CLINICAL PROTOCOL FOR CHAPERONING AND INTIMATE CARE

Transcription

1 CLINICAL PROTOCOL FOR CHAPERONING AND INTIMATE CARE RATIONALE The purpose of this protocol is to enable all Trust staff to provide high quality care in acute settings where Trust staff are based, primary care settings and in patients own homes, continually ensuring that patient dignity and privacy is maintained at all times (CQC 2010). This protocol is designed to help avoid misunderstandings and to minimise embarrassment for all concerned during intimate examinations or procedures. It is designed to protect the interests of both patients and clinicians. This protocol should be applied in all circumstances where there is a requirement of intimate examination and in cases where the patient may feel vulnerable. Elements of this policy will also apply to other situations where the patient may have difficulty understanding the need for particular procedures/interventions (CQC 2010; DH 2010). TARGET GROUP The protocol applies to all staff employed by the Trust working with patients across a broad spectrum of community care settings and acute settings where Trust staff are based. TRAINING All administrative staff who are required to undertake the role of formal chaperoning need to have been trained in the role and responsibilities of a chaperone using the Trust s Chaperone Training Resource. This is available on the Trust web site. If specific services require additional staff to undertake this training, this will be specified in their Service Training Matrix e.g. healthcare assistants in sexual health services Team leaders and senior practitioners can facilitate this training and a record of the training must be documented in the personal file of the staff member and a copy provided of the names of staff trained to the Leaning and Development Team for recording on the Trust s Central Training Database. This training is only required once, unless significant changes are made to current best practice in the NHS or an issue arises which indicates the member of staff requires retraining. RELATED POLICIES Please refer to relevant Trust policies and procedures. Page 1 of 11

2 ROLE OF THE CHAPERONE The NHS Clinical Governance Support Team (2005) state that: The role of the chaperone varies depending on the needs of the patient, the health professional and the intervention or procedure being carried out. The role may include: To provide protection of privacy and dignity to patients and safety of Trust staff. To provide reassurance to patients To act as chaperone as part of their role whilst assisting in an examination To assist with dressing activities (when made explicit to do so) To provide protection to healthcare professionals against unfounded allegations of improper behaviour In very rare circumstances to protect the clinician against an attack Chaperones may be able to identify unusual or unacceptable behaviour on the part of the health care professional Be sensitive and respectful of the patient s dignity and privacy Be prepared to reassure the patient if they show signs of distress or discomfort Be familiar with the procedures involved in a routine intimate examination Be prepared to raise concerns regarding a health professional if misconduct occurs TYPE OF CHAPERONE The designation of the chaperone will depend on the role expected of them and on the wishes of the patient. Informal Chaperones An informal chaperone is a person who is familiar to the patient, which includes family members, friends and non-clinical staff. Many patients feel reassured by the presence of a familiar person and this request in most cases is acceptable. This may be a family member or an individual requested by the patient. A situation where this may not be appropriate is where a child is asked to act as a chaperone for a parent. A child - a person who has not yet reached their 18 th birthday (DE 2010) - must never be asked to act as a chaperone for a parent undergoing an intimate examination or procedure. It is also inappropriate to expect a family member or friend who the patient has requested be present during the procedure, to take an active part in the examination or to witness the procedure directly. An informal chaperone, particularly a child, should not take an active part in the examination or witness the procedure directly, as they may not be necessarily relied upon to act as a witness to the conduct or continuing consent of the procedure. 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 be present. It is important to record the name of the chaperone and their relationship to the patient recording that this person was the patient s choice. Health records can play an important part in bringing perpetrators to justice if it is deemed necessary to do so. Please refer to the Trust s Safeguarding Adults Policy for further guidance and information. Page 2 of 11

