The White Practice ( Walton HC )
The White Practice ( Walton Health Centre ) is committed to providing a safe, comfortable environment where the safety of patients and staff is of paramount importance. Patients experiencing consultations, examinations and investigations need to feel and be safe and to experience as little discomfort and distress as possible. Equally health professionals are at a potential risk of their actions being misconstrued or misrepresented if they conduct examinations where no third party is present. Clinicians have a professional responsibility to minimise the risk of false accusations of inappropriate behaviour.
This policy presents principles and outlines the procedures that should be in place for appropriate use of chaperones for patients during examinations, investigations and care. It is largely based on the Model Chaperone Framework published by the NHS Clinical Governance Support Team in June 2005.
Guidance on chaperoning is for the assistance and protection of both patients and healthcare professionals. All clinicians have a responsibility to consider chaperoning issues and to work in accordance with the following principles.
Principles of Good Practice
Patients may find any examination distressing, particularly if these involve the breasts, genitalia or rectum (known as “intimate examinations”). Patients may also be distressed by consultations involving dimmed lights or close proximity of the clinician to the patients. Some individuals for personal or cultural reasons, may feel uncomfortable if the clinical examination requires them to undress and / or be touched and may feel vulnerable.
Chaperoning may help reduce distress, but must be used in conjunction with respectful behaviour, explanation, informed consent and privacy.
In attending a consultation it is assumed that a patient is seeking appropriate clinical assessment, diagnosis and treatment and therefore is granting implied consent to necessary physical examinations. However, before proceeding with a physical examination healthcare professionals should always seek to obtain, by word or gesture, some explicit indication that the patient understands the need for examination and agrees for it to take place.
What is a chaperone?
A chaperone is present as a safeguard for both parties (patient and healthcare professionals) and is a witness to the conduct and the patients continuing consent to the examination or procedure.
The precise role of the chaperone varies depending on the circumstances. It may include providing a degree of emotional support and reassurance to patients but more commonly incorporates:
- Providing protection to healthcare professionals against unfounded allegations of improper behaviour.
- Assisting in the examination or procedure, for example handing instruments during an examination or procedure
- Assisting with undressing, dressing and positioning patients
A chaperone is NOT used to reduce the risk of attack on a health professional.
Who may Chaperone?
There are two main types of Chaperone: ‘formal’ and ‘informal’.
Informal Chaperones are family, friends or supporters of the patient invited by the patient to accompany them in the consultation. Many patients feel reassured by the presence of a familiar person. Clinicians will accept the patients wish for an informal chaperone in almost all cases. The shortcomings of utilising informal chaperone include:
- they may not understand the boundaries between appropriate and inappropriate clinician behaviour within an examination or procedure
- they may not necessarily be relied upon to act as an independent witness to the conduct or continuing consent of the procedure.
Under no circumstances should a child be expected to act as a chaperone. However, if the child is providing comfort to the parent and will not be exposed to unpleasant experiences it may be acceptable for them to stay. It is inappropriate to expect an informal chaperone to assist in or take part in the examination or to witness the procedure directly.
A ‘formal’ chaperone implies a health care professional, trained as a chaperone. This person may be a receptionist, nurse or a healthcare assistant. This individual will have a specific role to play in terms of the consultation and this role should be made clear to both the patient and the chaperone. Chaperones must have sufficient training to understand the role expected of them and they must not be expected to undertake a role for which they have not been trained.
Protecting the patient from vulnerability and embarrassment means that the chaperone will usually be of the same gender as the patient. There may be occasions when no staff of the same gender as the patient are available. On any such occasion, provided it is clinically appropriate to delay the examination / procedure, the patient will be offered the option to rebook for the examination / procedure at a time when a clinician of their choice is available.
The patient always has the opportunity to decline a particular person as a chaperone if that person is not acceptable to them for any justifiable reason.
Training for chaperones
Members of staff who undertake a formal chaperone role shall undergo training for the role.
This will include an understanding of:
- What is meant by the term chaperone
- The specific details of different types of intimate examinations
- The rights of the patient
- The role and responsibility of the chaperone
- Policy and mechanism for raising concerns
Offering a chaperone
The relationship between a patient and healthcare professionals is based on trust. A practitioner may have known a patient for a long time but a chaperone should be offered in all circumstances that meet the criteria outlined in this policy regardless of how long the patient is known to the practitioner. Therefore all patients have equity of access to chaperones in identical clinical situations. Any patient is entitled to a chaperone if they feel one is required.
