Venepuncture and Cannulation E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: Essential Clinical Skills for Nurses
• Sprache: Englisch

Seitenzahl: 351

Veröffentlichungsjahr: 2011

Beschreibung

Venepuncture and cannulation are the most commonly performed invasive procedures in the UK, and are everyday procedures in health care practice. Venepuncture and Cannulation is a practical guide to these procedures. It assumes no prior knowledge and equips nurses and other health professionals with the clinical skills and knowledge they need in order to confidently perform venepuncture and cannulation in both hospital and community settings. * Explores relevant anatomy and physiology * Covers education and training, as well as legal and ethical issues * Considers potential complications, and patient perspectives * Provides guidance on the selection of the appropriate vein and equipment, and common blood tests

Leseprobe

Table of Contents

Cover

Table of Contents

Essential Clinical Skills for Nurses

Title page

Copyright page

Foreword

Contributors

Introduction

1 Legal and Professional Issues

INTRODUCTION

THE LEGAL ASPECT

THE PROFESSIONAL ASPECT

ACCOUNTABILITY

DUTY OF CARE

VICARIOUS LIABILITY

RECORD KEEPING

CONSENT TO TREATMENT

EVIDENCE-BASED PRACTICE

CONCLUSION

2 The Learning Experience

INTRODUCTION

KNOWLEDGEABLE AND PRACTICAL LEARNING

LEARNING METHODS

ASSESSING LEARNING

PROFESSIONALS LEARNING

CONCLUSION

3 Anatomy and Physiology

INTRODUCTION

OVERVIEW OF THE CIRCULATORY SYSTEM

ARTERIES, VEINS AND CAPILLARIES

STRUCTURE OF BLOOD VESSELS

THE NERVOUS SYSTEM

LOCATION OF VEINS

SYSTEMIC BLOOD FLOW

INTEGUMENTARY SYSTEM

CONCLUSION

4 Selection of Equipment

INTRODUCTION

VENEPUNCTURE

CANNULATION

CONCLUSION

5 Vein Selection

INTRODUCTION

METHODS OF VEIN SELECTION

IMPROVING VENOUS ACCESS

VEIN SELECTION

FACTORS THAT MAY AFFECT CHOICE FOR VENEPUNCTURE AND CANNULATION

CONCLUSION

6 Infection Control and Risk Management

INTRODUCTION

INFECTION CONTROL

RISK MANAGEMENT

CONCLUSION

7 Procedures for Venepuncture and Cannulation

INTRODUCTION

PREPARATION OF THE ENVIRONMENT AND THE PRACTITIONER

TECHNIQUES REQUIRED TO PERFORM VENEPUNCTURE

TECHNIQUES TO PERFORM CANNULATION

CARE AND MANAGEMENT OF CANNULA IN SITU

PROCEDURE FOR SAFE REMOVAL OF CANNULA

CONCLUSION

8 Complications

INTRODUCTION

ECCHYMOSIS/HAEMATOMA

MISSED VEIN

VASOVAGAL/SYNCOPE REACTION

NERVE INJURY

ARTERIAL PUNCTURE

PHLEBITIS

INFILTRATION AND EXTRAVASATION

INFECTION

CONCLUSION

9 Introduction to Routine Blood Tests, Normal Values and Relevance to Clinical Practice

INTRODUCTION

WHAT IS THE PURPOSE OF TESTING THE BLOOD?

FACTORS THAT INFLUENCE BLOOD RESULTS

METHODS USED TO OBTAIN SAMPLES OF BLOOD

CLASSIFICATION AND MEASUREMENT OF BLOOD RESULTS

HAEMATOLOGY

ORDERING HAEMATOLOGY BLOOD TESTS

HAEMATOLOGY BLOOD TESTS

BIOCHEMISTRY

BIOCHEMISTRY BLOOD RESULTS

CONCLUSION

10 Patient’s Perspective

INTRODUCTION

BLOOD AND INJECTION PHOBIA

FACTORS THAT CAN INFLUENCE PAIN AND ANXIETY

TECHNIQUES TO REDUCE ANXIETY AND PAIN

NON-PHARMACOLOGICAL METHODS OF REDUCING PAIN

PHARMACOLOGICAL METHODS OF REDUCING PAIN

CONCLUSION

Webliography

Glossary

Index

Essential Clinical Skills for Nurses

The Essential Clinical Skills for Nurses series focuses on key clinical skills for nurses and other health professionals. These concise, accessible books assume no prior knowledge and focus on core clinical skills, clearly presenting common clinical procedures and their rationale, together with the essential background theory. Their user-friendly format makes them an indispensable guide to clinical practice for all nurses, especially to student nurses and newly qualified staff.

