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A chaperone is an impartial observer present during an intimate examination of a patient.

Coronavirus (COVID-19)

The COVID-19 pandemic has accelerated the use of online and video consultations as part of core clinical practice. An online, video or telephone consultation does not negate the need to offer a chaperone. The same principles would apply.

The General Medical Council (GMC) have published guidance on how to provide appropriate patient care in online, video or telephone consultations. The guidance includes appropriate use of photographs and video consultations as part of patient care.

The Royal College of Nursing have produced a publication on genital examination in women. It includes some useful information on chaperoning which is applicable regardless of gender.

NHS England have produced some key principles for intimate clinical assessments undertaken remotely in response to COVID-19. They include how to conduct intimate examinations by video and the use of chaperones.

The GMC has published guidance on intimate examinations and chaperones. It provides a framework for all health care professionals. This sets out when and why a patient may need a chaperone and considerations that should be given. It is guidance only and not a mandate. If a GP wishes not to follow this guidance they should risk-assess the situation. They should record their logic or discussion clearly. Even by doing this rather than following the guidance, they will put themselves at risk.

Why is a chaperone needed?

All medical consultations, examinations and investigations are potentially distressing. Patients can find examinations, investigations or photography involving the breasts, genitalia or rectum particularly intrusive. These examinations are called 'intimate examinations'. Cultural factors should be considered. This is important when examinations are performed by members of the opposite sex. Also, any consultations where patients may feel vulnerable.

For most patients and procedures, respect, explanation, consent and privacy are all they need. They take precedence over the need for a chaperone. A chaperone does not remove the need for adequate explanation and courtesy. Neither can it provide full assurance that the procedure or examination is conducted appropriately.

It is important that children and young people are provided with chaperones. The GMC guidance states that a relative or friend of the patient is not an impartial observer. They would not usually be a suitable chaperone. There may be circumstances when a young person does not wish to have a chaperone. The reasons for this should be clear and recorded.

All staff must be aware that chaperones are to protect both patients and staff.

The Medical Defence Union has published guidance on chaperones. The Medical Protection Society have produced an article on providing chaperones.

Offering a chaperone

The chaperone policy should be clearly advertised through:

patient information leaflets

websites (where available) and

notice boards.

All patients should routinely be offered a chaperone during any consultation or procedure. This does not mean that every consultation needs to be interrupted to ask if the patient wants a chaperone to be present. The offer of chaperone should be clear to the patient before any procedure. Ideally at the time of booking the appointment.

For children and young people, their parents, relatives and carers should be made aware of the policy and why this is important.

Where a patient is offered but does not want a chaperone, it is important the practice has records, and coded in the records:

who the chaperone was

their title and

that the offer was made and declined.

If the patient has requested a chaperone and none is available, the patient must be able to reschedule within a reasonable timeframe. If the seriousness of the condition means a delay is inappropriate, this should be explained to the patient. It should be recorded in their notes. A decision to continue or not should be reached jointly. Special consideration needs to be given to examinations performed on home visits or during online, video or telephone consultations.

Chaperone training

All staff should have an understanding of the role of the chaperone. Staff should understand procedures for raising concerns.

Staff who undertake a formal chaperone role must have been trained so they develop the competencies required. Training can be delivered externally or provided in-house by an experienced member of staff. so that all formal chaperones understand the competencies required for the role.

Expectations of chaperones are listed in the GMC guidance. It states chaperones should:

be sensitive and respect the patient's dignity and confidentiality

reassure the patient if they show signs of distress or discomfort

be familiar with the procedures involved in a routine intimate examination

stay for the whole examination and be able to see what the doctor is doing, if practical

be prepared to raise concerns if they are concerned about the doctor's behaviour or actions.

Training should include:

what is meant by the term chaperone

what is an 'intimate examination'

why chaperones need to be present

the rights of the patient

their role and responsibilities.It is important chaperones should place themselves inside the screened-off area rather than outside of the curtains/screen (as they are then not technically chaperoning).

policy and mechanism for raising concerns.

Clinical staff who undertake a chaperone role will already have a Disclosure and Barring Service (DBS) check. See GP mythbuster 2: Who should have a DBS check. Non-clinical staff who carry out chaperone duties may need a DBS check. This is due to the nature of chaperoning duties and the level of patient contact. If a practice decides not to carry out a DBS check for any non-clinical staff, they need to provide a clear rationale for the decision. This should include an appropriate risk assessment.

Use of chaperones during video consultations

Many intimate examinations will not be suitable for a video consultation. Where online, video or telephone consultations take place, GMC guidance explains how to protect patients when images are needed to support clinical decision making. This includes appropriate use of photographs and video consultations as part of patient care.

Where intimate examinations are performed it is important that a chaperone is offered. Documentation should clearly reflect this. It is important to document who provided the chaperoning. It should also say what part of the consultation they were present for.

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A chaperone is an impartial observer present during an intimate examination of a patient. The COVID-19 pandemic has accelerated the use of online and video consultations as part of core clinical practice. An online, video or telephone consultation does not negate the need to offer a chaperone. The same principles would apply.

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999 and 112 is the national emergency response service in the UK. 112 is the pan-European equivalent to 999 and can be used in the UK.

Calling for assistance

Calls made using 999 or 112 are identified and prioritised by the communications providers and forwarded to, and then answered by, call handling agents in one of 7 call-handling centres. The call-handling centres are owned by BT Plc, who operate the service on behalf of all the communications providers (mobile, fixed line and broadband). An agent at one of the BT Plc call-handling centres responds with "emergency, which service?". The geographic location of the caller, which is normally automatically available, enables the call to be transferred to the relevant geographically located emergency service control room.

Ofcom, the independent communications regulator, oversees regulation of the telecommunications aspects of the 999-112 service through the General Conditions of Entitlement.

The statistics - 2021

35 million 999/112 calls a year, of which:

28,000 eCalls (included in mobile %)

Service

Percentage of calls

Police

44%

Ambulance

53%

Fire

3%

Coastguard

<1%

7 BT call centres.

144 local emergency services control rooms.