Staff should be aware that intimate examinations might cause anxiety for both male and female patients whether or not the examiner is of the same gender as the patient.
It is good practice to offer all patients a choice of the gender of their chaperone for their examination or procedure. If the patient is offered and does not want a chaperone it is important to record that the offer was made and declined.
If a chaperone is refused, a healthcare professional cannot usually insist that one is present. However, there may be cases where the practitioner makes a professional judgement that they cannot conduct the examination of procedure without a chaperone present and may decline to proceed without a chaperone. Examples include where the healthcare professional considers here is a significant risk of the patient experiencing distress, displaying unpredictable behaviour, or making false accusations. In any such case, the practitioner must make his/her own decision and carefully document their decision and rationale in the notes along with the details of any procedure undertaken.
Where a chaperone is needed but not available
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 (this may include simple waiting in the practice until a member of staff is available). If the seriousness of the condition dictates that a delay is inappropriate then this should be explained to the patient and recorded in their notes. A decision to continue or otherwise must be jointly reached.
In cases where the patient is not competent to make an informed decision then the healthcare professional must use their own clinical judgement and be able to justify their course of action. The decision and rationale should be documented in the patient’s notes.
It is acceptable for a healthcare professional 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 any such examination should be recorded in the patient’s notes.
Issues specific to children
Children and their parents or guardians must receive an explanation of the planned examination / procedure in order to obtain their informed consent, co-operation and understanding. If a minor presents in the absence of a parent or guardian the healthcare professional must ascertain if they are capable of understanding the need for an examination and the nature of the examination. In these cases it is advisable for a formal chaperone to be present for any intimate examinations.
In situations where abuse is suspected great care and sensitivity must be used to explain the reasons for, and nature of, the examination / procedure and ensure the patient’s comfort and dignity. In these situations healthcare professionals should consider if the patient may require referral for the examination / procedure to be carried out by the local child protection specialist practitioners in specialist facilities. The practice will refer to, and be guided by, local Child / Vulnerable Patient policies and seek advice from the Child Protection Lead/Team as necessary.
Issues specific to religion, ethnicity, culture and sexual orientation
All 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. Some patient’s ethnic, religious, cultural background and sexual orientation can make intimate examinations particularly difficult. For example, men or women may have a strong cultural or religious or belief system reason why they are adverse to examinations by clinicians of the opposite gender. A lesbian woman or gay man may wish intimate examinations to be performed by a healthcare professional of the opposite gender.
The patients beliefs, attitudes and concerns will not be presumed and will be discussed with the patient and taken into account. Each individual has very different needs and before the procedure these should be mutually agreed with the healthcare professional. The healthcare professional however will not collude with patients who are practising discrimination.
Issues specific to people with learning difficulties and mental health problems
For patients with learning difficulties or mental health problems that affect capacity, a familiar individual such as a family member or carer may be the best chaperone. A simple and sensitive explanation of the technique is vital.
Adult patients with learning difficulties or mental health problems who resist an examination or procedure must be interpreted as refusing to give consent and the procedure must be abandoned. In life-saving situations the healthcare professional must use their clinical judgement as to the best interests of the patient and must record their rationale fully in the patients notes. Advice and assistance is available from the Vulnerable Adults Support and Safeguarding teams and for mental health patients specialised advice and support can be sought from the Mental Health Care Team.
Non English speaking patients
If a non English speaking patient is examined an independent interpreter should be enlisted. This will help ensure the patient understands the proposed examination / procedure and is able to grant (or decline to grant) informed consent The interpretation service is usually provided over the telephone. The use of a formal chaperone may still be appropriate even if the interpreter is in the room as the interpreter may not be a trained chaperone. A family member or interpreter should not be used as a formal chaperone.
Should a patient require sedation for a particular procedure then it is strongly recommended that a chaperone / Nurse be present throughout the procedure and sedation period until the patient has recovered from the effects of the sedation. This is necessary because not only is the patient rendered more vulnerable, but also their understanding of events or recollection may be impaired. Hallucinations and delusions may occur when under sedation.
