Performing venesection in a person with a learning disability
Intended for healthcare professionals
CPD    

Free Performing venesection in a person with a learning disability

Joanne Blair Lecturer, School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland

Why you should read this article:
  • To refresh your knowledge of the clinical aspects of venesection

  • To increase your awareness of how to make venesection a positive experience for service users

  • To count towards revalidation as part of your 35 hours of CPD, or you may wish to write a reflective account (UK readers)

  • To contribute towards your professional development and local registration renewal requirements (non-UK readers)

People with learning disabilities face challenges in accessing healthcare services, particularly testing, screening and monitoring, which means that common conditions are often missed. Like anyone, people with learning disabilities develop conditions that require diagnosis, assessment and monitoring through the laboratory analysis of blood samples, so learning disability nurses need to be skilled at performing venesection. Obtaining informed consent and preparing the person psychologically and emotionally for the procedure is as important to its success as getting the clinical aspects right. This article discusses venesection in people with learning disabilities, explaining how nurses can support them before, during and after the procedure and describing a step-by-step approach to performing venesection in a person with a learning disability.

Learning Disability Practice. doi: 10.7748/ldp.2022.e2186

Peer review

This article has been subject to external double-blind peer review and has been checked for plagiarism using automated software

Correspondence

j.blair@qub.ac.uk

Conflict of interest

None declared

Blair J (2022) Performing venesection in a person with a learning disability. Learning Disability Practice. doi: 10.7748/ldp.2022.e2186

Published online: 23 June 2022

Aim and intended learning outcomes

The aim of this article is to describe how to perform venesection in a person with a learning disability, including preparing the person for the procedure, undertaking the procedure and providing post-procedural care. After reading this article and completing the time out activities you should be able to:

  • Explain why performing venesection effectively in a person with a learning disability is important.

  • Explain the importance of gaining the person’s consent for venepuncture.

  • Describe ways of supporting the person to anticipate and understand the procedure.

  • Outline the step-by-step procedure for performing venesection in a person with a learning disability.

  • Explain the benefits for the person of reflecting on the procedure with them afterwards.

Key points

  • Venesection is important for monitoring the health of people learning disabilities who may be unable to communicate their concerns or needs

  • The nurse needs to prepare the service user psychologically by explaining venesection and the rationale for it

  • Gaining consent from a service user for venesection entails providing information in a reassuring way

  • Depending on their needs, the service user may require reasonable adjustments such as a longer appointment or sedation

  • Proficiency in venesection is required to perform it successfully and to reassure the service user

  • Listening to the service user’s experience of venesection after the procedure may increase their willingness to undergo healthcare interventions

Introduction

People with learning disabilities face challenges in accessing healthcare services, particularly testing, screening and monitoring (Anderson et al 2013). Even with the introduction of annual health checks (NHS 2022), common conditions are often missed in that population.

Like anyone, people with learning disabilities develop conditions that require diagnosis, assessment and monitoring through the laboratory analysis of blood samples, so venesection is an important clinical skill for nurses working in learning disability settings.

The word venesection is used interchangeably with venepuncture, venipuncture and phlebotomy. The World Health Organization (2010) defined phlebotomy as ‘the act of drawing or removing blood from the circulatory system through an incision or puncture to obtain a sample for analysis and diagnosis’. Venesection, one of the most common procedures in healthcare (Reed et al 2017), supports diagnosis, assessment and monitoring (Shaw 2018) and is particularly important for monitoring the health of vulnerable patient groups, such as people with learning disabilities, who may be unable to communicate their concerns or needs. Venesection has an important role in making an accurate diagnosis, monitoring changes in people’s condition and checking the effectiveness of their treatment.

The health inequities experienced by people with learning disabilities are well documented (McMahon and Hatton 2021) and people with learning disabilities have been shown to die earlier than people without learning disabilities, often of avoidable deaths (Heslop et al 2014, Emerson et al 2016, Glover et al 2017, O’Leary et al 2018, Healthcare Quality Improvement Partnership 2019). Their comorbidities are increasingly managed through polypharmacy (Department of Health 2014, O’Dwyer et al 2017) which can lead to poorer health outcomes (Schoufour et al 2018), so their medicines must be closely monitored, particularly when establishing therapeutic levels.