The 999-112 Liaison Committee

Technical and operational oversight of the Service is provided by the 999-112 Liaison Committee, hosted by the Department for Science Innovation and Technology ( DSIT), previously Department for Digital, Culture Media & Sport ( DCMS). The terms of reference of the Committee can be found here below.

The Committee represents all organisations that have a role to play in delivering and managing the 999-112 service, these include: The Home Office, Department for Health & Social Care, the emergency services, Ofcom as the telecommunications regulatory body and the fixed and mobile communications providers.

The Committee also oversees sub-groups responsible for specific areas such as access to the service by vulnerable members of society, such as those with hearing impairments and the role played by emergency calls activated by smartphones. The Committee also has responsibility for the Code of Practice for the Public Emergency Call Service ( PECS) between communications providers and the emergency services. This document outlines the key roles and responsibilities of stakeholders involved in the conveyance of emergency calls from caller to the relevant emergency service.

Strategic leadership

The Liaison Committee is overseen by the 999-112 Strategic Leadership Group which reports to ministers. This Group considers strategic, policy-related issues that affect the 999 and 112 service that fall outside the scope of the operationally-focused Liaison Committee. This Group focuses particularly on issues that cut across all the emergency services in the UK. The terms of reference of the Group can be found below.

The telecommunications ecosystem is evolving rapidly. Technological advances have had a considerable effect on society's communication preferences. The Strategic Leadership Group is closely involved with all stakeholders to ensure that the 999-112 service remains fit for purpose.

Enquiries regarding Police and Fire - please contact the Home Office: public.enquiries@homeoffice.gov.uk

Enquiries regarding Ambulance - please contact the Department of Health & Social Care: dhsc.publicenquiries@dhsc.gov.uk

Enquiries regarding Maritime & Coastguard Agency - please contact: infoline@mcga.gov.uk

Enquiries regarding 999/112 connections or BT Call Handler queries - please contact the Department for Culture, Media & Sport: enquiries@dcms.gov.uk

Thank you for your feedback

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999 and 112: the UK's national emergency numbers

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999 and 112 is the national emergency response service in the UK. 112 is the pan-European equivalent to 999 and can be used in the UK.

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Welcome to the emergencySMS

The emergencySMS service lets deaf, hard of hearing and speech-impaired people in the UK send an SMS text message to the UK 999 service where it will be passed to the police, ambulance, fire rescue, or coastguard.

Simply by sending an SMS message to 999 you can call for help and the emergency services will be able to reply to you.

You will need to register your mobile phone before using the emergencySMS service, click on the Registering your phone link above for more information.

Click here to download the emergencySMS leaflet.

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SMS to the emergency services | EmergencySMS

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The emergencySMS service lets deaf, hard of hearing and speech-impaired people in the UK send an SMS text message to the UK 999 service where it will be passed to the police, ambulance, fire rescue, or coastguard. Simply by sending an SMS message to 999 you can call for help and the emergency services will be able to reply to you.

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The moment someone has a cardiac arrest, the clock starts ticking. Every minute without CPR and defibrillation reduces their chances of survival. But many defibrillators are never used because emergency services don't know where they are or how to access them.

This is where The Circuit comes in.

The Circuit - the national defibrillator network, provides the NHS ambulance services with vital information about defibrillators across the UK so that in those crucial moments after a cardiac arrest, they can be accessed quickly to help save lives.

That's why we urgently need you to register your defibrillator today.

Register your defibrillator

The moment someone has a cardiac arrest, the clock starts ticking. Every minute without CPR and defibrillation reduces their chances of survival. But many defibrillators are never used because emergency services don't know where they are or how to access them.

This is where The Circuit comes in.

The Circuit - the national defibrillator network, provides the NHS ambulance services with vital information about defibrillators across the UK so that in those crucial moments after a cardiac arrest, they can be accessed quickly to help save lives.

That's why we urgently need you to register your defibrillator today.

Watch Stuart's story to hear why registering today is so important

Why should you register your defibrillator?

A defibrillator registered on The Circuit could make the difference between life and death. Why?

1. If your defibrillator isn't registered on The Circuit, ambulance services can't find it when it's needed most.

2. Every defibrillator needs someone like you to make sure it's registered and ready to do its life saving work. The Circuit helps you to do that with regular reminders about the upkeep of your defibrillator.

3. Chances to save lives are being missed - defibrillators are currently being used in less than 1 in 20 out-of-hospital cardiac arrests.

The defibrillator you're responsible for could double a person's chance of survival. Take charge. Join The Circuit today.

Why should you register your defibrillator?

A defibrillator registered on The Circuit could make the difference between life and death. Why?

1. If your defibrillator isn't registered on The Circuit, ambulance services can't find it when it's needed most.

2. Every defibrillator needs someone like you to make sure it's registered and ready to do its life saving work. The Circuit helps you to do that with regular reminders about the upkeep of your defibrillator.

3. Chances to save lives are being missed - defibrillators are currently being used in less than 1 in 20 out-of-hospital cardiac arrests.

The defibrillator you're responsible for could double a person's chance of survival. Take charge. Join The Circuit today.

Watch Stuart's story to hear why registering today is so important

Which type of account should I choose?

To register your defibrillator/s you'll need to create an account. There are two types of account.

To help you decide which one suits you better, please see the guidance below.

Single Guardian

For a community group, a local business, sports club, parish council, local pub etc.

Individual, local group or organisation?

Less than 5 defibrillators?

All defibrillators are in your local area?

No need to manage a wider network of guardians and defibrillators?

..select a Single Guardian account.

Multiple Guardians

For retail chains, larger companies, regional/national charities, public sector organisations etc.

Regional or national group or organisation?

5 or more defibrillators?

Defibrillators widely distributed regionally or nationally?

A requirement for reporting tools to manage a wider network of guardians and defibrillators?