3 Formal Chaperones Formal Chaperones are used within the Trust as they are able to act as an advocate for the patient, helping to explain what will happen during the examination or procedure, and the reasons why. They can assess the patient s understanding of what they have been told, and also be a reassuring presence whilst the patient is having the examination or procedure, safeguarding against any unnecessary discomfort, pain, humiliation or intimidation (RCN 2006; CQC 2010; DH 2010). A formal chaperone implies a clinical health professional, such as a nurse or a specifically trained non-clinical staff member. 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 person undertaking the chaperone role. This may include assisting with undressing, if requested by the patient, or assisting in the procedure being carried out. In these situations staff should have an understanding of the procedure/intervention to help them gauge the role that is expected of them. It may not be appropriate for a non-clinical member of staff to comment on the appropriateness of the procedure; however they should have an awareness of what the procedure entails. GOOD PRACTICE PRINCIPLES The presence of a chaperone must be the patient s decision. It is good practice for patients to be offered a chaperone by Trust staff for any consultation, examination or procedure where one maybe required. Trained staff should be undertaking the chaperone role, rather than untrained staff with no specific training. No family member or friend of a patient should be expected to undertake any formal chaperoning role. Translators should not be undertaking any informal or formal chaperoning role. The patient should be offered where possible a choice of male or female chaperone to minimise embarrassment. The Trust will strive to meet the needs of patients on an individual basis. The service manager should be contacted if further advice is needed. The patient should always have the opportunity to decline a particular person as chaperone if that person is not acceptable to them for any reason. In all cases where the presence of a chaperone may intrude in a confiding clinicianpatient relationship, their presence should be confined to the physical examination. One-to-one communication should take place after the examination. Patients should be made aware of the availability of chaperones by Trust staff. If the patient does not want a chaperone, it should be recorded that an offer was made and declined within the patient s healthcare records. Page 3 of 11

4 If a chaperone is present, this should be recorded within the patient s healthcare records and the chaperone s name, status and designation must be documented. Chaperones should be positioned within the area according to the treatment being administered and the consultation taking place. For example, standing at an appropriate place near the head of the patient if a cervical smear test is being conducted. If, for justifiable practical reasons, a chaperone cannot be offered, this should be explained to the patient and, if possible, offer to delay the examination to a later date. This discussion and its outcome should be recorded within the patient s healthcare records. In more urgent cases, a decision to continue without a chaperone should be jointly reached. It is acceptable for a healthcare professional to perform an intervention/procedure without a chaperone being present if the situation is life threatening. This must be recorded appropriately in the patient s healthcare records. The principles for offering and using chaperones should apply to all settings, regardless of where care is being delivered. This includes during home visits and out of hours services. INTIMATE EXAMINATIONS The definition of an intimate examination may differ between individual patients for ethnic, religious or cultural reasons. In addition, some patients may have a clear preference for a health professional of specific gender due to their ethnic, religious or cultural background, because of previous experiences, or in view of their age. Where possible Trust Staff need to take individual needs and preferences into consideration and position themselves appropriately during the course of the intimate examination to prevent any further embarrassment to the patient. Before conducting an intimate intervention/procedure the health care professional must: Act with propriety and in a courteous and professional manner. Communicate sensitively and politely using professional terminology. Explain to the patient why an examination is necessary and give the patient the opportunity to ask questions. Explain what the examination will involve, in a way that the patient can understand, so that the patient has a clear idea of what to expect, including any pain or discomfort which they may possibly experience. Obtain consent from the patient prior to the intervention/procedure and document within the patient s healthcare records that consent has been obtained. Give the patient privacy to undress and keep the patient covered as much as possible to maintain their dignity. Do not assist the patient in removing clothing unless it has been clarified with them that assistance is required - this must be documented within the patient s healthcare records. Page 4 of 11

