NS367 Prescribed Evidence Assignment

Derek Hanley 57747951 BNGN3

Critique of a Clinical Policy

In this assignment the author will critically analyse the Policy for Registered Nurses
Deemed Competent in Venepuncture (Connolly Hospital 2008). The Author will
outline what is meant by venepuncture. Discuss the overall policy with an emphasis to
the subheadings within the following headings of education and training of nursing
staff and the venepuncture procedure. In writing this critique the author will offer
some recommendations to the current policy.

The policy provides direction for nurses by expanding their role in performing
venepuncture. This expansion of the nursing role must be undertaken in accordance
with reference to section 4.6 of the Scope of Practice Guidelines (An Bord Altranais
2000a) and the Professional Code of Conduct for Nurses (An Bord Altranais 2000b).
The training of nurses and midwives in venepuncture and intravenous cannulation has
been described by the Health Service Executive’s office of the Nursing Services
Director (HSE 2009) an important opportunity for nurses and midwives in playing an
invaluable role in the Irish clinical frontline, in the promotion of quality and
continuity of care through enabling patients to be treated effectively and efficiently in
the most appropriate healthcare environment. In the United Kingdom’s National
Health Service (NHS), venepuncture has been described as one of the most commonly
performed invasive procedure that is routinely undertaken by nurses (Ernst 2005).

The criteria for the venepuncture training is registered nurses with one year’s
experience who are skilled in current theory and practice on intravenous (IV) therapy,
and nurses working in the Outpatients, Emergency, Endoscopy/Gastrointestinal
Investigation Departments and Holly Day Hospital for Care of the Older Person. The
procedure will only be undertaken by nurses who have received the necessary
training, by attending the one day educational programme (Connolly Hospital 2008),
which ensures that the competent person performing venepuncture has a good
understanding of the anatomy and physiology of arteries, veins and associated nerves
(Lavery & Ingram 2005; Moore & Agar 2007; Phlebotomists Association Ireland
2009) and the follow up supervised practice. All nursing staff must be familiar with,
and adhere to all hospital policies, guidelines and protocols (Connolly Hospital 2008).

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Venepuncture is the procedure of entering a peripheral vein with a needle. It is usually

carried out to obtain a blood sample for diagnostic purposes and to monitor levels of
blood components (Dougherty & Lister 2008; Phlebotomists Association Ireland
2009; Weller 2009) and may also be for administering intravenous medications
(Harris 2008).

The policy, produced by the Nursing Practice Development Department is currently

valid with a review/renewal date in December 2010 (Connolly Hospital 2008). It is an
eleven page document with the following thirteen headings, title of policy, aims,
application, responsibility, signing off of policy and guidelines, notifications,
reviewing, auditing, acknowledgements, definitions, training/education of nursing
staff, venepuncture procedure and referencing. Within these headings there are sub-
headings, under the heading of training/education there are the following sub-
headings; professional responsibilities, criteria for venepuncture, nurses who have
previously undertaken a venepuncture training program and certification. The
following sub-headings appear under venepuncture procedure, indication, equipment,
preparation of patient, procedure, insertion of the needle and possible problems.

In critiquing the policy, the author feels the policy does cover the basics for the target
audience of nurses. It doesn’t acknowledge that there are phlebotomists employed
within the organisation, who usually, are not from a nursing background. They have
undertaken the necessary training for the position. Most of the phlebotomists are
either enrolled on the Certificate of Phlebotomy course, or have completed the course
that has been developed by the National Ambulance Service College and is certified
by Faculty of Nursing, DCU (Phlebotomists Association Ireland 2009; The Certificate
in Phlebotomy 2009).

Under subheading possible problems in the venepuncture procedure heading, there is

a list of bullet pointed problems, which are the following, patient anxiety, missed
vein, poor access, blood flow stops, spurt of blood on entry, haematoma and needle
stick injury. It looks at possible causes and preventative measures which are important

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(Connolly Hospital 2008). However the author feels that there should be another
subheading of caution, to advise nursing staff undertaking the procedure to avoid
veins that are fibrosed, inflamed or fragile (Peterborough NHS PCT 2007). If the vein
is bruised from injury or previous phlebotomy or in sites close to any infection. Veins
should also be avoided on the affected side of a patient who has had a stroke/CVA,
post mastectomy or post axillary dissection (Smith 1998) as this may lead to
impairment of the lymphatic drainage, which can influence the venous flow (Ernst
2005) regardless of whether there is an obvious lymphoedema. Also avoid areas
affected by any disabling disease such as rheumatoid arthritis (Brennan et al 1992).
Another important area over looked in the policy, is the venepuncture should never be
performed on a patient who is standing (Campbell et al 1999), as this may cause the
patient to faint or have a vasovagal attack.