..select a Multiple Guardian account

Single Guardian

For a community group, a local business, sports club, parish council, local pub etc.

..select a Single Guardian account.

Multiple Guardians

For retail chains, larger companies, regional/national charities, public sector organisations etc.

..select a Multiple Guardian account

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The Circuit - the national defibrillator network

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The Circuit - the national defibrillator network links a network of defibrillators to every ambulance service in the UK.

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Don't Forget The Bubbles (DFTB) is website dedicated to making us all better at caring for the child in front of us

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The NICE Clinical Knowledge Summary (CKS) site is only available to users in the UK, Crown Dependencies and British Overseas Territories

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NHS England » National safety standards for invasive procedures (NatSSIPS)

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In January 2023, the Centre for Perioperative Care published revised National Safety Standards for Invasive Procedures (NatSSIPs 2), designed to reduce misunderstandings or errors and to improve team cohesion. The standards, written by clinicians from multiple professions and specialties, re-launches the WHO checklist. It mandates key stop moments when the standard pathway is confirmed and […]

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Venepuncture is a vital procedure that is routinely used in the care and management of patients and is one of the most commonly performed invasive procedures ( Boyd, 2022). It enables health professionals to obtain a sample of blood for analysis by the puncture of a vein with a hollow-bore needle, vacuum system or butterfly infusion system ( Thomas, 2015). These investigations typically include biochemical to analyse certain parameters, such as potassium and sodium levels, haematological to determine blood measurements and microbiological to determine the presence of pathogens ( Gallagher, 2022). As this is a procedure that nurses may be asked to perform as part of their role, it is essential that they are adequately trained, competent in using the correct technique and aware of any advances or changes in the underpinning evidence ( Nursing and Midwifery Council (NMC), 2018)

Aseptic non-touch technique

The aseptic non-touch technique (ANTT) is a method employed to minimise the likelihood of patients contracting infections during clinical procedures. As set out by the Association for Safe Aseptic Practice (ASAP) (2021) it accomplishes this by safeguarding 'Key-Parts' and 'Key-Sites' from micro-organisms that might be transmitted from health personnel or nearby environments. 'Key-Sites' are classified as parts of the body into which infection might be introduced during a procedure, eg opening in the skin, urethra, cannula insertion site; whereas 'Key-Parts' are associated with the equipment that might come into contact with Key-Sites or other Key-Parts, eg, dressings, catheters and syringe tips. These should not be touched or only touched with sterile gloves and sterile equipment.

There are two main variations of ANTT: standard, which is used for uncomplicated, simple and quick procedures involving few Key-Sites or Key-Parts, and surgical, for those skills and procedures that are more complex, lengthy and involve multiple Key-Sites or Key-Parts. When carrying out a clinical procedure, an ANTT risk assessment is required to ascertain if the procedure necessitates the adoption of a standard or surgical ANTT approach. This involves assessing the difficulty of protecting the Key-Parts and Key-Sites associated with the skill, while also considering the number and sizes of the Key-Parts, environment, invasiveness, and user competency ( ASAP, 2021). For standard ANTT procedures, non-sterile gloves can be worn as the Key-Parts and Key-Sites are limited, such as in cannulation and venepuncture. However, for surgical ANTT procedures such as urinary catheterisation and wound care, sterile gloves must be worn, due to the level of invasiveness ( ASAP, 2021).

Informed consent, patient preparation and pain management

Before carrying out venepuncture, and where possible, it is necessary to obtain informed consent. This will include ensuring that patients are aware of the reasons for the need to take samples of their blood, what the associated risks and complications are and details of the procedure and aftercare ( Curr and Fordham-Clarke, 2022). Providing this level of information will not only safeguard that the patient can provide valid consent, but will also assist in building rapport and a trusting therapeutic relationship, which could help reduce any fears or anxieties. It is also imperative at this point to gauge how the patient is feeling about the procedure, as gaining an insight into potential fears, (eg fear of needles - trypanophobia) ( Perry et al, 2021), anxieties or preferences will allow for adequate preparation of the patient and the environment prior to the procedure. This can be achieved by asking questions such as 'Have you had this procedure before?' and 'How do you feel about the procedure?'. Any potential allergies also need to be determined before gathering the equipment, as alternative gloves and dressings may be required.

It is also important to consider not only the patient's comfort but also the potential to increase their pain, thus appropriate multimodal approaches to pain assessment and management need to be undertaken in order to minimise the risks of harm. This can include the use of pharmacological and non-pharmacological approaches such as distraction therapy and topical analgesics ( Ford, 2019).

Anatomy of the arm

When undertaking venepuncture, it is important to understand the anatomy and physiology of the veins, circulation and surrounding structures (arteries and nerves), in order to undertake safe and effective practice ( McCall, 2020). The superficial veins (median cubital, cephalic, and basilic) found in the antecubital fossa region of the arms, are the most commonly selected sites for venepuncture ( Figure 1a), as they are easily accessible and cause minimal discomfort for the patient ( Brooks, 2017). Metacarpal veins ( Figure 1b) can also be used as they are easy to visualise, and palpate; however, the use of these veins may be more painful and difficult in patients with poor skin turgor ( McCall, 2020).

Figure 1. Veins of the arm and hand

Choosing the correct site and vein

Although the arm is the most commonly used site for venepuncture, it is important to assess the most appropriate site for each patient. Factors that influence the decision include patient preference, past medical history, age, current comorbidities, skin condition, vein suitability and accessibility and reasons for use ( Gorski et al, 2021). Additionally, it is essential to consider which arm or limb to use, which vein to select within that limb and then which particular site on the skin (see Table 1).