5 When required private, warm comfortable and secure facilities for undressing and dressing should be provided. During the intervention/procedure Trust staff should:- Maintain the patient s privacy and dignity at all times throughout the intervention/procedure which should be conducted without interruption. Explain the procedure before it happens and, if this differs to what the patient thinks is to happen, then an explanation must be given and further ongoing consent from the patient should be sought. The intervention/procedure must be discontinued if the patient requests for this to happen. All discussions must be kept relevant and no personal comments made towards the patient. RESPECT AND DIGNITY Every member of staff has a duty to ensure that the privacy and dignity of all patients are respected (RCN 2006). Patients have the right to be treated with dignity at all times, to have their modesty protected and to remain autonomous and independent wherever possible (DH 2011). All staff need to introduce themselves and at all times wear their identity badge which must include their name, status and designation. Communication between staff and clients will always be of a respectful nature that is the use of full title otherwise requested or agreed by the patient/client. Patients will at all times be treated with respect and dignity, regardless of age, gender, religion, sexual orientation, disability or race. All Trust staff should avoid personal conversations with co-workers that exclude the patient during the intervention/procedure. Closing curtains or doors in areas where patients are expected to undress and also where the procedure will be performed. Patients undergoing any procedure or intervention should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only the part of anatomy that is required. Following the procedure, patients should have the opportunity to re-dress before the consultation continues. Wherever possible, the Trust will offer patients a choice of healthcare practitioner to meet their needs. Page 5 of 11

6 A chaperone should be offered to patients as appropriate and they should also be offered a choice as to who is present during the procedure. ENVIRONMENT Trust staff should aim to provide a safe comfortable environment where the safety of patients and staff is of paramount importance. Patients experiencing consultations, examinations and investigations need to be safe and to experience as little discomfort as possible. Clinical areas may differ in layout and design, therefore where possible drapes should be used to maintain patient privacy and dignity. If this is not possible, informal chaperones who are not involved in the clinical examination or procedure should stand in an appropriate area of the room where patient exposure is reduced to a minimum. CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult who is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. GOOD PRACTICE PRINCIPLES Verbal consent is sufficient for most examinations, however if a proposed procedure carries significant risk, it will be appropriate to seek written consent. Consent should always be appropriate to the treatment/investigation being carried out. Before conducting any intimate examination it is essential to explain to the patient why an examination is necessary and give them an opportunity to ask questions. Explain what the examination/procedure will include in a way that the patient can understand, so the patient has a clear idea of what to expect including any potential pain or discomfort. Time should be allowed for the patient/client to consider the implications, followed by a check to ensure that the information has been understood. All Trust staff must uphold patient s rights to be fully involved in decisions about their care (CQC 2010; DH 2010). Obtain the patient s permission before proceeding with any examination/procedure and discontinue if the patient asks you to do so. Page 6 of 11

7 If there is more than one clinician involved, the patient s consent should be sought after giving a thorough explanation of the need for their presence (DH 2001). For some patients the level of embarrassment increases in proportion to the number of individuals present. If examining a child, informed consent will be required from the authorised parent or guardian prior to the examination (DH 2001). Valid consent must be documented within the patient s healthcare records and evidenced using the appropriate Trust Consent forms located within the patient s notes. This section must be read in conjunction with the Trust s Consent Policy. SPECIAL CIRCUMSTANCES There may be situations where more explicit consent is required prior to intimate examinations or procedures, such as where the individual concerned is a minor, has special educational needs or does not have the capacity to consent (DH 2001). In these circumstances staff must refer to the Trust s Consent Policy for specific details relevant to their working environment and discuss with their line manager for further advice and Safeguarding Team if required. ISSUES SPECIFIC TO CHILDREN In the case of children, a chaperone would normally be a parent or carer or alternatively someone known and trusted or chosen by the child. Patients may also be accompanied by another minor of the same age, e.g. friend or companion. For Fraser competent young adults, the guidance relating to adults is applicable. Please refer to Fraser guidelines for further advice. Children and their parents or guardians must receive an appropriate explanation of the procedure in order to obtain their co-operation and understanding. If a minor presents in the absence of a parent or guardian, Trust staff must ascertain if they are capable of understanding the need for examination. In these cases it would be advisable for consent to be secured and a formal chaperone to be present for any intimate examinations, or if the patient requests one. ISSUES SPECIFIC TO RELIGION/ETHNICITY OR CULTURE The ethnic, religious and cultural background of some individuals can make intimate examinations particularly difficult. 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. Page 7 of 11

