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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).

Derek Hanley NS367 1

there is a list of bullet pointed problems. patient anxiety. or have completed the course that has been developed by the National Ambulance Service College and is certified by Faculty of Nursing. who usually. poor access. training/education of nursing staff. Under subheading possible problems in the venepuncture procedure heading. under the heading of training/education there are the following sub- headings. It doesn’t acknowledge that there are phlebotomists employed within the organisation. In critiquing the policy. auditing. spurt of blood on entry. The following sub-headings appear under venepuncture procedure. signing off of policy and guidelines. insertion of the needle and possible problems. application. It is usually carried out to obtain a blood sample for diagnostic purposes and to monitor levels of blood components (Dougherty & Lister 2008. NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 Venepuncture is the procedure of entering a peripheral vein with a needle. are not from a nursing background. criteria for venepuncture. Most of the phlebotomists are either enrolled on the Certificate of Phlebotomy course. Phlebotomists Association Ireland 2009. preparation of patient. It looks at possible causes and preventative measures which are important Derek Hanley NS367 2 . the author feels the policy does cover the basics for the target audience of nurses. equipment. acknowledgements. venepuncture procedure and referencing. The Certificate in Phlebotomy 2009). notifications. Within these headings there are sub- headings. blood flow stops. procedure. It is an eleven page document with the following thirteen headings. aims. Weller 2009) and may also be for administering intravenous medications (Harris 2008). title of policy. missed vein. They have undertaken the necessary training for the position. indication. which are the following. nurses who have previously undertaken a venepuncture training program and certification. The policy. responsibility. definitions. produced by the Nursing Practice Development Department is currently valid with a review/renewal date in December 2010 (Connolly Hospital 2008). reviewing. professional responsibilities. DCU (Phlebotomists Association Ireland 2009. haematoma and needle stick injury.

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. the director of a Central Californian Community Blood Donor Collection Centre. post mastectomy or post axillary dissection (Smith 1998) as this may lead to impairment of the lymphatic drainage. Tanner (2001) promotes the usage from infection control and safety measures. Also avoid areas affected by any disabling disease such as rheumatoid arthritis (Brennan et al 1992). which are changed in between patients and alcohol gel applied to their hands. 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. It now appears healthcare workers Derek Hanley NS367 3 . NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 (Connolly Hospital 2008). There has been an increase in the support of glove usage in taking bloods. which can influence the venous flow (Ernst 2005) regardless of whether there is an obvious lymphoedema. Veins should also be avoided on the affected side of a patient who has had a stroke/CVA. The author has observed on recent placements that the phlebotomists do wear gloves. 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. However the author feels that there should be another subheading of caution. It has since ceased to be a practice. and strongly endorses that wearing gloves does not replace hand hygiene. that wearing of non sterile gloves was recommended. 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. to advise nursing staff undertaking the procedure to avoid veins that are fibrosed. stated that wearing gloves was optional at their facility (California Blood Bank Society 2001). Another important area over looked in the policy. However down through the years phlebotomists have argued against the usage of gloves. nevertheless there only remained a small minority who opted not to wear gloves. If the vein is bruised from injury or previous phlebotomy or in sites close to any infection. The author noticed that in the preparation for the venepuncture procedure. inflamed or fragile (Peterborough NHS PCT 2007).

the Health Service Executive’s Office of the Nursing Services Director (HSE 2009) surveyed all the acute hospitals in Ireland. Moore & Agar 2007). 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. The median cubital vein is a superficial vein of the upper limb. Weinstein 2007). The survey looked at the numbers educated in Derek Hanley NS367 4 . visual inspection and palpation. The potential sites include the basilic vein. It is generally a good site for a cannula (Laverty & Ingram 2005. Connolly Hospital (2008) promoted the usage of gloves when taking bloods. In between subheading preparation of patient. It would also be useful if there were diagrams or pictures of these sites in this subheading (Venepuncture 2009). The Basilic vein is a large superficial vein of the upper limb that helps drain parts of hand and forearm. It determines the location and condition of the vein (Dougherty 2008. It originates on the ulnar side of the dorsal venous network of the hand. The author highlights the importance of the assessment technique which in the opinion of the author should be included in the policy. Palpitation is an important assessment technique. It also distinguishes veins from arteries and tendons and identifies the presence of valves and detects deeper veins (Dougherty 2008). NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 are more in tune with current guidelines on the topic. During 2008. also as a revision tool for nurses who haven’t done the procedure for some time. the author feels that another subheading should be introduced entitled selection of sites for the procedure. This provides an opportunity for inexperienced nurses to gain confidence in performing the procedure. There are two stages of locating a vein. and comparing the policy to Peterborough PCT NHS Trust (2007) in the United Kingdom. The cephalic vein is a superficial vein of the upper limb. has realised that in Ireland we do not yet have an approved code of practice standards in relation to venepuncture. The policy omits the most prominent vein is not always the most suitable vein for the patient (Weinstein 2007). median cephalic vein and the cephalic vein (Laverty & Ingram 2005. Laverty & Ingram (2005) reiterate the importance of nurses and midwives knowing the structure of veins. median cubital vein. of which Connolly Hospital participated. The author on researching this policy. training and procedures. and it travels up the base of the forearm and arm. Moore & Agar 2007).