Other titles in the Essential Clinical Skills for Nurses series:

Personal Hygiene Care

by Lindsay Dingwall 978-1-4051-6307-1

Care of the Dying and Deceased Patient: A Practical Guide for Nurses

by Philip Jevon (Editor) 978-1-4051-8339-0

ECGs for Nurses, 2nd Edition

by Philip Jevon 978-1-4051-8162-4

Sexual Health

by Kathy French (Editor) 978-1-4051-6831-1

Clinical Examination Skills

by Philip Jevon 978-1-4051-7886-0

Nursing Medical Emergency Patients

by Philip Jevon, Melanie Humphreys, Beverley Ewens 978-1-4051-2055-5

Trauma Care: Initial Assessment and Management in the Emergency Department

by Elaine Cole (Editor) 978-1-4051-6230-2

Wound Management

by Carol Dealey 978-1-4051-5541-0

Clinical Assessment and Monitoring in Children

by Diana Fergusson 978-1-4051-3338-8

Infection Prevention and Control

by Christine Perry 978-1-4051-4038-6

Treating the Critically Ill Patient

by Philip Jevon 978-1-4051-4172-7

Monitoring the Critically Ill Patient, 2nd Edition

by Philip Jevon (Editor), Beverley Ewens (Editor) 978-1-4051-4440-7

Leg Ulcer Management

by Christine Moffatt, Ruth Martin, Rachael Smithdale 978-1-4051-3476-7

Pain Management

by Eileen Mann, Eloise Carr 978-1-4051-3071-4

Care of the Neurological Patient

by Helen Iggulden 978-1-4051-1716-6

Central Venous Access Devices: Care and Management

by Lisa Dougherty 978-1-4051-1952-8

Respiratory Care: Essential Clinical Skills for Nurses

by Caia Francis 978-1-4051-1717-3

Pressure Area Care

by Karen Ousey (Editor) 978-1-4051-1225-3

Stoma Care

by Theresa Porrett, Anthony McGrath 978-1-4051-1407-3

Intravenous Therapy

by Theresa Finlay 978-0-632-06451-9

This edition first published 2011. © 2011 by Blackwell Publishing Ltd

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Library of Congress Cataloging-in-Publication Data

Venepuncture and cannulation / edited by Sarah Phillips, Mary Collins, Lisa Dougherty.

p. ; cm. – (Essential clinical skills for nurses)

 Includes bibliographical references and index.

 ISBN 978-1-4051-4860-3 (pbk. : alk. paper)

1. Veins–Puncture. 2. Catheterization. 3. Nursing. I. Phillips, Sarah, 1972- II. Collins, Mary, 1971- III. Dougherty, Lisa. IV. Series: Essential clinical skills for nurses.

 [DNLM: 1. Phlebotomy–nursing. 2. Catheterization–nursing. WY 100.1]

 RM182.V46 2011

 615'.39–dc22

2010041325

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781444393217; Wiley Online Library 9781444393231; ePub 9781444393224

Foreword

Venepuncture and cannulation are two commonly practiced invasive procedures in the hospital and community setting that have remained unchanged despite technological developments of the past decades. These are not complex procedures, however there are a number of factors that contribute to correctly performing them, presented by the authors in this book.

The wide variety of clinicians offering these skills to their patients is welcome and makes the most of the talent in the NHS, while offering patients choice and an efficient service. However, such diversity risks different types of practices evolving. It is therefore essential that a clear, concise yet informative text is available for clinicians to lead forward best practice in the most appropriate and informative way.

The book provides a comprehensive yet concise overview of relevant information and assumes no specialist knowledge. The text is augmented by useful tables and diagrams and is logically presented for reading and reference purposes. Competent practice and patient experience are integrated throughout with additional designated chapters from both the patient perspective and the educational experience. This demonstrates the editors’ commitment to providing a text with a strong emphasis on high quality patient care, and the importance of training and education in order to achieve that aim. All relevant aspects are covered, beginning with professionals, and their duty of care and legal responsibilities. The book is completed by a review of the patient experience, specifically what we know about their experience and how this can shape our practice.

I welcome this book as the first publication on venepuncture and cannulation in the United Kingdom. It is further example of how the NHS in particular, remains at the forefront of pioneering clinical practice development in healthcare worldwide. Expertise, patient experience and evidence based practice are shared by texts like this to ensure practising clinicians may take available knowledge and skill forward and continue to offer a first class service for our patients.