Table 1. Choosing the correct site

Avoid arms affected by a cerebrovascular accident

Avoid arms impacted post mastectomy or node dissection

Avoid arms affected by lymphoedema

Choose arms/hands with good capillary refill

Choose the non-dominant arm (if this is patient's preference)

Veins which are easily palpable

Veins with largest diameter

Avoid fragile and sclerosed veins

Avoid veins irritated from previous use

Avoid visible valves

Avoid veins with fibrosis

Avoid veins close to arteries

Avoid sites affected by intravenous drug use

Avoid sites with haematomas, oedema, or thrombus

Avoid sites with a fistulae or vascular graft

Avoid areas of inflammation

Avoid areas with burns or scars

Equipment

There is a wide variety of hollow-bore needles and vacuum systems that are available for venepuncture; therefore, it is imperative that you familiarise yourself with the equipment that is used by your trust. See Box 1 for an example list of the equipment that is required.

Box 1.Sample equipment list for venepuncture

Gloves

Apron

Alcohol gel

Procedural tray

Disposable tourniquet

Alcohol-based cleansing product

Needle

Tube holder

Vacuum blood collection tubes

Sterile gauze

Dressing or adhesive tpe

Sharps disposal bin

Request forms (signed, dated and labelled)

Pillow

Source: Lister et al, 2021

Blood collection tubes and order of draw

Traditionally, blood samples were obtained by needle and syringe, but advances in technology and medical devices led to this being superseded by vacuum blood collection tube systems ( Blann and Ahmed, 2014). These glass or plastic tubes contain a partial vacuum, which encourages the movement of blood from the vein into the tube, and the amount of vacuum present will determine the amount of blood required within the container ( Lister et al, 2021). The tubes also contain additives, such as anticoagulants (eg, sodium citrate, lithium heparin) or substances to allow a serum sample to be obtained, and which additive is used is dependent on which analysis techniques are to be conducted in the laboratory ( Blann and Ahmed, 2014). In order to mix the blood with the contents, the tubes must be inverted, and the number of inversions will depend on the manufacturer's instructions ( Lister et al, 2021). It is also essential that the additives within the various tubes are not mixed with each other and therefore if more than one tube is to be used, these must be used in a specific order ( Thomas, 2015). Higgins (2013) suggested that within the blood analysis continuum, errors during the collection of the samples are where the most errors occur. Order of draw protocols should, therefore, be adhered to.

Tourniquets

In nursing practice, tourniquets can be used as a means of maximising successful attempts on first insertion (Shaw, 2014). Several types can be found in practice, these should be disposable, easy to use and latex-free ( Lister et al, 2021). When applying the tourniquet, it is also imperative that it is removed as soon as possible (not exceeding 60 seconds) as the tourniquet will cause venous stasis, localised acidaemia and haemoconcentration, which affect the blood for analysis ( Higgins, 2013; Pagana et al, 2020). Consequently, Gorski et al (2021) do not advocate the use of a tourniquet, stating that it should be avoided if possible. Therefore, practice may differ, and it is imperative that you abide by local trust policy when deciding if a tourniquet is to be used.

Site preparation

Although there is some controversy about whether skin cleansing of the site is necessary, the Infusion Nurses Society guidelines ( Gorski et al, 2021) state that skin antisepsis should be performed prior to all venepunctures to prevent the risk of infection. It can be prepared with a cleansing agent that is alcohol-based, such as 70% isopropyl alcohol or 2% chlorhexidine in 70% alcohol ( Loveday et al, 2014). The technique for how the skin should be prepared must be in accordance with the manufacturers' instructions, which will be specific to the products being used.

Risks and hazards

As with any clinical procedure, the trained health professional must be aware of the risks involved, for themselves, the patient and others. Further details in relation to blood-borne infection, sharps safety, phlebitis, arterial puncture and extravasation can be found in the accompanying article entitled 'A guide to cannulation in adults' ( Ford, 2023).

Safety of the practitioner

One of the greatest dangers to health professionals when undertaking procedures using hollow-bore needles is the risk of contracting a blood-borne infection via a sharps injury ( Health and Safety Executive, 2013). Due to the frequency of undertaking venepuncture, nurses are one of the health professional groups most at risk ( Woode et al, 2015). Health professionals can be exposed to 30 potentially dangerous pathogens, including hepatitis B and C ( European Biosafety Network, 2011). Therefore, in order to ensure safe practice, personal protective equipment (PPE), which is a universal precaution, must be worn. Kinlin et al (2010) claimed that the use of gloves has been shown to be beneficial in reducing the transmission of blood-borne infections by decreasing the inoculum of blood introduced during a sharps injury. Additionally, all devices used must adhere to sharp safety regulations, must be checked before use, as instructed by the manufacturers and disposed of correctly ( Health and Safety Executive, 2013).

What is the correct procedure for venepuncture?

As health professionals, it is important to work within guidelines and policies and use evidence-based practice ( Nursing and Midwifery Council (NMC), 2018). The use of a standard ANTT for the preparation and performance of the procedure can minimise the risk of contamination and risk of infection ( Loveday et al, 2014):

Communicate with the patient, gain informed consent and ascertain preferences, allergies and fears

Decontaminate hands and gather and assemble relevant equipment (Figure 2a)

Place the limb in a comfortable, accessible position (use a pillow if necessary)

To assess which vein to use, a tourniquet can be used to make the veins more visible. Make sure the tourniquet is appropriately applied 7-10 cm above the chosen site. However, it should only be tight enough to impede venous return and not obstruct arterial flow. Asking the patient to open and close their fist, or using gravity and hanging the patient's arm down, may also encourage venous filling

Palpate with two fingers or the thumb, to find the best available vein (Figure 2b). NB veins do not pulsate

Decontaminate hands and apply PPE (Ford and Park, 2018; 2019)

Clean the chosen site with the alcohol-based preparation equipment and allow it to dry (Figure 2c). Do not re-palpate, as this will increase the risk of contamination

Remove the sheath from the needle and inspect for damage

Warn the patient they will feel a sharp scratch

Use one hand to apply traction on the skin a few centimetres below the site and avoid touching the clean area (Figure 2d)

With the bevel upwards, insert the needle at about a 10-30 degree angle (this will vary depending on the manufacturer's guidelines). Some needle equipment will allow you to see if you are correctly situated in the vein with a visual flashback - if this is not the case, you will have to attach the vacuum collection tube to observe for successful blood flow

Attach the vacuum collection tube to the device connected to the end of the needle (plastic holder) (Figure 2e)

Allow the required blood for that specific collection container to be collected, and as soon as blood runs freely, release the tourniquet (Figure 2f)

Remove the vacuum collection tube and invert as per manufacturer's instructions

Once all the required blood has been obtained, hover the gauze over the needle site (do not press down yet)

Retract the needle and put pressure on the site with the gauze

Click the safety cap (over the needle) with your thumb and dispose of it in the sharps container

Remove PPE, wash hands, label specimens and document the care, noting any witnessed difficulties.

