Chaperone Policy

Summary

All clinical consultations, examinations and investigations are potentially distressing. Many patients find examinations, investigations, inspection or photography involving the rectum, genitalia or breasts particularly intrusive (these examinations are collectively referred to as “intimate examination”).

The basic principles of respect, explanation, consent and privacy apply to all patients undergoing such examinations and imaging. Appropriate technique, sensitive behaviour and expertise of staff are of paramount importance. This policy defines who is responsible for obtaining consent, securing a chaperone when required and the set procedure for consultations, examinations and investigations.

The chaperone should be regarded as a third party to a clinical examination providing:
• Support and reassurance to the patient
• Practical help to the clinician e.g. handing instruments, etc.
• Discouraging unfounded allegations of improper behaviour by acting as witness to the procedure

Requirements

It is the responsibility of the professional undertaking the procedure to determine if a chaperone is required take appropriate steps to obtain one, and ensure a suitable environment. Whilst this policy mainly relates to the intimate examination of patients, it is often appropriate to use a chaperone for history taking and less intrusive physical examinations, depending on the patient and the circumstances.

Patients must be prepared for examination by staff ensuring that adequate information and explanation is given as to why the examination or procedure is needed. Easily understood literature and diagrams where possible should be provided to support verbal information.

Consent must be obtained relevant to the procedure being undertaken.

For children under the legal age of consent (16 years), they and their parents or guardians must receive an appropriate explanation of the procedure in order to obtain their co-operation and consent. There is a legal requirement to obtain consent from their legal guardian. However, in light of the Children Act (1989) and the Fraser Guidelines, regard must be given to ‘the ascertainable wishes and feelings of the child concerned considered in light of their age and understanding’. In situations where a child under the age of 16 years is considered to have full understanding but refuses consent, further counselling and advice should be sought from the patient’s GP or Consultant.

For patients with learning difficulties or mental illness, a familiar individual such as a family member or carer may be the best person to support the person during a procedure. In this situation, a properly trained chaperone will still be required as well, to act as a witness to the procedure. Only in exceptional circumstances should a family member, friend or carer be act in the capacity of chaperone. A careful simple and sensitive explanation of the technique is vital. Adult patients with learning difficulties or mental illness who cannot give consent and consequently resist any intimate

examination or procedure must be interpreted as refusing to give consent and the procedure must be abandoned. In life-saving situations professionals should consider their duty of care and may act under common law in the best interests of the patient.

Attention must be given to the environment ensuring adequate privacy is afforded to maintain dignity.

Staff should be aware that darkened rooms for ophthalmoscopy or other similar procedures, while not considered ‘intimate examinations’, may also lead patients to feel vulnerable. The close physical proximity of the clinician necessary for this type of examination can also be felt as intrusive by the patient, or open to misinterpretation

Staff must be aware that intimate examinations may cause anxiety for both male and female patients and whether the examiner is of the same gender as the patient or not.

A chaperone should be offered to all patients undergoing intimate examinations/ procedures irrespective of gender of either the patient or the health professional. If the patient prefers to be examined without a chaperone this request should be honoured and recorded in the patients’ health records. Examination of the chest or heart in women, which usually involves touching the breasts (e.g. lifting them up to hear the mitral valve), can be considered to be an intimate examination requiring the presence of a chaperone.

A chaperone should provide reassurance to the patient and may assist an infirm or disabled patient with dressing and undressing. The health professional undertaking the examination should offer assistance with undressing only if absolutely necessary.

The chaperone maintains communication and eye-contact with the patient while the clinician’s attention is focused on the examination. Some patients’ level of embarrassment may increase in proportion to the number of individuals present.

Where the presence of a chaperone may intrude in a confiding clinician-patient relationship it should be confined to the physical examination. One-to-one communication should take place after the examination.

It is acceptable for a health 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. This should be recorded in the patients’ health records.

It is acceptable for a friend, relative or carer to be present during a procedure if that is the wish of the patient. This does not, however, negate the need for a properly trained chaperone to be present in accordance with policy.

Children can be accompanied by a parent, guardian or friend, but this does not negate the need for a properly trained chaperone to be present in accordance with policy. Friends can provide emotional support but cannot adequately perform the chaperone

function, as they would not necessarily be aware of the normal procedures involved in an examination and would not necessarily recognise a deviation from the normal procedure.

In situations where abuse is suspected great care and sensitivity must be used to allay fears of repeat abuse.

There should be no undue delay prior to examination once the patient has removed any clothing.

During the examination/procedure:
• Be courteous
• Offer reassurance
• Keep discussion relevant. Avoid unnecessary personal comments
• Encourage questions and discussion
• Remain alert to verbal and non-verbal indications of distress from the patient
• Any requests that the examination be discontinued should be respected.

The ethnic, religious and cultural background of some women can make intimate examinations particularly difficult, for example, Muslim and Hindu women have a strong cultural aversion to being touched by men other than their husbands. 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. Wherever possible, particularly in these circumstances, a trained female healthcare practitioner should perform the procedure.

It should not be assumed that it is acceptable to the patient for relatives to remain present during procedures.

Induction of new clinical staff should include training on the appropriate conduct of intimate examination. Trainees should be observed and given feedback on their technique and communication skills in this aspect of care.

Chaperones should be trained for the role and administrative and clerical staff should not be used for the purpose unless they have had such training. Training must be offered encompassing the role, the nature of the examination for which a chaperone may be required, accountability and record keeping and the relationship with the patient.

Intimate Examinations

In addition to complying with section 1.0, the following must be taken into account.

Valid consent must be obtained to carry out the procedure by the professional who is capable of undertaking the procedure or trained in obtaining consent.

Most patients will accept intimate examinations if the necessity for the procedure is explained and the examination is performed by a member of staff who is skilled, sympathetic and gentle.

Consent for intimate examination – verbal. This must be obtained prior to all examinations and following explanation, discussion and information giving. Consent for intimate examination – written In the case of a woman who is a victim of an alleged sexual attack valid written consent must be obtained for the examination and collection of forensic evidence.

Intimate examination should never be carried out for non-English speaking patients without an interpreter/advocate (taking account of gender) being present (except in an emergency).

Intimate examination should take place in a closed room or well screened bay that cannot be entered while the examination is in progress. Examination should not be interrupted by phone calls or messages.

Where appropriate a choice of position for the examination should be offered for example left lateral, dorsal, recumbent and semi-recumbent positions for speculum and bimanual examinations. This may reduce the sense of vulnerability and powerlessness complained of by some patients.

Once the patient is dressed following an examination or investigation the findings must be communicated to the patient. If appropriate this can be used as an educational opportunity for the patient. The professional must consider (asking the patient as necessary) if it is appropriate for the chaperone/advocate to remain at this stage.

Details of the examination including presence/absence of chaperone and information given must be documented in the patient’s health records. The identity of the chaperone should be recorded in the health records.

Care should be taken that all verbal communication between clinician and patient and between clinician and chaperone are appropriate to the situation

If an intimate examination is indicated and no chaperone is available, the patient should be offered an alternative appointment when a chaperone can be present, unless the examination is indicated as an emergency, when this should be clearly documented in the patient’s records.