The author noticed that in the preparation for the venepuncture procedure, that
wearing of non sterile gloves was recommended. However down through the years
phlebotomists have argued against the usage of gloves. It must be noted that both the
Phlebotomists Association Ireland and the United Kingdom’s National Association of
Phlebotomists jointly endorse the usage of gloves whilst taking samples. Some
phlebotomists have argued that wearing gloves prevents them from feeling the
patients veins (Tanner 2001). In the United States a practice of cutting the tip off the
top of glove was a practice in the 1990’s (Ernst 2000) to enable phlebotomists to feel
veins. It has since ceased to be a practice. There has been an increase in the support of
glove usage in taking bloods, the director of a Central Californian Community Blood
Donor Collection Centre, stated that wearing gloves was optional at their facility
(California Blood Bank Society 2001), nevertheless there only remained a small
minority who opted not to wear gloves. Tanner (2001) promotes the usage from
infection control and safety measures, and strongly endorses that wearing gloves does
not replace hand hygiene. The author has observed on recent placements that the
phlebotomists do wear gloves, which are changed in between patients and alcohol gel
applied to their hands. The author feels that the debate about not wearing gloves for
taking bloods would appear to be outdated argument that lost creditability in the late
1990’s and early years of the twenty first century. It now appears healthcare workers

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are more in tune with current guidelines on the topic. Connolly Hospital (2008)
promoted the usage of gloves when taking bloods.

In between subheading preparation of patient, the author feels that another subheading
should be introduced entitled selection of sites for the procedure. The potential sites
include the basilic vein, median cubital vein, median cephalic vein and the cephalic
vein (Laverty & Ingram 2005; Moore & Agar 2007). The Basilic vein is a large
superficial vein of the upper limb that helps drain parts of hand and forearm. It
originates on the ulnar side of the dorsal venous network of the hand, and it travels up
the base of the forearm and arm. The median cubital vein is a superficial vein of the
upper limb. The cephalic vein is a superficial vein of the upper limb. It works with the
basilic vein via the median cubital vein at the elbow and is located in the superficial
fascia along the anterolateral surface of the biceps brachii muscle. It is generally a
good site for a cannula (Laverty & Ingram 2005; Moore & Agar 2007). It would also
be useful if there were diagrams or pictures of these sites in this subheading
(Venepuncture 2009). This provides an opportunity for inexperienced nurses to gain
confidence in performing the procedure, also as a revision tool for nurses who haven’t
done the procedure for some time. The policy omits the most prominent vein is not
always the most suitable vein for the patient (Weinstein 2007). There are two stages
of locating a vein, visual inspection and palpation, Palpitation is an important
assessment technique. It determines the location and condition of the vein (Dougherty
2008; Weinstein 2007). It also distinguishes veins from arteries and tendons and
identifies the presence of valves and detects deeper veins (Dougherty 2008). The
author highlights the importance of the assessment technique which in the opinion of
the author should be included in the policy. Laverty & Ingram (2005) reiterate the
importance of nurses and midwives knowing the structure of veins.

The author on researching this policy, and comparing the policy to Peterborough PCT
NHS Trust (2007) in the United Kingdom, has realised that in Ireland we do not yet
have an approved code of practice standards in relation to venepuncture, training and
procedures. During 2008, the Health Service Executive’s Office of the Nursing
Services Director (HSE 2009) surveyed all the acute hospitals in Ireland, of which
Connolly Hospital participated. The survey looked at the numbers educated in

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venepuncture and intravenous cannulation, and to see how many nurses actually used
their skills after certification. The recommendations of the survey highlight need for
each health service provider to create a unified code of practice in this skill
base/procedure, also the training of undergraduates in venepuncture and intravenous
cannulation. The author would like to draw reference to this HSE document for the
next review of the current policy in December 2010.