Venepuncture and Cannulation – Essential Clinical Skills for Nurses, provides a core text for anyone practicing these skills, not just nurses. The extensive referencing and content from authors, with both expertise and knowledge in this field, make this book both an excellent starting and reference point. It will become a pivotal reference for the clinician who strives to master, rather than simply acquire these skills.

Professor Lord Darzi PC, KBE, FMedSci, HonFREng

Professor Darzi holds the Paul Hamlyn Chair of Surgery at Imperial College London where he is Head of Division of Surgery. He is internationally respected for his innovative work in the advancement of minimal invasive surgery and the development and use of allied technologies. Research led by Professor Darzi is directed towards achieving best surgical practice through both innovation in surgery and enhancing the safety and quality of healthcare.

Contributors

Andrea Blay Consultant Nurse Critical Care, Chelsea and Westminster Hospital NHS Foundation Trust

Mary Collins Clinical Practice Educator, Imperial College Healthcare NHS Trust

Annie de Verteuil Senior Clinical Skills Trainer, Royal Berkshire NHS Foundation Trust

Mirjana Dojcinovska ST2 Respiratory Medicine, Papworth Hospital NHS Foundation Trust

Lisa Dougherty OBE Nurse Consultant Intravenous Therapy, The Royal Marsden NHS Foundation Trust

Sarah Hart Formerly Clinical Nurse Specialist Infection Control, The Royal Marsden Hospital NHS Foundation Trust

Lorraine Hyde Matron Day Services, The Royal Marsden Hospital NHS Foundation Trust

Wendy Morris Infection Prevention and Control Nurse, Royal Berkshire NHS Foundation Trust

Sarah Phillips Education and Organisation Consultant, Vein Train Ltd

Barbara Witt Nurse Phlebotomist, The Royal Marsden Hospital NHS Foundation Trust

Introduction

Sarah Phillips and Mary Collins

This book aims to equip healthcare practitioners with underlying theory prior to gaining competence in the hospital and community settings for the practical skills of venepuncture and cannulation. It is predicted that users of this book are the practitioner who is updating their knowledge about these skills or the novice who is learning the skill of venepuncture or cannulation for the first time before undertaking supervised practice in the clinical environment.

Intravenous access is a skill that is growing amongst all healthcare practitioners and there are a number of reasons why it is required:

1. Administration of ‘short-term low-risk intravenous therapy e.g. administration of blood and blood produces, isotonic fluids and drugs whose pH and osmolarity are similar to that of blood’ (Scales 2005, p. 48).

2. New roles and autonomy for community nurses (Maben & Griffiths 2008, p. 13).

3. Nurses responsible for the management of whole episodes of care for patients (Maben & Griffiths 2008, p. 13).

4. Provision of ‘safe, effective and prompt nursing interventions’ a core element of good quality nursing care (Maben & Griffiths 2008).

5. The Hospital at Night (HaN) concept is one such example to achieve seamless clinical care with one or more multiprofessional teams who between them have the full range of skills and competencies to meet patients’ immediate needs.

The chapters individually highlight good practice, and therefore quality care, in the stages that collectively ensure the patient’s safety throughout the procedure of venepuncture and cannulation. This is pertinent in light of the current agenda that focuses on quality outlined in the Darzi report High Quality Care for All (2008a). This report places emphasis on achieving effective and high quality healthcare services by enabling practitioners to utilise their skills, knowledge and expertise appropriately and effectively. ‘NHS staff make the difference where it matters most and we have an obligation to patients and the public to enable them to make best use of their talents’ (Darzi 2008a, p. 10).

The authors of this book consider education and training to be pivotal in providing best practice for patients in these skills. It is equally recognised that achieving this basic requirement is challenging for practitioners and managers in today’s fast moving healthcare. The following recommendations offer a realistic way forward in modern healthcare and are echoed throughout this book:

Flexible – provision of education and training must be sufficiently flexible to give professionals both the breadth and depth of expertise that they need to deliver the high quality care to which they aspireFocused on quality – high quality care requires the provision of high quality education and trainingPromoting life-long learning: Staff in all roles and settings need opportunities to continuously update the skills and techniques that are relevant to delivering high quality care through, for example, work-based learning. …

Darzi (2008b, p. 12)

For the purpose of the book the practitioner refers to anyone who is undertaking the skills of venepuncture and cannulation. This can be a healthcare assistant, phlebotomist, physician’s assistant, medical student, registered nurse, midwife, qualified doctor or radiographer. References are made to paediatrics; however, this book is focused on cannulation and venepuncture for the adult or adolescent.

