The Use of Chaperones During Sensitive Examinations and Procedures

I. POLICY

It is the policy of the University of Michigan/Michigan Medicine to provide and utilize patient chaperones when requested or necessary during sensitive examinations, procedures and care.

II. POLICY PURPOSE

  1. The purpose of this policy is to provide a consistent, standard and safe care environment within Michigan Medicine. There can be physical, psychological, and cultural reasons why chaperones may be requested or needed. This policy promotes respect for the patient dignity and the professional nature of the examination. Health professionals should only perform sensitive examinations, procedures or care in accordance with this policy.
  2. A chaperone may be provided to help protect and enhance the patient's comfort, safety, privacy, security, and/or dignity during sensitive examinations or procedures. The chaperone is frequently also present to provide assistance to the health professional with the examination, procedure or care.
  3. A chaperone’s presence may also provide protection to health professionals against unfounded allegations of improper behavior. A health professional may request a chaperone for any examination, procedure or care.
  4. For patients with mental health needs, neurodevelopment disorders, or for cultural/religious reasons, sensitive examinations, procedures or care may be especially threatening or confusing. A chaperone, particularly one trusted by the patient, may help the patient through the process with the minimum of distress.
  5. The use of chaperones, while vital, is only a part of our institution’s efforts for safe and responsible care.  Maintaining and fostering a culture of responsibility, mutual accountability, education for practitioners and patients, and appropriate response to suspected unprofessional or unsafe behavior is paramount to our mission.

III. DEFINITIONS

  1. Chaperone
    1. A chaperone is a person who acts as a witness for a patient and a health professional during a medical examination, procedure or care. A chaperone should stand in a location where he or she is able to assist as needed and observe the examination, procedure or care.
    2. A chaperone may be a health care professional or a trained unlicensed staff member. This may include medical assistants, nurses, technicians, therapists, residents and fellows. A student enrolled in a health profession’s school/program may serve as a chaperone IF:  The student has completed a Michigan Medicine approved chaperone training module AND the student formally chooses to be a chaperone by attestation. In certain circumstances (i.e, assisting with equipment or a complicated examination), a health professional may choose to have a separate chaperone in addition to the student.  Students that choose not to be a chaperone will not be penalized in any fashion.
    3. Whenever possible, but not required, the chaperone should be the gender that the patient feels most comfortable with. A chaperone may also assist the health professional or provide support to the patient with personal hygiene, toileting or undressing/dressing requirements if requested or needed by the patient.
    4. Family members or friends of an adult patient should not be expected to undertake any chaperoning role in normal circumstances. A family member may be present during sensitive examinations, procedures or care if it is the expressed desire of the patient but should not serve as a chaperone for the purposes of this policy. For vulnerable adult patients, an accompanying caregiver, social worker, or group home escort can be present along with a Michigan Medicine chaperone to alleviate potential stress to the patient.
    5. Family members CANNOT act as the chaperone for adolescent patients nor can family members opt out of a chaperone on behalf of their adolescent child.
    6. EXCEPTION: A family member, parent or legal guardian may serve as a chaperone for a pediatric patient (age 0-10) examination except for examinations, procedures or care where there is placement of finger(s), speculum, swabs, or any other instruments into the vagina or rectum or if there is a suspicion of abuse.
  2. Sensitive Examination or Procedure
    1. A sensitive examination, procedure or care for the purposes of this policy includes the physical examination of, or a procedure involving the genitalia, rectum, (regardless of gender) or female breast or the breast of a patient who identifies as female.
    2. Sensitive nursing care or procedures for the purposes of this policy includes care that involves placement of finger(s), swabs, or medications / medical equipment on or into the vagina, penis, urethra or rectum.
      1. EXCEPTION:  Nursing care that includes perineal cleansing and care as a part of everyday personal hygiene assistance (e.g. diaper changes, incontinence care, bathing) or perineal checks/care that do not involve cervical assessment for dilation.
    3. In acknowledgement of the fact that a patient’s personal and cultural preferences may broaden their own definition of a sensitive examination, procedure or care, chaperones will always be provided for other examinations, procedures or care if requested by a patient, family member or legal guardian.
  3. Types of Consent Policies
    1. OPT IN Policy:  A chaperone will be provided if requested by a patient for any examination, procedure or care.
    2. OPT OUT Policy: A chaperone will be present during the examination, procedure or care unless declined by the patient.
      1. Documentation in the patient’s record, including the name of the chaperone is required using a dot phrase such as:
        “The sensitive parts of the examination were performed with xx as a chaperone”. [MICHART dot phrase: .CHAPERONE]
      2. The patient does have a right to opt-out of having a chaperone present for certain examinations, procedures and care. This refusal should be documented in the patient's record and it is recommended that the following documentation is used:
        "A chaperone was offered for this sensitive examination, but the patient requested that a chaperone not be present." [MICHART dot phrase: .CHAPREFUSE]
      3. If the health professional is uncomfortable with the patient's request for no chaperone (e.g., male health professionals performing gynecological exam, female health professionals performing a scrotal exam, patients who exhibit seductive behavior, etc.), the purposes of this policy to protect their interests should be explained to the patient. If the patient continues to decline a chaperone, the health professional may refuse to perform the exam/procedure/care and can consider contacting their supervisor or the Office of Clinical Affairs.
    3. MANDATORY POLICY: A chaperone must be present or the examination, procedure or care should not be performed.
  4. Health Professional
    1. A Medical Staff Member, Clinical Program Trainee, Advanced Practice Nurse, Certified Nurse Midwife, Imaging Technologist, Physical Therapist, Physician Assistant, Registered Nurse, Licensed Registered Nurse, and unlicensed assistive personnel (e.g. nursing techs, nursing assistants, medical assistants).
  5. E.   Patient
    1. A patient is a personwho requires medical care, who is receiving medical treatment or is under a health professional’s care for a particular disease or condition.
      1. Pediatric patient:  Age 0 – 10 years
      2. Adolescent patient: Age 11 – 17 years
      3. An adult patient is a person who has attained the age of majority (18 yrs.) and is therefore regarded as independent, self-sufficient, and responsible.
      4. A vulnerable patient is defined as: anyone under the age of 18 or a person who lacks the capacity to give informed consent or is unable to protect him or herself from abuse, neglect or exploitation. This includes those who only lack momentary capacity due to sedation.