It was also never mentioned that venepuncture should never be performed standing patient. The Health Service Executive’s Office of the Nursing Services Director has highlighted the need for specific codes of conduct with venepuncture procedure. NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 venepuncture and intravenous cannulation. 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. however as this has only recently been recommended following the survey. post mastectomy. and to see how many nurses actually used their skills after certification. also the training of undergraduates in venepuncture and intravenous cannulation. 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. and has in this critique recommended additional sections of information. Whilst the policy did include important information regarding possible problems faced in the performing of the procedure. but fails to mention that there are phlebotomists employed throughout the organisation to perform this duty. 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. after all in drawing up a policy their expert knowledge is valuable. it failed to include the avoidance of using veins on the affected side of patient who has had a stroke/CVA. The author would like to draw reference to this HSE document for the next review of the current policy in December 2010. Nevertheless the author feels that there is room of improvement in the existing policy. and opt to only wash hands and apply hand gel in between patients. A recognition and acknowledgement of their work would be appreciated. or dissection of their lymphatic drainage. or where they have an arthritic limb. Derek Hanley NS367 5 . The recommendations of the survey highlight need for each health service provider to create a unified code of practice in this skill base/procedure. The policy states that venepuncture is an expansion of the nurses’ role in clinical practice.

Ernst. Dublin: Connolly Hospital. The Code of Professional Conduct for Each Nurse and Midwife. 2000a. L. 7th Ed.. [Online]. Policy for nurses deemed competent in Venepuncture. Maini R. Medical Laboratory Observer. 1992. S.cbbs.431. The Scope of Nursing and Midwifery Practice. 2000. 2008. & Lister. Feldmann M. 8 (7) pp 426. An Bord Altranais. N.M. IV Therapy in Practice. Campbell. NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 References An Bord Altranais. Phlebotomist Gloving. Oxford: Wiley-Blackwell. 2008. and Limber. C.. 2000b. [Accessed 24 Nov 2009]. Carrington. L. H. A practical Guide to venepuncture and management of complications. Connolly Hospital. 1999. Available from: <http://www.. Dougherty. Oxford: Blackwall Publishing.. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. D.. Dougherty. TNF alpha. 2008.pdf>. 2nd ed. Derek Hanley NS367 6 . Californian Blood Bank Society 2001. 12 (4) p16. Brennan F. Dublin: An Bord Altranais. Dublin: An Bord Altranais. British Journal of Nursing.A pivotal role in rheumatoid arthritis? British Journal Rheumatology 31 (2) pp 293-298.

Baltimore: Lippincott Williams and Wilkins. Tanner. HSE. Peterborough NHS Primary Care Trust. Baltimore: Lippincott. Peterborough: Peterborough NHS Primary Care Trust. Williams and Wilkins. Lavery. 11 (6) p16. 2007.. Dublin: Phlebotomists Association Ireland. To Glove or Not to Glove: That is the Question. I. S. Phlebotomists Association Ireland. M. 3rd Ed. Nursing Standard. P. 3 (3) pp 1-2. National Association of Phlebotomists Newsletter. Venepuncture Policy and Procedure.. Midwives: The Official Magazine of the RCM. Venepuncture: Best Practice. A. Smith J (1998) The practice of venepuncture in Lymphoedema. 7 (2) p97 – 98. European Journal of Cancer Care. & Agur. Derek Hanley NS367 7 . J. 2005.2009. J. 2005. How to perform venepuncture. Harris. Applied Phlebotomy.L. 2001. R. NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 Ernst. Dublin: Office of Nursing Services Director. D. & Ingram. Moore. 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. K. Essential Clinical Anatomy. 2009.. 2008. 2007. 19 (49) pp55-65. Phlebotomists Association Guidelines Handbook.

2009. London: Bailliere Tindall Elsevier. Philadelphia: Lippincott. B. [Accessed 20 Nov 2009].M. 25th Ed.ciph. Bailliere’s Nurses’ Dictionary for Nurses and Health Care Workers. Plumer’s Principles and Practice of Intravenous Therapy. Available from: http://www. Derek Hanley NS367 8 . NS367 Prescribed Evidence Assignment Derek Hanley 57747951 BNGN3 The Certificate in Phlebotomy-2009. Weller. Williams and Wilkins. Weinstein. Available from: http://venepuncture. [Accessed 21 Nov 2009]. 2007. [Online]. 8th Ed.20megsfree. Venepuncture Teaching Resource [Online].