Figure 2. Venepuncture procedure using a vacuum blood collection tube

Top tips

The following information has been collated by Northumbria University staff in relation to some of the common errors that students encounter when undertaking venepuncture.

Missed vein: ensure you use your fingers to anchor the vein, this will stop the vein from moving and will also stretch the skin for better visibility. If you also choose one of the largest veins, then the likelihood of missing the vein will be reduced

Blood spray: ensure you advance the needle tip far enough into the vein, if the tip has entered before the rest has advanced under the skin, you have only achieved partial needle insertion, and leakage may occur. Avoid superficial veins to help reduce the likelihood of this occurring

Blood stops flowing: this is probably due to the angle of insertion or if the tip of the needle has made contact with a valve, the vein wall or if the vein has collapsed. To remedy this, gently advance or reposition the needle

Spatter of blood that then stops: you have possibly pushed the needle too far, and it has exited the vein on the posterior side. Remove the needle and apply pressure

Simulation-based education (SBE) is a widely used teaching method in healthcare education that uses patient simulators, task trainers (such as those used in the images in Figure 2) and virtual technologies. It has been proven to be an effective way to support clinical placement, prepare health professionals for their future work, and address the necessary qualities and proficiencies that nurses and other health professionals need to possess, and improves knowledge and behaviours, particularly related to clinical skills, when compared with traditional training techniques (NMC, 2023).

Conclusion

Venepuncture is a clinical skill, which requires health professionals to have a sound understanding of the underpinning principles, as well as a comprehensive awareness of the technique aligned with the clinical procedure. Therefore, although it is important to review local and national guidelines and associated literature, it is also vital to use every opportunity to practise this skill in clinical practice, in addition to using alternative education and learning strategies such as simulation-training aids, in order to maintain contemporary practice.

KEY POINTS

Venepuncture is a widely practised invasive procedure, which uses an aseptic non-touch technique and requires a sound understanding of anatomy and physiology

This skill is associated with several risks for both health professionals carrying out the procedure and the individual who requires the intervention

For students, the opportunity to practise this skill in clinical practice is sometimes difficult; therefore, alternative education and learning strategies such as simulation can prove extremely beneficial in acquiring and maintaining practice

CPD reflective questions

What anatomical knowledge and patient assessment skills do you need to consider essential before attempting venepuncture? How does this knowledge help in reducing the risks associated with this procedure?

How do you ensure the proper selection and utilisation of equipment, and are there any recent advancements in equipment that you should be aware of and incorporate into your practice?

In your practice, how do you effectively communicate with patients about the procedure, obtain informed consent, and provide them with information about potential risks? How can you improve your patient communication and education regarding venepuncture?

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At a glance: a guide to venepuncture in adults - British Journal of Nursing

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The aseptic non-touch technique (ANTT) is a method employed to minimise the likelihood of patients contracting infections during clinical procedures. As set out by the Association for Safe Aseptic Practice (ASAP) (2021) it accomplishes this by safeguarding 'Key-Parts' and 'Key-Sites' from micro-organisms that might be transmitted from health personnel or nearby environments.

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Tetracaine gel for local anaesthesia – Medicines For Children

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This leaflet is for parents and carers about how to use this medicine in children. Our information may differ from that provided by the manufacturers, because their information usually relates to adults. Read this leaflet carefully. Keep it somewhere safe so that you can read it again.

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Introduction

Your role may involve 'taking bloods' from patients, residents or service users. The technical term for taking bloods is 'phlebotomy.'

This guide explains why phlebotomy is so important. It will explain who can take blood samples, the importance of good training and what this training may involve.

It's aimed at anyone working in health and social care. Even if you're unlikely to take blood samples, you may need to support colleagues or patients, request blood tests or help patients respond to results. So, it's good practice for all staff to understand how and why phlebotomy is performed.

Contents

What is 'phlebotomy'?

How do I become a Phlebotomist?

The need for specialised training

What does phlebotomy training involve?

Workplace competency

Choosing a training provider

Keeping up to date

Sources of further reading

What is 'phlebotomy'?
Definition
Phlebotomy is the practice of obtaining venous blood (i.e. from a vein) samples from patients. You may also hear it referred to as 'venepuncture'. Venepuncture is a broader term, meaning puncturing a vein to draw blood but also for other procedures, such as to administer an intravenous injection.

Phlebotomy is a routine task in hospitals, GP surgeries, out-patient clinics and other healthcare settings. When obtained, blood samples are sent to a laboratory for testing and analysis.
What sort of things can blood samples help with?
The doctor or nurse who requests the blood sample will specify what tests they want you to take. These can include: full blood count, urea and electrolytes (known as 'U&E's), thyroid function tests etc. Each result is then analysed against the normal range. So, for example, if someone's white blood count is high this can indicate the presence of an infection or something else.

A wide range of medical conditions and illnesses can be diagnosed by investigating the chemical structure of blood samples. It's also a way of measuring and monitoring the progress of some health issues and managing certain medical conditions such as heart, liver or kidney disease or diabetes.
Clinical and care staff using this skill

Until relatively recently it was only doctors and senior nurses who performed phlebotomy. However, over the past couple of decades, changes to everyone's roles mean that phlebotomy is now routinely carried out by all grades of nurses and health care assistants.