IV.POLICY STANDARDS

An adult or vulnerable patient or their legal guardian may request a chaperone for any examination or procedure. It is good practice to discuss with patients the different options to have a chaperone present during sensitive examinations and procedures as defined above. 

  1. Opt-In Exams/Procedures/Care:  For the following exams/procedures/care, a chaperone can be offered but is not required
    1. Examination of or procedures to the urethra in both males and females are considered OPT-IN and do not require a chaperone unless requested by the patient or legal guardian.
    2. Breast radiology procedures including mammography, ultrasound, interventional, and MRI will be considered OPT-IN and do not require a chaperone unless requested by the patient or legal guardian.  A breast physical exam during mammography is OPT-OUT, meaning a chaperone will be present unless declined by the patient or legal guardian.
    3. Echocardiograms will be considered OPT-IN and do not require a chaperone unless requested by a patient.
    4. Standard patient care protocols such as listening to the heart or lungs or placing EKG leads will be considered OPT-In and do not require a chaperone unless requested by a patient or legal guardian.
    5. In all patient care scenarios, the patient should be appropriately draped and the drape utilized as a barrier between the patient and the health professional. Every effort should be made to maintain the patient’s dignity and physical privacy.
  2. Opt-Out Exams/Procedures:  For the following exams/procedures in non-vulnerable adults, a chaperone must be present unless declined by the patient:
    1. Breast examination of a post-pubertal female patient or the breast of a patient that identifies as female
    2. Palpation of the external genitalia
    3. Placement of finger(s), speculum, swabs, or any other instruments into the vagina or rectum
  3. Mandatory Exams/Procedures/Care:  A chaperone is mandatory during a sensitive examination, procedure or care as listed in Section IV.B for all vulnerable patients as defined in Section III.E.1.d.
  4. Emergency Situation:  Emergency care should not be impeded by this policy

