Mid Hampshire Healthcare (MHH) as an NHS Organisation and the service that they operate are committed to the provision of high-quality health care in all aspects of its services to patients, visitors; local community’s and staff members. It attaches the highest importance to ensuring that a culture that values patient privacy and dignity is embedded within the organisation.
MHH recognises that clinical consultations, examinations and investigations have the potential to cause some people distress. Consultations that happen inside a clinic room or within the patients home can sometimes lead to patients feeling vulnerable.
Intimate and personal care is key to a person’s self-image and respect. The apparent intimate nature of many health care interventions, if not practiced in a sensitive and respectful manner, can lead to misinterpretation and occasionally allegations of abuse, such as neglect, physical injury, emotional or sexual abuse. Not understanding the cultural background of a patient can lead to confusion and misunderstanding with some patients believing they have been the subject of abuse. It is important that all health care professionals are sensitive to these issues and are alert to the potential for patients to feel abused and/or violated. Very careful consideration should be given to patients who have had a previous traumatic examination or have been a victim of sexual assault in the past.
This policy sets out guidance that must be followed for the use of chaperones within our services and the procedures that should be in place for examinations and investigations and is for the protection of both patients and staff. This policy also includes the key principles of communication and record keeping in relation to chaperoning to ensure that MHH staff / patient relationship is maintained and to act as a safeguard against formal complaints, or in extreme cases, legal action.
Clinical professional judgment should be utilised at all times: each situation will require a risk assessment by the clinician with clear decision-making processes reflected within the patient’s record.
This policy should be used in conjunction with existing guidance from Professional bodies with reference to the following MHH Policies:
Consent to Examination and Treatment
Clinical Record Keeping
Freedom to speak up: raising concerns (whistleblowing) policy for the NHS
Mental Capacity Act 2005
Safeguarding Children and Safeguarding Adults
Personal Safety & Lone Worker Policy
Incident Reporting Policy
Confidentiality and Data Protection Policy
Infection prevention and Control Policy
Promoting Equality, Valuing Diversity and protecting Human Rights
This policy applies to all healthcare professionals working within MHH including medical staff, nurses, healthcare assistants, allied health professionals, medical students, and in the patient’s home, this list is not exhaustive.
This policy will be disseminated via Intradoc website to all staff, the policy will also be available on the MHH website.
For this policy, the following definitions are used:
Chaperone: There is no common definition of a ‘chaperone’: the role varies according to the needs of the patient, the healthcare professional, and the examination or procedure being carried out.
Formal Chaperone: A formal chaperone is a healthcare professional, who has undertaken appropriate chaperone training, i.e. all medical and registered staff and healthcare support workers
Informal Chaperone: A relative or friend of the patient is usually an impartial observer and would not be a suitable formal chaperone, however you should comply with any request to have such a person present, as well as a chaperone if the patient so wishes.
This policy advocates that wherever healthcare services are provided that patients are aware that they can access a chaperone to support their care treatment and examination.
No family member or friend of a patient should be routinely expected to undertake any formal chaperoning role in normal circumstances.
The presence of a chaperone during a clinical examination and treatment must be the clearly expressed choice of a patient (however the default position should be that all intimate examinations are chaperoned).
Chaperoning should not be undertaken by anyone other than chaperone-trained staff: The use of untrained administrative staff as a chaperone, is not acceptable.
The patient must have the right to decline any chaperone offered if they so wish. Clinicians can also refuse to undertake a task if they feel they warrant a chaperone but the patients declines.
MHH recognises that it is essential that members of staff are confident in their responsibilities and their ability to chaperone. It is recognised that for primary care, developing and resourcing a chaperoning policy will have to consider issues such as one to one consultation’s in the patient’s home and the capacity of individual practices to meet the requirements of the policy.
Reported breaches of the chaperoning policy should be formally investigated through MHH’s risk management and clinical governance arrangements and treated, if determined as deliberate, as a disciplinary matter.