Other clinical staff able to take bloods may include student nurses, associate nurses, trainee phlebotomists, and medical students. There will also be times when phlebotomy is carried out by paramedics, and trainee paramedics.

However, there are also specialists who focus specifically on this procedure. They are known as 'phlebotomists'.

Phlebotomists carry out venepuncture procedures for a variety of purposes, including taking blood samples from children (paediatrics), Glucose Tolerance Tests (known as 'GTTs') and inserting cannulas. They are usually skilled at finding a vein in a challenging situation!

Phlebotomists are usually trained on the job. So, if this is something you want to specialise in, you should apply for a position as a trainee phlebotomist, e.g. in a hospital or GP surgery.

The minimum age to start training is usually 17.

How do I become a Phlebotomist?
Qualifications and skills needed
There are usually no entry requirements, though some employers may ask for at least two GCSEs (or equivalent). Some employers and trainers require a BTEC or equivalent vocational qualification in health and social care, or previous healthcare experience, e.g. as a healthcare assistant.

As you will be working closely with patients, relatives and other healthcare staff you will need to be:

Kind and caring

Good with people

Patient

Organised

A good communicator

Able to work as part of a team

Follow instructions

Explain procedures in simple terms to others

As part of your workplace training you will attend a specialist training course where you have the chance to learn the knowledge and skills you will need for your role. Let's look at the training in more detail, and why it's so necessary.

The need for specialised training

Even though phlebotomy is often considered a routine procedure, it is still important that you are trained properly.

As with all clinical procedures, there are risks and complications if phlebotomy is not carried out carefully. This is largely because you are puncturing not just the patient's skin but also the vein. This is known as an 'invasive' procedure.

Important aspects of the role include knowing how to minimise discomfort, pain or distress for your patient as well as reducing the risk of infection - for you as well as your patient.

Training helps you learn the skills needed to draw blood smoothly, minimise the risks and manage the patient's response.

According to guidelines issued by WHO (World Health Organisation), before undertaking phlebotomy, health workers 'should be trained in, and demonstrate proficiency for, the blood collection procedures on the patient population that will be within their scope of practice.'

If you are a registered nurse, paramedic, doctor etc you will have a professional accountability when undertaking - or delegating- this skill. This requires you to have the knowledge skills and competency to perform the role.

You may also have to take refresher trainer if:

You haven't performed phlebotomy for a while, e.g. after a career break or change in role.

You lack confidence or demonstrate a lack of competence.

What does phlebotomy training involve?

Though you will be expected to develop competence in phlebotomy in a real clinical environment, it all starts with understanding the theory behind it. And practicing skills in a training environment.
Theory
Phlebotomy theory training looks at:

The anatomy and physiology of veins in the human arm and leg, and how to decide which one to use.

Infection control.

Which equipment and technique to use for which category of patient or purpose.

How blood clotting works.

Communication and patient preparation.

Preparing the room and your workspace.

Safe handling of 'sharps' (items that may cut or puncture your skin, such as needles).

How to prevent needle stick injuries (when you accidentally scratch or puncture the skin on yourself of a patient).

What to do if there is a needle stick injury.

Contra-indications for venepuncture - which means when it would be unsafe to proceed, or when special measures are required to minimise risk.

Any potential complications and what to do.

Correct labelling and reporting requirements.

Practical training
Once you're familiar with the theory, you will be given supervised opportunities to gain practical skills in phlebotomy.

To start with, you may practise on a special dummy patient (mannequin). You will need to talk through what you're doing to demonstrate your knowledge to your mentor.

Following this, you would be given opportunities to draw blood from live patients, under close supervision.

Specialist training
Depending on where you work, you may be trained specifically in phlebotomy related to your field. So, this could be drawing blood for paediatric, neonatal and intensive care, or for blood transfusion purposes, for example. This would also dictate how long your supervisory period extends before you can take bloods independently.

If you're training to be a phlebotomist, your course would be far more comprehensive. You would need to demonstrate competency across various venepuncture techniques.

Workplace competency

Having completed the theory and practical elements of your training, the next stage would put your new skills to use on a ward or in other clinical setting. You will work under the supervision or a skilled and qualified mentor (e.g. senior nurse). This is referred to as a 'workplace competency assessment'.

During this time your performance is measured against agreed competency frameworks. That means the standards that have been agreed for phlebotomy in your health field.

Your mentor will use this time to help perfect your skills. For you, the workplace competency assessment is a chance to ask questions and benefit from constructive feedback.

The sort of thing your mentor would be looking at, includes:

Whether you understand relevant legislation, national guidelines, organisational policies and protocols that relate to taking blood samples.

Your grasp of accountability, and your duty to report any problems.

The correct way to take blood samples to ensure all risks - particularly infection - are managed and controlled.

The type and function of different blood collection systems.

Your ability to recognise and respond to common adverse reactions and things that could go wrong during blood sampling.

How you prepare your patient, manage their experience and provide information on caring for the puncture site.

Choosing a training provider

If you want to enrol on a phlebotomy training course, this section will help you to decide which one best meets your needs.

If you're applying for training through an employer, they are required to carry out due diligence, meaning they must ensure the training provision is appropriate.

If you're considering using an external training provider, you should base your choice on such things as:

Cost: what do you get for your money?

Syllabus content - does the course cover the essential information laid out in the WHO guidelines on drawing blood: best practices in phlebotomy?

Will it prepare you to meet the Skills for Health: Standard for obtaining venous blood samples?

Certification - has a relevant professional body endorsed the course completion certificate?

Quality - does the training provider have proper accreditation and evidence of their quality assurance plan?

Qualifications of trainers - are they accredited in this field from an appropriate health related organisation?

CPD - will the course help you acquire CPD hours and meet your revalidation requirements?

Reviews - does the training provider have testimonials from previous trainees?

Keeping up to date

As with any clinical skill it is important that you keep up to date with any changes to local and national guidance. You may want to consider subscribing to relevant professional newsletters as well as networking with other colleagues who routinely perform venepuncture.