Where a healthcare professional is working in a situation away from other colleagues, for example during a home visit, the same principles for offering and use of chaperones should apply. The healthcare professional may be required to risk assess the need for a formal chaperone and should not be deterred by the inconvenience or complexity of making the necessary arrangements. In all instances the outcome must be documented.
In all cases where the presence of a chaperone may intrude in a confidential clinician-patient relationship their presence should be confined to the physical examination. Confidential communication between the healthcare professional and the patient should, where possible, take place before and after the examination or procedure when confidentiality is easier to maintain.
Communication and record keeping
The key principles of communication and record keeping will ensure that the healthcare professional and patient relationship is maintained. This will assist patient comfort and dignity, their confidence in the professionalism of the clinician and practice and also safeguard the clinician against formal complaints, or in extreme cases, legal action.
The most common cause of patient complaints is a failure in communication between both parties, either in the practitioner’s explanation of, or the patients understanding of, the process of examination or treatment. It is essential that the healthcare professional explains the nature of the examination and offers patients a choice whether to continue. Chaperoning in no way removes or reduces this responsibility.
Details of the examination including the presence or absence of a chaperone and the information given must be documented in the patient’s clinical record. The records should make clear from the history that the examination was necessary.
In any situation where concerns are raised or an incident has occurred this should be dealt with immediately in accordance with the Incident Reporting Procedure.
Regardless of the patient’s role, the guidelines from medical regulatory bodies are clear: it is always the doctor’s responsibility to manage and maintain professional boundaries – utilising chaperones effectively is a way of managing relations with patients, where the ultimate responsibility for ensuring that relations remain on professional footing rests with you.
In 2004 the Committee of Inquiry looked at the role and use of chaperones, following its report into the conduct of Dr Clifford Ayling (see useful links). It made the following recommendations:
- Each trust should have its own chaperone policy and this should be made available to patients.
- An identified managerial lead (with appropriate training).
- Family members or friends should not undertake the chaperoning role.
- The presence of a chaperone must be the clear expressed choice of the patient; patients also have the right to decline a chaperone.
- Chaperones should receive training.
Why use chaperones?
- Their presence adds a layer of protection for a doctor; it is very rare for a doctor to receive an allegation of assault if they have a chaperone present.
- Acknowledge a patient’s vulnerability.
- Provides emotional comfort and reassurance.
- Assists in the examination.
- Assists with undressing patients.
- Enables them to act as an interpreter.
What is an intimate examination?
Obvious examples include examinations of the breasts, genitalia and the rectum, but it also extends to any examination where it is necessary to touch or be close to the patient; for example, conducting eye examinations in dimmed lighting, taking the blood pressure cuff, palpitating the apex beat. Consult GMC and NMC advice on intimate examinations (see further information).
How to develop a chaperone policy
Here is a useful checklist for the management of a consultation:
- Establish there is a need for an intimate examination and discuss this with the patient.
- Explain why an examination is necessary and give the opportunity to ask questions; obtain and record the patient’s consent.
- Offer a chaperone to all patients for intimate examinations (or examinations that may be construed as such). If the patient does not want a chaperone, record this in the notes.
- If the patient declines a chaperone and as a doctor you would prefer to have one, explain to the patient that you would prefer to have a chaperone present and, with the patient’s agreement, arrange for a chaperone.
- Be aware and respect cultural differences. Religious beliefs may also have a bearing on the patient’s decision over whether to have a chaperone present.
- Give the patient privacy to undress and dress. Use paper drapes where possible to maintain dignity.
- Explain what you are doing at each stage of the examination, the outcome when it is complete and what you propose to do next. Keep the discussion relevant and avoid personal comments.
- Record the identity of the chaperone in the patient’s notes.
- Record any other relevant issues or concerns immediately after the consultation.
- In addition, keep the presence of the chaperone to the minimum necessary period. There is no need for them to be present for any subsequent discussion of the patient’s condition or treatment.
(Written information detailing the policy should be provided for patients, either on the practice website or in the form of a leaflet.)
Key points to remember
- Inform your patients of the practice’s chaperone policy.
- Record the use, offer and declining of a chaperone in the patient’s notes.
- Ensure training for all chaperones.
- GPs do not have to undertake an examination if a chaperone is declined.
- Be sensitive to a patient’s ethnic/religious and cultural background. The patient may have a cultural dislike to being touched by a man or woman or undressing.
- Do not proceed with an examination if you feel the patient has not understood due to a language barrier.