The overall conclusion of the policy is that it does achieve the requirement for the
target audience of registered nurses who have been deemed competent in
venepuncture. Nevertheless the author feels that there is room of improvement in the
existing policy, and has in this critique recommended additional sections of
information. The policy states that venepuncture is an expansion of the nurses’ role in
clinical practice, but fails to mention that there are phlebotomists employed
throughout the organisation to perform this duty. A recognition and acknowledgement
of their work would be appreciated; after all in drawing up a policy their expert
knowledge is valuable.

Whilst the policy did include important information regarding possible problems
faced in the performing of the procedure, it failed to include the avoidance of using
veins on the affected side of patient who has had a stroke/CVA, post mastectomy, or
dissection of their lymphatic drainage, or where they have an arthritic limb. It was
also never mentioned that venepuncture should never be performed standing patient.

The inclusion of research based practice into the usage of wearing gloves whilst
taking bloods would have been useful for staff that dislike wearing them, and opt to
only wash hands and apply hand gel in between patients.

The Health Service Executive’s Office of the Nursing Services Director has
highlighted the need for specific codes of conduct with venepuncture procedure,
however as this has only recently been recommended following the survey, the author
feels that Connolly Hospital has in fact worked within their own scope of practice in
mentioning the relevant An Bord Altranais guidelines at this present time.

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References
An Bord Altranais. 2000a. The Scope of Nursing and Midwifery Practice. Dublin: An
Bord Altranais.

An Bord Altranais. 2000b. The Code of Professional Conduct for Each Nurse and
Midwife. Dublin: An Bord Altranais.

Brennan F.M., Maini R. N., Feldmann M. 1992. TNF alpha- A pivotal role in
rheumatoid arthritis? British Journal Rheumatology 31 (2) pp 293-298.

Californian Blood Bank Society 2001. [Online]. Available from:

<http://www.cbbs.org/enf/2001/goves.pdf>. [Accessed 24 Nov 2009].

Campbell, H., Carrington, M., and Limber, C. 1999. A practical Guide to

venepuncture and management of complications. British Journal of Nursing. 8 (7) pp
426- 431.

Connolly Hospital. 2008. Policy for nurses deemed competent in Venepuncture.

Dublin: Connolly Hospital.

Dougherty, L. 2008. IV Therapy in Practice. 2nd ed. Oxford: Blackwall Publishing.

Dougherty, L., & Lister, S. 2008. The Royal Marsden Hospital Manual of Clinical
Nursing Procedures. 7th Ed. Oxford: Wiley-Blackwell.

Ernst. D. 2000. Phlebotomist Gloving. Medical Laboratory Observer. 12 (4) p16.

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Ernst, D., J. 2005. Applied Phlebotomy. Baltimore: Lippincott, Williams and Wilkins.

Harris, J. 2008. How to perform venepuncture. Midwives: The Official Magazine of

the RCM. 11 (6) p16.

HSE.2009. Findings from the survey of Venepuncture and Intravenous Cannulation

Eductaion and Training among Nurses and Midwives Employed in acute Hospitals
within the Republic of Ireland. Dublin: Office of Nursing Services Director.

Lavery, I., & Ingram, P. 2005. Venepuncture: Best Practice. Nursing Standard. 19
(49) pp55-65.

Moore, K.L., & Agur, A. M. R. 2007. Essential Clinical Anatomy. 3rd Ed. Baltimore:
Lippincott Williams and Wilkins.

Peterborough NHS Primary Care Trust. 2007. Venepuncture Policy and Procedure.
Peterborough: Peterborough NHS Primary Care Trust.

Phlebotomists Association Ireland. 2009. Phlebotomists Association Guidelines

Handbook. Dublin: Phlebotomists Association Ireland.

Smith J (1998) The practice of venepuncture in Lymphoedema. European Journal of

Cancer Care. 7 (2) p97 – 98.

Tanner. S. 2001. To Glove or Not to Glove: That is the Question. National

Association of Phlebotomists Newsletter. 3 (3) pp 1-2.

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The Certificate in Phlebotomy-2009. [Online]. Available from: http://www.ciph.ie

[Accessed 20 Nov 2009].

Venepuncture Teaching Resource [Online]. Available from:

http://venepuncture.20megsfree.com [Accessed 21 Nov 2009].

Weller. B., F. 2009. Bailliere’s Nurses’ Dictionary for Nurses and Health Care
Workers. 25th Ed. London: Bailliere Tindall Elsevier.

Weinstein, S.M. 2007. Plumer’s Principles and Practice of Intravenous Therapy, 8th
Ed. Philadelphia: Lippincott, Williams and Wilkins.

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