Reflecting on your own practice is an important aspect of your CPD. Not only is this mandatory for some professionals (e.g. nurses) but it can help you learn and develop.

If you are a phlebotomist, you can become a member of the National Association of Phlebotomists (NAP) or associate members of the Institute of Biomedical Science (IBMS). These provide information on good practice and news of developments in this field.

You could also network with colleagues who routinely perform venepuncture to stay updated.

Sources of further reading
National Association of Phlebotomists FAQ Step into the NHS: phlebotomist Health careers: phlebotomist

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The Ultimate Guide to Phlebotomy Training | Skills for Health

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This guide explains why phlebotomy is so important. It will explain who can take blood samples, the importance of good training and what this training may involve.

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I have been training GPs in life support for 20 years and have always striven to deliver relevant and resonant training. Over the past 2 years I have been applying some new techniques underpinned by the simulation teaching I have received as a Resuscitation Officer and found that these have transferred naturally into the GP treatment room.

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Chaperoning is the process of having a third person present during such consultations to:

provide support, both emotional and sometimes physical to the patient.

to protect the doctor against allegations of improper behaviour during such consultations, and sometimes to provide practical support.

Scope of Guidance

This policy applies to all healthcare professionals working within the organisation, including medical staff, nurses, health care assistants, allied health professionals, medical students, and complementary therapists working with individual patients in surgeries, clinic situations and in the patient's home. This guidance also covers any non-medical personnel who may be involved in providing care.

When, and How, Should a Chaperone be Offered?

Information concerning the availability of chaperones is made to patient by:

Signs in each consulting and treatment room
Chaperoning information on practice website, patient information leaflet and registration pack

It will only be apparent that a chaperone will be necessary once the consultation is started. The triggers that make the offer of a chaperone necessary include:

when an intimate examination is deemed necessary. This offer should be accompanied by an explanation as to why the examination is required.

when an examination which is not intimate, but involves close proximity, physical contact or dim lighting is necessary and the clinician is concerned that a chaperone is necessary; this may be to protect him/herself, or if the patient is particularly vulnerable or at risk.

whether the patient and clinician are the same sex or not is not relevant; an offer of a chaperone should be made regardless. However, if the sex of both parties is the same it is likely that the clinician will less frequently consider themselves to need a chaperone present to proceed as the risk of allegation is reduced, though they must be aware it is by no means absent.

During the Consultation in Which a Chaperone is Required

It is important to provide an environment in which the patient feels relaxed, and is given privacy to undress in preparation for the examination.

Prior to examination, the patient must be given a full explanation of the reason for the examination and what will be done and if possible how it will feel.

There should be no undue delay prior to examination once the patient has removed any clothing.

During an intimate examination

Offer reassurance

Be courteous

Keep discussion relevant

Avoid unnecessary personal comments

Encourage questions and discussion

Remain alert to verbal and non-verbal indications of distress from the patient

Intimate examination should take place in a closed room or well-screened bay that cannot be entered while the examination is in progress.

Where appropriate a choice of position for the examination should be offered for example left lateral, dorsal, recumbent and semi-recumbent positions for speculum and bimanual examinations. This may reduce the sense of vulnerability and powerlessness complained of by some patients.

Once the patient is dressed following an examination or investigation the findings must be communicated to the patient.

Any requests that the examination be discontinued should be respected.

Who Can Be a Chaperone?

A friend or relative of the patient is in inadequate chaperone - they are neither trained nor independent; however in reality the clinician may well appropriately feel that their presence will reduce the risk of allegations, and may therefore allow an examination to proceed even if a chaperone is offered and declined; but a chaperone should still be 'offered'.

An appropriate chaperone is otherwise any member of the Care Navigator team; all are trained appropriately and have a DRB check - both are requirements for them to be a chaperone.

The chaperone should be the same sex as the patient; otherwise the patients anxiety and risk of allegation will increase.

Role of the Chaperone

Their role can be considered in any of the following areas:

1. Providing emotional comfort and reassurance to patients

2. To act as an observer of the examination to protect the clinician from false allegation.

3. Empowered to alert their line manager should they feel any improper behaviour has occurred.

If the clinician requires practice assistance during the examation, for example during a coil insertion, they should request an HCA or nurse to support them, and that person would then provide both practical and physical support as well as implicity acting as a chaperone. In this case, they may be a differing sex from the client, but as they are providing a clinical function this is acceptable - a full explanation needs to be given to the patient and their agreement obtained.

The chaperone should introduce herself/himself to the patient giving her name and explaining that she is a member of the Practice who has received training to act as a chaperone. The two parties should have a short conversation between themselves to ensure there is clear understanding of the role and expectations.

Recording of Chaperone Offers

Whenever the clinician feels a chaperone may be necessary, it should be offered.

Whenever the offer is made, that fact should be recorded on EMIS, together with either the fact that it was declined, or the name of the person performing the role of chaperone entered in the associated free text box.

If the offer is declined, but the clinician feels they are at risk without a chaperone being present, it is appropriate and correct them to:

further explain why a chaperone is necessary and re-offer one

refuse to proceed with the examination and ask the patient to rebook with a clinician of the same sex; this is the best possible scenario for the examination to be safely performed, but even then it may be that a same sex clinician will also feel a chaperone is necessary and again decline to proceed; these cases must be dealt with individually, but the clinician has no obligation to proceed with an action which he is uncomfortable in doing. The patient insisting it is done is not a sufficient justification to put clinicians at risk. All these decision processes and explanations must be recorded on EMIS.

The only exception to this is if there is an urgent medical need for the examination to proceed - in this scenario patient safety may and should override clinician's assessment of their own risk.

Where a Chaperone is Needed But Not Available

If the patient requests a chaperone, but an appropriate one is not available, the appointment should be re-booked at a time when one is available. The only exception is when there is urgent clinical need - this should be explained to the patient and alternate actions taken (for example referral to AEU).

