Someone to watch over me

A CLOSER look at the role of the dental nurse may be timely following the recent introduction of mandatory registration for all dental care professionals. In particular, the chaperone function is frequently undervalued. Now that the dental nurse has, through General Dental Council (GDC) registration, a more official status in the practice, Hugh Harvie, a dento-legal adviser with MDDUS, believes the time is right for this important role to be more fully recognised.

“The dental nurse not only provides clinical assistance at the chair-side but also provides support and comfort to a patient,” he says. “Many patients greatly value the dental nurse who often acts as a key interface with the dentist”.

This article will examine the role of the chaperone and the GDC’s position, and consider who can act as a chaperone in the absence of the dental nurse and what should happen in an ‘out-of-hours’ setting.

Other person in the room

The Council for Healthcare Regulatory Excellence (CHRE) lays down guidelines for the regulatory bodies responsible for healthcare providers, including the GDC. It has produced a document called Clear sexual boundaries between healthcare professionals and patients: responsibilities of healthcare professionals. As in many documents generic to the provision of healthcare, the ways in which dentistry differs from other professions are not acknowledged. This passage, however, may be applicable to dental practice:

“A chaperone does not need to be a healthcare professional but ideally they should understand the procedures involved in the examination. They should be sensitive to the patient’s dignity and privacy, be prepared to support the patient if they show signs of discomfort or distress and be confident to raise concerns about a healthcare professional should suspected misconduct arise.”

The value of a chaperone is certainly clear in a dento-legal context, says Mary McCann, another dental adviser at MDDUS. “The dental nurse may prove a valuable witness if allegations arise about the professionalism or conduct of a dentist, or if a dispute arises over matters of fact in a complaint or claim of negligence.”

While the CHRE guidance says the chaperone need not be a healthcare professional, in dentistry it is almost inevitable that in normal circumstances the chaperone will indeed be a healthcare worker such as a dental nurse. This is because the GDC’s ethical guidance, Principles of Dental Team Working, recommends “when treating patients, make sure there is someone else, preferably a registered team member present in the room, who is trained to deal with medical emergencies”.

This comes under the heading ‘carrying out treatment’ and is the sole reference to the dental nurse’s chaperone role, albeit inexplicit. The GDC’s emphasis appears to be in relation to a potential medical emergency. If, however, you are looking for a clear description of the chaperone from the GDC, you will be disappointed.

Hugh Harvie comments: “The GDC provides guidelines as opposed to being prescriptive. This guidance may appear to lack definition but this approach allows consideration to be given to individual circumstances”.

One example might be an out-of-hours emergency appointment or domiciliary visit. It might not always be possible to have a dental nurse or trained person present and, in those circumstances, the dentist could request that the patient has a carer or friend accompanying them. Alternatively, the dentist could take a member of his or her family to the practice. Once again, the GDC is not prescriptive, stating in its guidance: “You are responsible for assessing the possible risk to the patient of continuing with treatment in the absence of a trained person”.

While there may be an element of discretion, the GDC has demonstrated the value it places on the presence of a third person when treating patients. A dentist from the southeast of England was recently suspended for, among other things, working without a dental nurse, in contravention of GDC guidelines.

Intimate examination

The GDC view that there should ideally be a third person present in the surgery when patients are being treated is one significant difference between dentistry and other healthcare professions. By contrast, the GMC only recommends that there is a third person present when any kind of intimate examination is undertaken.

While dentistry does not involve examinations of a comparable intimacy to those carried out in a medical setting, the dentist should recognise that certain patients may feel vulnerable. Some employers are unequivocal about the chaperone role of the dental nurse. For instance, an advertisement posted in December 2007 for a senior specialist dental nurse at Scunthorpe General Hospital specified all the duties it wanted performed including: chaperone patients, maintaining privacy, dignity and confidentiality.

Similarly, the Scottish Government’s National Standards for Dental Services describes the role of the dental nurse in the following way: “A person who assists the dentist at the chair-side during dental treatment, acts as a chaperone, often has administrative duties and infection control responsibilities. They cannot provide dental treatment.”

Part of team working

Outside dentistry, the situation is less clear-cut. This is despite a document produced by the NHS Clinical Governance Support Team and designed to introduce procedures into medical settings. Published in 2005, Guidance on the role and effective use of chaperones in primary and community settings is a comprehensive document covering all aspects of chaperoning. But difficulties continue in properly defining the role of chaperone, as reflected in a healthcare briefing paper entitled Chaperones: a help or a hindrance? recently circulated by Arnish Goorbin of RadcliffeLeBrasseurs, a top law firm in the medical sector.

“The core problem facing the issue of chaperones is a lack of consistency,” states Goorbin. In what situations is a chaperone necessary? “It may be that a female patient is uncomfortable with the touch of a male practitioner without the presence of another person in all circumstances.”

Consistency is not so much a problem in dentistry as the presence of a dental nurse is inherent in the concept of ‘four-handed dentistry’. A piece of GDC guidance which is highly pertinent is to be found in Standards for Dental Professionals: “Co-operate with other team members and colleagues and respect their role in caring for patients”.

Hugh Harvie strongly believes that the dental nurse’s role as chaperone should command respect. It is so important that, in the absence of a dental nurse, another member of the team should be ready to step in.

“The chaperone role has many aspects, including support and protection for both the patient and dentist and at times acting as a valuable communication interface,” he said. “My view is that dentists, hygienists and therapists who have clinical contact with patients should always, where possible, have a member of staff present in the room with them.”

• Caroline Holland is a freelance writer on medical and dental matters