed consent
frequently referred to the written form rather than to a joint
decision-making process between clinician and patient. This
finding supports the work of Whitney, McGuire, &
McCullough (2004). Indeed, several physicians gave priority
to written informed consent mostly because it was
considered to be a safeguard against legal suits. Physicians
who held this belief were concerned about patients’
increasing awareness of their rights and ever-increasing
access to medical information. This finding can be seen as a
misinterpretation of informed consent that deviates from the
goal of patient safety (Wachter, 2008), as it shifts the focus of
informed consent to the physician, and away from patients’
involvement in the process. This finding illustrates why in
daily practice informed consent was mostly focused on
obtaining a signature from the patients as opposed to
engaging in an SDM process. Also, it indicates that physicians
prefer nurses to act as their delegates rather than as patients’
advocates who may contribute independent issues from
nurses’ own expertise.
On the other hand, we notice a “veiled paternalism”
phenomenon. Kon (2007) describes this phenomenon as
Journal of Interprofessional Care

HOSPITAL
PHYSICIAN
Time related issues
Financial concern
Quality of teamwork
Concern of Legal
Suit
Supporting facilities
Clarity of informed
related policy
consent
NURSES
Roles
and competence
Figure 1. Stakeholders in informed consent process and their influencing factors.
physicians’ holding convictions that some patients were
unable to comprehend information, were difficult to engage
in a discussion about treatment or were incapable of
making well-considered decisions. This view toward patients
was also found by Sciortino (1999) and considered by
other researchers as barriers to patient participation in
decision-making (Gravel et al., 2006; Legare et al., 2008).
Another, similar, barrier that emerged from our findings was
that our participants hardly ever mentioned the importance
of exploring patients’ perceptions, which is central to the
partnership style of physician – patient communication
(Silverman, Kurtz, & Draper, 2005). This finding was in
line with Kon (2007) and Yousuf et al. (2007).
Whatever maybe the cause of their misperceptions on the
informed consent process, we believe that physicians hold a
strong willingness to improve this process. Their concern of
the importance of the legal protection can be taken as a
momentum for the implementation of an improvement
strategy. We are aware that physicians, as other stakeholders
in the informed consent process, live within their own
environment that influences the way informed consent is
practiced (see Figure 1). In this setting, the environment of
physicians was the hospital. Thus, we argue that education on
informed consent and communication skills training only
will not offer satisfactory solutions (Grol & Wensing, 2005),
given the strong impact of time constraint and hospital
support (Gravel et al., 2006; Legare et al., 2008).
Based on our findings, we advocate a strategy to improve
the informed consent process. This could be performed by
offering physicians help to overcome their time constraints
by involving nurses in the informed consent process and by
providing standardized medical information aids (Legare
et al., 2010). It is also necessary to strengthen nursing
advocacy roles for the best interest of the patients (Vaartio
et al., 2006). Nurses should be able to assess patients’
concerns and encourage them to express these to the
q 2012 Informa UK, Ltd.
PATIENT OR PHYSICIAN SAFETY? 217
PATIENT
(AND PHYSICIAN)
SAFETY ENVIRONMENT
PATIENT
Patients’ ability to
understand
Patients’
perception of risk
Informed
Consent
parties
from other
Information
FAMILY
Involvement
physicians (Lobo, 2002). Nurses can play a role in
empowering patients to engage in SDM (Windle et al.,
2008). To achieve this, nurses would benefit from learning
assertiveness in their communication skills (e.g. Hall, 2005;
Wolf, 2006). In addition, in order to improve the informed
consent process, physicians and nurses should be able to
work in a blame-free culture, which is a basic investment
for patient safety (Wachter, 2008).
This study has a number of limitations. First, APS’
position in hospital management was associated with efforts
to promote positive partnership relations between physicians
and patients and also between physicians and nurses, which
may have unduly affected the trustworthiness of the study.
To help counteract this, the qualitative analysis was also
performed, independently, by IN, whose position was more
neutral. Second, while the number of interviewees in the first
phase was limited, the themes that emerged from this data set
were confirmed by the data gathered from the questionnaire.
CONCLUDING COMMENTS
The study suggests opportunities for improvement in the
informed consent process. The main stakeholders (patients,
physicians and hospitals) positively contributed to this
process, but sometimes acted as barriers as well. This study
explored in what way the role of nurses could contribute to
the process and how nurses can further develop competencies
in order to play a vital collaborative role in the informed
consent process.
ACKNOWLEDGEMENTS
The authors thank Herkutanto and Sugiharto Tanto for
supporting the presentation for doctors, and Mereke Gorsira
and Jill Whittingham for the English editing.
218 A.P. SUSILO ET AL .
Declaration of interest
The authors report no conflict of interest. The authors alone
are responsible for the content and writing of the paper. The
principal investigator (APS) was working part time for the
hospital management to support the medical committee and
the nursing committee in developing a credentialing system.
The other researchers had no institutional relationship with
the hospital. The hospital hosted the presentation for
physicians and provided meals.
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