Chapter 1 considers the legal and professional aspects which the practitioner must familiarise themselves with prior to undertaking the learning experience, which is the focus of Chapter 2. Preparing for these procedures requires some specific knowledge and understanding, therefore anatomy and physiology is covered in Chapter 3 and selecting the correct equipment, for example blood bottles, cannulae, for the procedure in Chapter 4. A particularly important consideration for the success of these procedures is to ensure that the patient has the best experience possible. This means selecting the correct vein is crucial and Chapter 5 looks at assessing the patient, inspection and palpation of the vein, and considers some challenges that the practitioner may encounter. In view of the increasing numbers of intravascular catheter-related bloodstream infections, Chapter 6 addresses infection control and risk management. Preparation of both the patient and the practitioner increases the success of these procedures and these are considered in Chapter 7 in procedures for venepuncture and cannulation. Complications are a reality and Chapter 8 helps the practitioner to identify when they occur and problem-solve to minimise injury for the patient. Chapter 9 covers different types of blood tests and factors that must be considered when taking blood. Finally, central to the success of these procedures is the patient and their perspectives are addressed in Chapter 10.

SOME DEFINITIONS OF COMMON TERMS USED IN THIS BOOK

Cannulation: The ‘insertion of a tube into a body duct or cavity, is performed to provide access to the circulation for the administration of short-term, low-risk intravenous therapy’ (Scales 2005, p. 48).

Venepuncture: The term used to describe the procedure of ‘Entering a vein with a needle’ (Dougherty & Lister 2011, p. 920).

REFERENCES

Darzi, A.W. (2008a) High Quality Care For All: NHS Next Stage Review Final Report. DH, London.

Darzi, A.W. (2008b) A High Quality Workforce. NHS Next Stage Review. DH, London.

Dougherty, L. & Lister, S. (2011) The Royal Marsden Hospital Manual of Clinical Nursing Procedures, 8th edn. Wiley Blackwell, Oxford.

Maben, J. & Griffiths, P. (2008) Nurses in Society: Starting the Debate. National Nursing Research Unit King’s College London, London.

Scales, K. (2005) Vascular access: a guide to peripheral venous cannulation. Nursing Standard, 19(49), 48–52.

1

Legal and Professional Issues

Lorraine Hyde

LEARNING OUTCOMES

The practitioner will be able to:

Understand key aspects of the legal framework that are relevant to these skills.Understand how healthcare organisations operate within this framework, in relation to these skills.Consider the professional aspects for these skills.Understand the importance of evidence-based practice.

INTRODUCTION

Venepuncture and cannulation are the most commonly performed invasive procedures in the NHS. To perform these procedures well, and to ensure a satisfactory outcome for the patient, requires the practitioner to have relevant and up-to-date knowledge and skill (Dougherty 2008). This chapter focuses on the legal and professional implications for nurses who perform these procedures within their practice setting.

THE LEGAL ASPECT

The nursing profession seeks to deliver high quality care at all times and the role of the nurse has expanded significantly over the past decade. The evolving range of responsibilities can be complex in nature and are related to the technological and medical advances within the healthcare setting. The nurse’s role, whilst offering intellectual stimulation and professional satisfaction, brings with it the potential for increased legal risks (Hyde 2008). Nurses must have a working knowledge of the law and how it applies to their practice in order to be safe and competent practitioners.

Sources of Law

The law derives from two main sources. The first is Acts of Parliament and Statutory Instruments (also known as statute law) which are enabled by the powers given to Parliament (Hyde 2008). These statutes, which take precedence over all other laws, include the legislation of the European Community. Laws of the European Community automatically become part of the law in the United Kingdom (Dimond 2005). There are many statutes that apply to nursing, such as the Nurses Midwives and Health Visitors Act 1997, the National Health Service Act 1977 and the Health Act 1999.

The common law (also known as case law) is the second source, which is derived from decisions made by judges in individual cases. Thus, common law operates through a system of precedent. The judge, when considering the facts before him and deciding upon a case, is bound by the decision in law made by judges at an earlier case if it is relevant to the facts before him and if that decision was made by a higher court to that in which he is sitting (Dimond 2005). The established order of precedence means that decisions made in the United Kingdom Supreme Court, the highest court of the land, are binding over all lower courts except itself, but would be subject to relevant precedents established in the European Court of Justice (Dimond 2005).