THE ROLE OF THE FORMAL CHAPERONE
The role of the formal chaperone may vary according to the clinical situation and can include:
Providing the patient with physical and emotional support and reassurance
Ensuring the environment supports privacy and dignity
Providing practical assistance with the examination
Safeguarding patients from humiliation, pain, distress or abuse
Providing protection to healthcare professionals against unfounded allegations of improper behaviour
Identifying unusual or unacceptable behaviour on the part of the healthcare professional or the patient
Providing protection for the healthcare professional from potentially abusive patients
Provide protection to healthcare professionals against unfounded allegations of improper behaviour made by the patient
Chaperones should be
Sensitive and respectful of the patient’s dignity and confidentiality
Familiar with the procedures involved in routine intimate examinations and will be able to identify any unusual or unacceptable behaviour on the part of the health care professional
Prepared to ask the examiner to abandon the procedure if the patient expresses a wish for the examination to end
Ensure their presence at the examination is documented by the examining professional in the patient’s medical record
Prepared to raise concerns if misconduct occurs and immediately report any concerns to the Service Delivery Manager and Nurse Development and Quality Manager, and via the Datix system
OFFERING A CHAPERONE
All patients should be routinely offered a chaperone. The offer of a chaperone should be made clear to the patient prior to any procedure, ideally at the time of booking the appointment. It should not be assumed that a patient does not require a chaperone and clinical staff should use their professional clinical judgment to assess the clinical situation and how the consultation unfolds, at each visit.
If the patient is offered and does not want a chaperone it must be recorded in the patients notes that the offer was made and declined. If a chaperone is refused but the healthcare professional (HP) is concerned the HP can equally refuse the procedure unless it is an emergency or detrimental to the patient’s health.
Patients decline the offer a chaperone for a number of reasons: because they trust the Nurse, think it unnecessary, require privacy, or are too embarrassed. However, there are some cases where the (usually male) Nurse/GP may feel unhappy to proceed.
This may be where a male Nurse/GP is carrying out an intimate examination, such as a breast examination.
Other situations are where there is a history of violent or unpredictable behaviour on behalf of the patient to see another health professional.
For some patients, the level of embarrassment increases in proportion to the number of individuals present.
In order for patients to exercise their right to request the presence of a chaperone, a full explanation of the examination, procedure or treatment to be carried out must be given to the patient. This should be followed by a check to ensure that the patient has understood the information and gives consent.
The healthcare professional is responsible for:
Establishing the patient’s needs for a chaperone during their explanation about the clinical examination, consultation or treatment.
Ensuring a suitable chaperone is present should the patient choose to have one
Consideration should be given to the chaperone being of the same sex as the patient wherever possible to protect the patient from vulnerability and embarrassment
Seeking and recording the patient’s consent to have relatives or carers present during examinations or procedures
Patients should be reassured that all staff understand their responsibility not to divulge confidential information
The chaperone should only be present for the examination itself, and most discussion with the patient should take place while the chaperone is not present
Recording the presence of, and the name of the chaperone in the patient’s healthcare record
Recording whether a patient has declined a chaperone at any point during the process in the patient’s healthcare record
Identifying and recording any preferences or objections resulting from diverse religious, cultural or ethnic backgrounds as early as possible to avoid the potential for causing offence. The individual requirements of the patient regarding choice of chaperone should be respected
Ensuring that facilities are available for patients to undress in a private, undisturbed area. There should be no undue delay prior to examination once the patient has removed any clothing
Infection control measures must be adhered to when using blankets or drapes
Staff must ensure curtains / doors are closed during all examinations and procedures. Where curtains/doors are closed staff will gain permission before entering to ensure privacy
Staff will ensure patients do not feel vulnerable to intrusion and that curtains, which do not remain tightly closed, do not compromise privacy and dignity
The patient will not be asked to take off more clothing than is necessary and will be provided with an appropriate gown / garment that is acceptable to them in order to protect their modesty
Patients will be given privacy to dress and undress and should not be assisted in removing clothing unless it has been clarified that assistance is needed
Staff should be aware and sensitive to religious customs and beliefs
Following any physical examination, patients will have an opportunity to re- dress before the consultation continues
WHERE A CHAPERONE IS DECLINED
If a patient prefers to undergo an examination / procedure without the presence of a chaperone this should be respected and their decision documented in their clinical record.