V. PROCEDURE ACTIONS

  1. Clinical sites and patient and procedure units will staff their clinical areas to appropriately accommodate this policy.
  2. Confidential clinician/patient communication should generally take place before or after the sensitive examination, procedure or care (i.e., without the chaperone present) unless the patient or health professional requests otherwise.
  3. For sensitive examinations or procedures, the following practices should be followed:
    1. The scope of the examination, procedure or care and the reasons for examination, procedure or care should be explained to the patient and/or legal guardian. If appropriate, written information clearly stating why and how the procedure is to be performed should be available for patient education.
    2. If a patient with decision-making capacity declines a part of or the whole examination, procedure or care, it should not be done. The refusal should be noted in the chart.
    3. The health professional should provide privacy for a patient to dress and undress.
    4. The health professional should generally not assist with removing or replacing the patient's clothing, unless the patient is having difficulty and/or requests assistance. The chaperone may also be available for such assistance.
    5. A patient must be provided with an adequate gown or drape.
    6. All exams/procedures/care should follow established UMHS standards for infection control.
  4. A chaperone has the right to stop a sensitive procedure, examination or care if they feel that the health professional’s behavior is inappropriate or unacceptable.  A chaperone who witnesses inappropriate or unacceptable behavior on the part of the health professional will immediately report this to their manager or another senior manager, even if they did not stop the procedure while it was ongoing.
  5. It is the responsibility of the health professional to ensure that accurate records are kept of the clinical contact, which also includes records regarding the use or refusal of a chaperone (see Section III.C. above).
  6. If the health professional is in a department that has a separate policy regarding sensitive examinations, procedures or care that exceeds this policy, those policies should be followed.  Specific policies tailored to a department must receive ECCA approval prior to implementation.
  7. Health professional non-compliance with this chaperoning policy should be reported to the Medical Director, Service Chief, or Chair. The Patient Relations & Clinical Risk should also be notified. If anonymity is desired, the Compliance Hotline can also be called at 866-990-0111, or submit an online report (http:www.compliancehotline.umich.edu/).

VI.  REFERENCES

  1. A.  Policies
    1. Beebe Medical Center, Beebe Medical Center Chaperone Policy & Procedures (DDMGPC5000-5/2011), 2011.
    2. Johns Hopkins Health System, Johns Hopkins Medicine Quality and Safety Clinical Practice Manual:  Patient Care Policies, Chaperone Policy (PATP001), September, 2016, JHM Risk Management Committee.
    3. MidMichigan Health, UMHS Chaperone Present During Examination Policy, November, 2017, Sean Kesterson & Brenda Turner.
    4. Tameside Hospital, U.K. Tameside Hospital NHS, Chaperone Policy, Nasrin Khadim
    5. University of Wisconsin Health Center, UWHC Departmental Policy for Chaperones for Sensitive Exams (12.05), February, 2014; Deborah Tinker, Director, Ambulatory Nursing.
  2. B.  Publications
    1. AMA Code of Medical Ethics. Issued December 1998 adopted June 1998. Opinion 8.21 - Use of Chaperones During Physical Exam.
    2. AMA Principles of Medical Ethics.  Adopted June 2016.  Chapter 1:  Opinions on Patient –Physician Relationships
    3. Gawande, Atul. Naked. New England Journal of Medicine. August 18, 2005. 
    4. Paterson, Ron (AAHPRA) Independent review of the use of chaperones to protect patients in Australia, February 2017.
    5. American Academy of Pediatrics. Policy Statement – Use of Chaperones During the Physical Examination of the Pediatric Patient. May, 2011.
    6. ACOG committee opinion no. 373: Sexual misconduct. (2007). Obstetrics and Gynecology, 110(2 I), 441-444. doi:10.1097/01.AOG.0000263920.00566.72.
    7. Morgan, R, Katzman, D, Kaufman, M, Goldberg,E & Toulany, A.  Thanks for asking: Adolescent attitudes and preferences regarding the use of chaperones during physical examinations.  Paediatric Child Health, Vol21;4:191-195.
    8. Policy Statement—Protecting Children From Sexual Abuse by Health Care Providers. (2011). Pediatrics. doi:10.1542/peds.2011-1244.
    9. O'Lynn, C., & Krautscheid, L. (2011). Original Research: 'How Should I Touch You?': A Qualitative Study of Attitudes on Intimate Touch in Nursing Care. AJN The American Journal of Nursing, 111(3), 24-31. doi:10.1097/10.1097/01.naj.0000395237.83851.79.
    10. The Use of Chaperones during Sensitive Examinations and Treatments. (2014). Journal of Obstetric, Gynecologic, & Neonatal Nursing, 43(5), 677-677. doi:10.1111/1552-6909.12498.

Authors:  Dee Fenner, Mahmoud Al-Hawary, Laura Anderson, Terrill Bravender, Kristin Cox, Lindsey Herrel, Jennifer Lukela, Christine Marsh, Bethany Mohr, Marc Moote, Jen Shifferd, Andrew Shuman, Patty Wagenshutz, Molly White, Jesus Cepero.

Policy Owner:  Office of Clinical Affairs

Reviewed by:  Executive Committee on Clinical Affairs, Nursing Executive Committee

Approved by: NEC, 4/22/2019, ECCA, 4/23/2019

The Policy owner is authorized to approve (and update as required) operational procedures supporting the implementation of this Policy, which may include details of how to operationalize the policy for specific patient populations or clinical care locations.  Before approving any such procedures, the Policy owner must consult with impacted stakeholders.  Any major disagreements about such procedures can be escalated to ECCA/NEC.