The legal system is divided into two main branches, criminal and civil law. Criminal law relates to crime and breaches can lead to prosecution, whilst civil law deals with all other cases (Hodgson 2002). Civil law is the branch of law whereby a civil action for negligence in relation to the liability of the nurse would be heard. A patient who has suffered harm as a consequence of inadequate care whilst being treated by the nurse can claim compensation for a breach of duty of care. It is therefore important that the nurse has an understanding of liability in relation to civil action.

THE PROFESSIONAL ASPECT

Statutory regulation of nurses is the function of the Nursing and Midwifery Council (NMC). The professional register is a means of declaring that a reasonable standard of competence and conduct is expected from those named in it. It is also stating that these are the people to whom the NMC has declared its expectations, given its advice and presented its standards, and to whom it can call to account. The Nursing Midwifery Order 2001 requires the NMC to have specific statutory committees, these are the:

Screeners and Practice Committees – who consider allegation and establish if the complaint is well founded but who may refer the matter to the other committee for considerationInvestigating Committee (IC)Conduct and Competence Committee (CCC)Health Committee (HC).

Integral to the NMC function is to protect the public from persons whose fitness to practise is impaired. Fitness to practise implies the registrant’s suitability to be on the register without restrictions. Some of the ways in which fitness to practise may be impaired are by misconduct, lack of competence, physical or mental ill-health or a criminal conviction. The CCC holds hearings in public to encourage transparency and to reflect the NMC’s public accountability. The sanctions that are available to the committees include issuing a caution, suspension from the register or removal from the register. As a way of ensuring that practitioners are fit to practise and are able to provide relevant and evidence-based nursing intervention, the NMC provides guidance through its Code, which was updated in April 2008. It states: ‘The people in your care must be able to trust you with their health and wellbeing’, and it requires the nurse or midwife to:

make the care of people your first concern, treating them as individuals and respecting their dignitywork with others to protect and promote the health and wellbeing of those in your care, their families and carers, and the wider communityprovide a high standard of practice and care at all timesbe open and honest, act with integrity and uphold the reputation of your profession. NMC (2008) p. 1

ACCOUNTABILITY

The concept of accountability is influenced by issues such as authority and autonomy and is related to the concept of pro­fessionalism. Watson (2004) states that ‘accountability is the hallmark of a profession’ in that training and professional registration is required in order to practise. The nurse has both professional and legal accountability for her practice. Nurses are accountable to:

the NMC in terms of the code of conduct, and the sanction could be removal from the registerthe patient through civil law, and the sanction could be to be sued by the patientthe employer through contract of employment/employment tribunal, and sanction could be loss of jobthe public through criminal law/courts, and the sanction could be criminal prosecution (Hyde 2008).

There can be overlap within these areas of accountability. For example, if a nurse witnesses a car accident, legally she is not obliged to stop at the scene and offer assistance; however, professionally she would be expected to. The NMC states that the nurse is ‘accountable for the care she delivers in emergency situations’.

Accountability is implicit within any area of practice where the practitioner is delivering care. The NMC defines accountability as ‘responsible for something or someone’, and to be responsible requires knowledge. Clark (2000) describes accountability as meaning ‘the professional takes a decision or action not because someone has told him or her to do so, but because, having weighed up the alternatives and consequences in the light of the best available knowledge, he or she believes it is the right decision or action to take’. The NMC states that in exercising their professional duty nurses must be able to justify their actions as well as their decisions, which is not possible unless the nurse has the necessary knowledge.

Legal accountability applies to every citizen, and nurses like all other professionals are personally accountable through law for their actions or omissions. Such individual legal accoun­tability is channelled through the criminal and civil law in the courts (Tingle 2004). The NMC 2008 code also emphasises that the nurse ‘must act lawfully, whether those laws relate to professional practice or personal life’; thus accountability is continuous.

Litigation within healthcare in the United Kingdom has increased over the years and has huge financial implications for the NHS (Dougherty 2003). During 2006–2007 the NHS Litigation Authority (NHSLA) dealt with 5426 clinical negligence claims which cost £579.3 million. Over 80% of these cases were settled out of court (NHSLA 2008). The challenges of nursing within an increasingly complex healthcare framework, and the many competing priorities, mean that the risk of litigation is always present.

DUTY OF CARE

All nurses owe the patients they care for a duty of care. Liability is likely if that duty has been breached, the breach being a failure to meet the required standard of care. The standard of care required is determined by the Bolam test: ‘the standard of the ordinary skilled man exercising and professing to have that special skill. A man need not possess the highest expert skill at the risk of being found negligent. … it is sufficient if he exercise the ordinary skill of an ordinary man exercising that particular art’ (Bolam v. Fern Hospital Management Committee 1957). This standard is well established as is Bolitho (1997): ‘when challenged, if expert opinion could not withstand logical analysis then the judge has the right to conclude that the body of opinion is not reasonable or responsible’ (Foster 2002). Consequently, when justifying clinical decisions or actions the practitioner would be expected to have considered their competencies within a particular situation as well as best practice principles if they were subject to litigation.