The only exclusion to this is when intimate examinations or procedures are performed, where it is mandatory to have a chaperone as outlined in this policy.
If the patient has declined a chaperone for an intimate examination where it is mandatory to have a chaperone, the clinician must explain clearly to the patient why a chaperone is necessary. In this case, the patient may wish to consider requesting referral to an alternative care provider. The examination should not proceed without a chaperone.
Any discussion about chaperones and the outcome should be recorded in the patient’s notes or electronic record. That the offer of a chaperone was made and declined should always be recorded.
WHERE A CHAPERONE IS NEEDED BUT NOT AVAILABLE
Every effort should be made to provide a chaperone and where possible a chaperone of the same sex as the patient should be offered. On occasions where it is not possible to provide a chaperone of the same sex as the patient the following considerations will be considered:
The wishes of the person requiring the examination
The consequences if the person does not receive the care
Whether the urgency of the care needed makes it an immediate necessity
The length of time before a same gender member of staff can be present
If the patient has requested a chaperone and none are available at that time the patient must be given the opportunity to reschedule their appointment within a reasonable timeframe.
If either the practitioner or the patient does not want the examination to go ahead without a chaperone present, or if either is uncomfortable with the choice of chaperone, the examination may be delayed to a later date when a suitable chaperone will be available, as long as the delay would not adversely affect the patient’s health.
If the seriousness of the condition would dictate that a delay is inappropriate then this should be explained to the patient and recorded in their notes.
A decision to continue or otherwise should be jointly reached. In cases where the patient lacks Mental Capacity to make an informed decision then the healthcare professional must decide in the patients’ best interests and record and be able to justify this course of action.
It is acceptable for the staff member (or other appropriate member of the healthcare team) to perform an intimate examination without a chaperone if the situation is life threatening or speed is essential in the care or treatment of the patient. The rationale for undertaking this must be recorded in the patients’ medical records.
WHO CAN BE A CHAPERONE?
A variety of people can act as a chaperone but staff undertaking a formal chaperone role must have had the appropriate training. It is strongly recommended that chaperones should be clinical staff familiar with procedural aspects of personal examination however where there are other appropriately trained members of staff available to chaperone, they will be asked.
You must have an enhanced DBS in order to be a chaperone within any of our services.
It is recommended that members of staff who undertake a formal chaperone role have undergone training such that they develop the competencies required for this role. MHH staff have access to Chaperone training relevant to their role within the Bluestream platform of training modules.
These include an understanding of:
What is meant by the term chaperone?
What is an “intimate examination”?
Why chaperones need to be present?
The rights of the patient
Their role and responsibility e.g. advocate
Policy and mechanism for raising concerns
Induction of new non-registered staff should include training on the appropriate conduct of intimate examination, and the role of the chaperone, if appropriate for their role and clinical area. All registered clinical staff should understand the role of the chaperone and the procedures for raising concerns.
Consent is a patient’s agreement for a health professional to provide care. Before examination, treatment or care for any person you must obtain their consent, and this will be recorded in the care record.
Patients may indicate consent non-verbally (for example by presenting their arm for their pulse to be taken), orally, or in writing.
For the consent to be valid, the patient must: be competent to make the particular decision, and have received sufficient information to make it, and not be acting under duress.
Every adult has the right to make his / her own decisions and must be assumed to have capacity to do so unless it is proved otherwise. This means that you cannot assume that someone cannot decide for themselves just because they have a particular medical condition or disability.
Before proceeding with an examination however it is vital that the patient’s informed consent is obtained. This means that the patient must; be competent to make the decision; have received sufficient information to reach a decision and is not acting under duress.