If the doctor wants for whatever reason a chaperone to be present, but one is not available, then again the appointment should be re-scheduled unless there is overriding medical need when each case should be taken individually (again referral to AEU could be considered), or the clinician may consider the clinical need overrides his own risk to exposure.

Careful recording of all decision making processes must be made.

Issues of Consent

Consent may be implicit in attending a consultation - for example, a patient attending with a breast lump may reasonably be assumed to expect a breast examination. However, it is always prudent to obtain consent after explanation before all intimate examinations. Verbal consent is sufficient.

The clinician may assume that the patient is seeking treatment and therefore consenting to necessary examinations. However before proceeding with an examination, healthcare professionals should always seek to obtain, by word or gesture, some explicit indication that the patient understands the need for examination and agrees to it being carried out. Consent should always be appropriate to the treatment or investigation being carried out.

The clinician must however be aware that:

an assessment of capacity may occasionally be necessary to ensure consent is valid.

that if consent is given, either actual or implied, this is nothing to do with the offer of a chaperone. A patient may consent to an intimate examination, but still request, assume or prefer a chaperone to be present so a chaperone offer should still, always, be made.

Special Circumstances

If there are medico-legal reasons for the examination, for example after alleged assault, or perhaps because of abuse, the clinician should be aware that written consent may be necessary for the examination to be valid. The clinician should make appropriate enquiries first.

This will be an unusual and rare occurrence.

Issues Specific To Children

In the case of children a chaperone would normally be a parent or carer or alternatively someone known and trusted or chosen by the child. Patients may be accompanied by another minor of the same age. For competent young adults the guidance relating to adults is applicable.

The age of Consent is 16 years, but young people have the right to confidential advice on contraception, pregnancy and abortion and it has been made clear that the law is not intended to prosecute mutually agreed sexual activity between young people of a similar age, unless it involves abuse or exploitation. However, the younger the person, the greater the concern about abuse or exploitation. Children under 13 years old are considered of insufficient age to consent to sexual activity, and the Sexual Offences Act 2003 makes clear that sexual activity with a child under 13 is always an offence.
In situations where abuse is suspected great care and sensitivity must be used to allay fears of repeat abuse.

Healthcare professionals should refer to their local Child Protection policies for any specific issues.

Children and their parents or guardians must receive an appropriate explanation of the procedure in order to obtain their co-operation and understanding. If a minor presents in the absence of a parent or guardian the healthcare professional must ascertain if they are capable of understanding the need for examination. In these cases it would be advisable for consent to be secured and a formal chaperone to be present for any intimate examinations.

Further information about confidentiality, data protection and consent can be found at Working Together to Safeguard Children (Department of Health 1999).

Issues Specific to Religion, Ethnicity or Culture

The ethnic, religious and cultural background of some women can make intimate examinations particularly difficult, for example, some patients may have strong cultural or religious beliefs that restrict being touched by others. Patients undergoing examinations should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only that part of the anatomy that requires investigation or imaging. Wherever possible, particularly in these circumstances, a female healthcare practitioner should perform the procedure.

It would be unwise to proceed with any examination if the healthcare professional is unsure that the patient understands due to a language barrier. If an interpreter is available, they may be able to double as an informal chaperone. In life saving situations every effort should be made to communicate with the patient by whatever means available before proceeding with the examination.

Issues Specific to Learning Difficulties/Mental Health Problems

For patients with learning difficulties or mental health problems that affect capacity, a familiar individual such as a family member or carer may be the best chaperone. A careful simple and sensitive explanation of the technique is vital. This patient group is a vulnerable one and issues may arise in initial physical examination, "touch" as part of therapy, verbal and other "boundary-breaking" in one to one "confidential" settings and indeed home visits.

Adult patients with learning difficulties or mental health problems who resist any intimate examination or procedure must be interpreted as refusing to give consent and the procedure must be abandoned, unless the patient has been sectioned. In life-saving situations the healthcare professional should use professional judgement and where possible discuss with a member of the Mental Health Care Team.
The series Books Beyond Words (Gaskell Publications), especially "Looking After My Breasts" and "Keeping Healthy Down Below" may be helpful.

Lone Working

Where a health care professional is working in a situation away from other colleagues e.g. home visit, the same principles for offering and use of chaperones should apply.

In reality it is more likely here that a relative or friend will be available - this person may well be acceptable as a chaperone to both patient and clinician.

Where it is not appropriate or available, or the clinician feels unable to proceed with a formal chaperone, the clinician may need to rebook the visit and return accompanied by, for example, a district nurse or HCA to provide chaperone role, or request the patient attend the surgery at a later date.

If there is an overriding medical need and urgency, then this should take priority, or may cause the clinician to consider an alternative route of disposal such as referral to AEU.

Health care professionals should note that they are at an significantly increased risk of their actions being misconstrued or misrepresented if they conduct intimate examinations where no other person is present, especially in the patient's home. The clinician has every right, except in cases of dire emergency, to protect themselves from such risk.

Communication & Record Keeping

Details of the examination including presence/absence of chaperone and information given must be documented in the patient's medical records.

If the patient expresses any doubts or reservations about the procedure and the healthcare professional feels the need to reassure them before continuing then it would be good practice to record this in the patient's notes. The records should make clear from the history that an examination was necessary.

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Written by two prolific authors, this book deals with a variety of issues common in the target areas of practice. There are 6 main sections including a detailed analysis of assistive equipment and problem-solving scenarios. Flow-charts assist with various issues such as decision making for single-handed care, transferring a client with one or two carers and moving a client from the floor etc.

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Welcome to the PCDC Course Booking Portal. We are a not-for-profit organisation offering training courses and programmes for those working in primary, secondary, community and private healthcare and social care.

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Welcome to the PCDC Course Booking Portal. We are a not-for-profit organisation offering training courses and programmes for those working in primary, secondary, community and private healthcare and social care. On this portal you can view our upcoming courses, apply for a course and manage course booking(s).

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