For a successful litigation the plaintiff must establish three principles on the balance of probabilities. These are:

that a duty of care was owed by the defendant to the plaintiffthat there has been a breach of that dutythat, as a result of that breach, the plaintiff has suffered harm of a kind recognised in law and which is not too remote.

For example, a litigation claim could be evoked if in the course of her duty, a nurse inserted a peripheral cannula using poor technique which caused the patient an injury.

VICARIOUS LIABILITY

NHS Trusts and other employers have two forms of liability: (1) direct liability, i.e. the Trust itself is at fault; and (2) vicarious or indirect liability, i.e. the Trust is responsible for the faults of others, mainly its employees (Dimond 2005). It is a necessary requirement that the employee was acting within the course of their employment and that they were authorised to perform the procedure. For example, a nurse whilst caring for a patient obtains a blood sample from the patient and during the procedure the patient sustains a nerve injury. If the nurse did not have the necessary training or authorisation to perform the procedure, the patient would be able to claim clinical negligence. It is possible that the employer could seek to recover from the employee any compensation which may be paid out. However, the Department of Health advise against such practice (Dimond 2005).

The changing culture of clinical negligence claims has been reflected in the updated code of conduct. The NMC states that the nurse should have personal indemnity insurance and that if the nurse cannot arrange it then she must declare it to the person for whom she is caring as they need to be aware of that fact due to the potential for a clinical negligence claim. Such a declaration relates to registered nurses and not to non-registered healthcare personnel. Indemnity insurance is provided through professional organisations and trade unions.

RECORD KEEPING

Maintaining accurate records is fundamental to nursing practice and yet it is often overlooked, especially when workload demands are high. However, the NMC describes good record keeping as a ‘tool for professional practice and one that should help the care process. It is not separate from this process and it is not an optional extra to be fitted in if circumstances allow’ (NMC 2009).

Failure to document interventions accurately could have serious consequences. In terms of cannulation, records should demonstrate site selection, number of attempts and any problems encountered during the procedure. The record should be signed and dated with the time of insertion. Furthermore, records should demonstrate the care of the peripheral device as well as the outcome of treatment (Dougherty 2008). The nurse should remember that these records will be used in the event of a negligence claim being brought against her and will serve to protect her if the documentation is detailed and relevant. In the absence of relevant records, nursing practice can be called into question since there is no evidence to prove that the interventions took place. The nurse may also find it difficult to recall details since memory fades with time and recall can be scanty. Opinions may then be made about the nurse’s fitness to practise because of failures in documentation, since ‘good record keeping is an integral part of nursing and midwifery practice, and is essential for to the provision of safe and effective care’ (NMC 2009). Furthermore, the practitioner and employer lose protection against negligence claims in the absence of clear and accurate records. Documents provided as evidence in court would be scrutinised and any failures would compromise the practitioner when they came to give evidence. Consequently, to neglect this area of practice is to open oneself to potential professional and legal complications.

CONSENT TO TREATMENT

The notion of consent is based on the principle of respect for the person and thus on the concept of human rights of life and liberty (Tschudin 2003). Central to the thinking about the nursing care of the patient is the philosophical concept of autonomy. On the premise that people know what is in their best interest, the ethical principle states that the choices of mature people must be respected and, reflecting this principle, the law insists that consent is, in the vast majority of cases, a prerequisite to the care of the patient (Cox 2001). As a registered nurse it is imperative that consent is obtained before any treatment or care is initiated. For consent to be valid the practitioner must ensure that consent is:

given by a legally competent persongiven voluntarilyinformed (which includes information about the procedure as well as any known risks related to the intervention) (NMC 2008)

Consent may be given in a variety of ways and the law does not require consent to be given in a particular way. Implied, verbal, written and expressed consent are all equally valid; however, they can vary in their value as evidence in proving that consent was given (Dimond 2005). Examples of consent are: (1) a nurse is about to obtain a blood pressure reading and the patient holds out their arm for the procedure, then the consent is implied; (2) the nurse asks the patient if she can obtain a blood sample and the patient agrees, then the consent is verbal; (3) the nurse, prior to insertion of a central venous access device and following a comprehensive explanation of the procedure, asks the patient to sign a written document to confirm consent to the procedure.