When patients are not able to consent for themselves you must always act in their best interest; involve the person in the decision making; have regard for past and present wishes and feelings and consult with others who are involved in the persons care. There must be no discrimination.
ISSUES SPECIFIC TO RELIGION, ETHNICITY OR CULTURE
The ethnic, religious and cultural background of some women can make intimate examinations particularly difficult, for example, some patients may have strong cultural or religious beliefs that restrict being touched by others, particularly members of the opposite sex.
Patients undergoing examinations should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only that part of the anatomy that requires investigation or imaging. It would be unwise to proceed with any examination if the healthcare professional is unsure that the patient understands what is being communicated due to a language barrier.
In life saving situations every effort should be made to communicate with the patient by whatever means available before proceeding with the examination.
An interpreter is not to be used as a chaperone under any circumstances.
ISSUES SPECIFIC TO LEARNING DIFFICULTIES/MENTAL HEALTH PROBLEMS
All patients with communications needs, learning disabilities or mental health problems that affect capacity must have a formal chaperone for all intimate examinations/procedures. Family or friends who understand their communications needs and are able to minimise any distress caused by the procedure could also be invited to be present throughout any examination if the patient so wishes.
A careful simple and sensitive explanation of the technique is vital. This patient group is a vulnerable one and issues may arise with initial physical examination, “touch” as part of therapy, verbal and other “boundary-breaking” in one to one “confidential” settings and indeed home visits.
Adult patients with learning difficulties or mental health problems who resist any intimate examination or procedure must be interpreted as refusing to give consent and the procedure must be abandoned.
In life threatening situations the healthcare professional should use professional judgment and where possible discuss with a member of the Mental Health Care Team and this discussion and rationale to proceed documented within the patient record.
All Staff must be aware of the implications of the Mental Capacity Act (2005) (‘MCA’) and cognitive impairment. If a patient’s capacity to understand the implications of consent to a procedure, with or without the presence of a chaperone, is in doubt, the procedure to assess mental capacity must be undertaken. This should be fully documented in the patient’s notes or electronic record, along with the rationale for the decision. (see the Mental Capacity Act 2005 Policy including the Deprivation of Liberty Safeguards).
Where a healthcare professional is working in a situation away from other colleagues’ the same principles for offering and the use of chaperones should apply.
Where it is appropriate family members / friends may take on the role of informal chaperone. In cases where a formal chaperone would be appropriate, i.e. intimate examinations, the healthcare professional would be advised to reschedule the examination to a more convenient time or location.
In cases where this is not an option, for example due to the urgency of the situation or because the practitioner is community based, the rationale for proceeding without a chaperone present and what examination was carried out must be documented in the patient record as soon as possible.
Healthcare professionals should note that they are at an increased risk of their actions being misconstrued or misrepresented if they conduct intimate examinations where no other person is present.
Further information can be obtained by referring to the Mid Hampshire Health Care Community Lone worker policy.
COMMUNICATION AND RECORD KEEPING
The most common cause of patient complaints is a failure on the patient’s part to understand what the healthcare professional was doing in the process of treating them. It is essential that the healthcare professional explains the nature of the examination to the patient and offers them a choice whether to proceed with the examination at that time. The patient will then be able to give an informed consent to continue with the consultation. Where English is not the 1st language the use of an interpreter should be advocated / offered. This discussion must be recorded in the patient’s record.
Details of the examination including the presence / absence of a chaperone and information given to the patient must be documented in the medical records. Use of clinical templates will standardize the documentation within the patient’s record. The chaperone will make a record in the patients notes after examination, this will state that where were no problems, or give details of any concerns or incidents that occurred.
If the patient expresses any doubts or reservations about the procedure and the healthcare professional feels the need to reassure them before continuing then this must be recorded in the patients’ record; the records should make clear from the history that an examination was necessary.
In any situation where concerns are raised or an incident has occurred a Datix report is required this should be completed immediately after the consultation and concerns raised with the service manager.
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