8 It would be unwise to proceed with any examination if the healthcare professional is unsure that the patient understands due to a language barrier. Interpreters are not able to Multidisciplinary CP09 act as chaperones as they may not understand the clinical intervention/procedure being undertaken; therefore they may be unable to fully safeguard the patient against harm. ISSUES SPECIFIC TO LEARNING DIFFICULTIES/MENTAL HEALTH PROBLEMS Adults with learning difficulties or mental health problems who resist any intimate intervention or procedure must be interpreted as refusing to give consent and the procedure should be abandoned and an assessment should be made of whether the patient can be considered as having capacity or not. If the patient has capacity, despite learning difficulties or mental health problems, the investigation or treatment cannot proceed. However, if the patient lacks capacity, they should be treated according to his or her own best interests. Assessing best interests must take into account the potential for physical and psychological harm but in some situations it may be necessary to proceed in an appropriate manner (DH 2001). All Trust staff must be aware of the legislation regarding mental capacity, ensuring that people who lack capacity remain at the centre of the decision making process and are fully safeguarded (DH 2010). Provision of health care in the patient s best interests needs to be considered with other key health and social care professionals or carers in line with the Trust s Consent Policy. LONE WORKING Where a healthcare professional is working in a situation away from other colleagues, the same principles for the offering and use of chaperones should apply within the Trust. When a formal chaperone is required, Trust staff need to attempt to reschedule the appointment to a more convenient location or time. However in the cases where this is not an option Trust staff must ensure that communication and contemporaneous record keeping are treated as paramount. RECORDING It is essential that Trust staff explain the nature of any examination/procedure to patients and offer them a choice of whether to proceed with the examination at that time. The patient is then able to give valid consent to continue with the procedure/intervention. Details of any procedure/intervention including the presence/absence of a chaperone and information given must be documented within the patient s health care records. It must be documented if the patient expresses any doubts or reservations about the procedure being undertaken and any reassurance given. The following must be recorded in the patient s healthcare records:- The patient has given permission for the examination to take place. Page 8 of 11

9 The fact that a chaperone was offered and accepted or declined. Multidisciplinary CP09 The presence and identity of the chaperone including their name, status and their designation. The result of any discussion regarding delaying an examination until the chaperone can be present. Any other information that the health care professional performing examination/procedure feels relevant or necessary. It must be explicit from the health records that the examination or procedure was necessary Any situation where concerns are raised or an incident has occurred Formal chaperones should record in the healthcare records they where present in the capacity of a chaperone including the time they arrived and the time they left. In any situation where concerns are raised by either Trust staff or the patient, an incident report must be completed as soon as possible following the incident and the appropriate Line Manager informed. Please refer to Trust s Disclosure Policy for further information. INCIDENT REPORTING Clinical incidents or near misses must be reported and a Trust Incident Form must be completed SAFEGUARDING ADULTS In any situation where staff may consider the patient to be a vulnerable adult, they need to follow Trust Safeguarding Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patients health records. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy Page 9 of 11

10 and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. Multidisciplinary CP09 If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. REFERENCES Care Quality Commission (2010) Essential standards of quality and safety. Clinical Governance Support Team (2005) Guidance on the Role and Effective Use of Chaperones in Primary and Community Care Settings. Department for Children, Schools and Families (2010) Working Together to Safeguard Children. Department of Health (2001) Reference guide to consent for examination or treatment. _ pdf Department of Health (2005) Responding to domestic abuse: A handbook for health professionals. ance/dh_ Department of Health (2010) Essence of Care. ance/dh_ Department of Health (2011) The Operating Framework for the NHS in England 2012/13. ance/dh_ Royal College of Nursing (2006) Defending Dignity Challenges and Opportunities for Nursing. Page 10 of 11

11 CONTROL RECORD Title Clinical Protocol for Chaperoning and Intimate Care Purpose Provide staff with fundamental principles on chaperoning and initimate care. Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Caroline Hewitt Document Librarian QGS Groups consulted with :- Clinical Policies and Procedures Group Infection Control Approved N/A Date formally approved by Risk and Governance Group March 2012 Method of distribution Intranet Archived Date 16 th March 2012 Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 Quality and Governance Service N First version Status New / Revised / Trust Change Page 11 of 11