Giving full explanations of what is being done, and why, how and when, is essential for the patient to remain a free agent and exercise the right to say no (Tschudin 2003). It is often difficult for nurses to accept a patient’s refusal to give consent. However, an action of battery may be brought if treatment is given in the face of an explicit refusal of consent (McHale 2001).

EVIDENCE-BASED PRACTICE

The radical modernisation of the healthcare system that culminated in the publication of the NHS Plan (Department of Health 2000) empowered nurses to undertake a wide range of complex clinical skills which were traditionally the remit of the medical profession. The nursing profession has embraced the role expansion. However, the role expansion is inextricably linked with the risk of professional and legal complications for the nurse. The procedure of venepuncture and cannulation is commonly practised by nurses (Dougherty 2008). The importance of being competent to perform these procedures must never be underestimated since the consequences of bad technique and lack of knowledge can be serious. Skill is required to learn techniques and use equipment but of equal importance is the knowledge that is required to apply evidence-based practice, assess the patient, problem-solve, manage complications. A good knowledge of equipment is necessary to protect the practitioner from risks such as sharps injury, and agencies such as the National Patient Safety Agency (2007) advocate the use of needle-free systems whenever possible.

The NMC code (NMC 2008) states that each nurse must ensure that their practice is up to date; the notion of lifelong learning is inherent in the code and nurses are encouraged to actively seek out and comply with training programmes which will help inform their professional practice. Failure to maintain knowledge would be viewed as a breach of the code since the NMC emphasises the importance of maintaining competency in order to deliver safe and effective nursing care.

There is currently no national agreed training programme for venepuncture or cannulation; however, the RCN (2010) have published the third edition of their Standards for Infusion Therapy, which is essential reading for nurses performing venepuncture and cannulation. There is a risk in assumptions being made about the fact that such procedures, being commonplace, are easy to perform and require minimal knowledge. The reality is that in order for the nurse to deliver safe and effective care and to be competent to work without supervision she must demonstrate that she has maintained her knowledge and skill (NMC 2008).

It has become common practice for organisations to allow non-registered staff to perform cannulation and venepuncture following a period of training. If the procedure is being performed under the delegation of the registered nurse then she must be satisfied that the delegation is appropriate and be aware of the outcomes of the delegation. The nurse or midwife must:

establish that anyone they delegate to is able to carry out their instructionsconfirm that the outcome of any delegated task meets the requires standardsmake sure that everyone they are responsible for is supervised and supported NMC (2008).

Clearly, the nurse is ultimately accountable for her actions as well as decisions.

CONCLUSION

The dynamic nature of healthcare makes it essential for nurses to keep up to date with advances in clinical practice to ensure they are fit for purpose. To ensure safe, effective and professional practice requires the nurse to maintain a good knowledge of the professional and legal requirements which influence the delivery of care.

REFERENCES

Clark, J. (2000) Accountability in Nursing, Second WHO Ministerial Conference on Nursing and Midwifery in Europe. Munich, 15–17 June 2000.

Cox, C. (2001) The Legal Challenges Facing Nurses. Discussion paper. Royal College of Nursing, London.

Department of Health (2000) The NHS Plan: a plan for investment, a plan for reform, Cm 4818-I. Department of Health, London.

Dimond, B. (2005) Legal Aspects of Nursing, 4th edn. Pearson Education, Harlow.

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2

The Learning Experience

Sarah Phillips

LEARNING OUTCOMES

The practitioner will be able to:

Evaluate if it is appropriate to learn these skills.Evaluate potential learning and assessment resources.Identify local learning opportunities.Realistically assess the complexities of learning within his/her own workplace.Consider his/her own and other professionals’ needs when learning.Plan a successful route to achieve competency.

INTRODUCTION

This chapter explores different approaches to education, training and assessment for venepuncture and cannulation. As courses differ locally, strengths and weaknesses of educational methods are highlighted so that learners can avoid common pitfalls and identify potential resources. Competence is a theme throughout but has been specifically related to assessment approaches. The environment of work and learning is discussed, drawing on behavioural sciences to offer illumination on the complexities involved in learning at work. Different professional groups are later introduced so the learner can consider specific educational requirements for themselves and those around them.

Learners will benefit from taking time to consider if it is realistic and appropriate to acquire these skills in terms of gaining competency and maintaining expertise once competent. Training, education and development is only effective if what is being taught is needed and wanted and the reason for poor current uptake understood. Mager (1992) suggests these fall into two simple rules:

Rule 1: Training is appropriate only when two conditions are present:

There is something that one or more people do not know how to do.They need to be able to do it.

Rule 2: If they already know how, more training won’t help.

KNOWLEDGEABLE AND PRACTICAL LEARNING

Theoretical Learning

The clinical area is rich with stimulating learning experiences but this can also be challenging for learners because it is also distracting. Learners therefore benefit from protected time in an environment conducive to acquiring theoretical knowledge including anatomy, physiology, specialised terminology and equipment design. An environment which has been designed for learning encourages active questioning because it should feel safer and less exposing for learners. Equally, patients need not experience discussions that may be anxiety-provoking and irrelevant to their own situation. This falls in line with the Essence of Care Benchmark for Communication. ‘Communica­tion takes place at a time and in a communication environment that is acceptable to all parties’ (DH 2003b, p. 3).

Any division of theory and skill must be done carefully because it creates an artificial split that does not reflect the reality of healthcare roles, which require thinking and doing together. Benner et al. (1998) informs us that expert nurses make decisions about care by ‘Thinking-in-Action’ which is particularly relevant for these practical skills. Theory remains essential to provide a solid foundation to enable safe practice, but should not be the sole source of knowledge and understanding. Indeed it is too limiting for these skills because normal patient variation creates unpredictable outcomes that need to be learnt in practice. Mastering these skills therefore requires the learner to source learning tools and methods that are designed to include key theoretical elements (see Table 2.1) but also have a fundamental objective of facilitating integration of practical skill with theory.

Table 2.1 Key theoretical knowledge required

Anatomy:Anatomy and physiology of the normal arm including skin, veins, arteries and nerves and the feel and appearance of healthy veins including the presence of valves and junctions.Selection of vein and problems associated with venous access due to thrombosed, sclerosed inflamed and fragile veins, the effect on veins of ageing and the disease process, previous treatment, lymphoedema or the presence of infection.Equipment:Improving venous access.Selection of device and other equipment.Appropriate collection tubes and precautions required.Components of the equipment and how the design can be optimised in practice.Risk management (reducing risk of needlestick injury, etc.).Performing the procedure (demonstration, techniques, etc.).Patient:Assessment of patient needs.Importance of patient’s identification and correct labelling and transport of specimens.Pharmacological and non-pharmacological interventions. (i.e., use of local anaesthetic or psychological management of anxious patients).Consideration of anatomical and physiological complications (injury, bruising, phlebitis).Infection prevention issues (hand washing, use of gloves, skin preparation, and waste disposal).Prevention and management of complications during insertion (haematoma, nerve injury, infiltration, extravasation, etc.).Monitoring and care of site (phlebitis assessments, flushing, dressing, removal of device).Patient information and education (leaflets, advice to notify staff of any adverse reactions).Professional and legal aspects (consent, professional guidance, knowledge and skills maintenance and documentation).Understanding of the rationale for the blood test or cannula.

Experiential Learning

The diverse approaches to learning, including cognitive, social and humanist, offer useful sources to aid understanding of different responses to learning. According to experts from such disciplines, learning from experience is highly effective (Bion 1961; Gagné 1965; Knowles 1973, Bandura 1977; Rogers 1983). This is particularly positive for these skills because the clinical environment has an abundance of expertise and situations which naturally facilitate learning through experience.

Rogers (1983) believes that experiential learning has five qualities:

It involves the whole person – both feelings and cognitive processes.It is self-initiated, with a sense of discovery coming from within.It is pervasive and makes a difference in the behaviour, attitudes and maybe the personality of the learner.It is evaluated by the learner, who knows if his or her needs have been met or not.The essence of it has meaning.

The lecture format is highly effective for some elements of the subject (as described above) but is lacking as a sole method of education for these skills. In fact, words could be viewed as inadequate for the task of trying to communicate distinct and minute patient and anatomical variations that will eventually make the difference between expert and novice practitioner. A combined practical and cognitive approach provides the optimal approach to effective learning and is readily available in clinical practice. Supervised practice, for example, utilises the rehearsal type of learning that Gagné (1965) informs us helps individuals to retain information for longer. In this way, the predominant psychomotor activities necessary for these skills require learners to organise responses, initiate the activity, monitor the process, and refine it with corrective moves after the first tries. Further, social learning is readily available, which Bandura (1977) reveals as advantageous because of the value of observing experienced role models. Finally, transferability is also increased as a result of students being able to practise knowledge and skills in a functional context, so that it is easier to imagine what it is like on the job (Bridges 1992).