Staff knowledge, confidence, competence and training in relation to venesection can significantly affect the quality of blood samples taken (Makhumula-Nkhoma et al 2015). Failure to obtain a usable blood sample can impede or delay the diagnosis and treatment of potentially serious conditions. Therefore, it is crucial that learning disability nurses who undertake venesection are competent to do so. Gaining informed consent from the person and reassuring them through adequate preparation is as important to a successful outcome as getting the clinical aspects of the procedure right.

This article describes how to perform venesection in people with learning disabilities and how nurses can support service users before, during and after the procedure. It includes a step-by-step description of venesection in a person with a learning disability. Parents and carers have an important role supporting the person and collaborating with nurses to ensure venesection is performed successfully, but that role is beyond the scope of this article.

Role of learning disability nurses

While people with learning disabilities should be encouraged to use mainstream healthcare services, with reasonable adjustments made where needed, learning disability nurses are often best placed to carry out procedures such as venesection. Learning disability nurses may also have a role in educating others about the needs of people with learning disabilities who undergo procedures such as venesection. Doody et al (2022) emphasised that nurses with specialist skills and knowledge in learning disability are required to ensure people with learning disabilities receive high-quality health services.

It is important to involve service users in their care and in decision-making before, during and after the procedure. Adopting a person-centred approach ensures that attention is paid to the person’s traits and needs and that they receive adequate support. In the UK, the Code: Professional Standards of Practice and Behaviour for Nurses, Midwives and Nursing Associates (Nursing and Midwifery Council (NMC) 2018) states that nurses must act always to treat people as individuals, uphold their dignity, deliver care and treatment effectively and in a timely manner, and encourage and empower each person to make decisions regarding their care. Learning disability nurses are well placed to ensure that people with learning disabilities are afforded the time and dignity to make informed decisions about procedures such as venesection.

It can be useful for nurses who are planning to perform venesection in a person with a learning disability to think of the procedure as encompassing three stages:

  • Preparing the person for the procedure.

  • Performing the procedure.

  • Providing post-procedural care.

TIME OUT 1

Think about a service user in your area of work. Are there any factors that would make it challenging for them to undergo venesection? If so, what are these factors and how could you mitigate them?

Preparing the person for the procedure

Anxiety or distress are natural reactions in anyone undergoing a blood test, but people with learning disabilities may not be able to manage these emotions in the same way as people without learning disabilities usually do. It is important to know how to recognise anxiety or distress in a person with a learning disability and understand how their learning disability affects their reasoning, emotions and reactions. This will assist the nurse in adapting their communication and present venesection in a reassuring way. The person and their family will be reassured to know that the nurse understands the person’s potential communication difficulties, cognitive impairment and sensory issues, and whether they tend to express these through behaviour that challenges, as well as any reasonable adjustments or additional support they may need. It is important to remember that behaviour that challenges is often a way for the person with a learning disability to control what is going on around them and may reflect the fact that they do not possess more usual methods of expressing their needs (McGill 2021). de Winter et al (2011) noted that behaviour that challenges can be caused or exacerbated by ill health.

Optimal preparation is essential to ensure that the person with a learning disability understands the rationale for venesection and what the procedure entails. The time taken for preparation should be based on the person’s specific needs but also on how urgent the blood test is. The nurse will need to:

  • Establish whether the person has communication difficulties, cognitive impairment and/or sensory issues, and whether they may react to the procedure through behaviour that challenges.

  • Determine the person’s understanding of the procedure, whether they understand why it is needed and whether they have had blood taken before.

  • Ask about needle phobia, fear of procedural pain and existing trauma due to a previous negative experience of venesection.

  • Check whether the person has any allergies, for example to latex or plasters. While most equipment is now latex free, irritants such as the adhesive used in plasters may cause an allergic reaction.

Easy-read information or social stories about venesection can be used to explain the procedure. Providing easy-read information can be an effective way of involving the person in decision-making, thereby supporting their right to make their own choices (Adams et al 2018). Easy-read information, however, needs to be tailored to the person’s needs and, depending on their cognitive ability, they may require extra support to understand it and use it appropriately (Callus and Cauchi 2020). Using teaching skills such as ‘teach back’ – where information is presented in small chunks and the person is asked to ‘teach it back’ to the nurse (Klingbeil and Gibson 2018) – can assist in establishing the person’s understanding of the procedure and in identifying aspects that are more worrying than others.

As specialist professionals, learning disabilities nurses are well placed to undertake the listening and teaching elements involved in the preparation stage, ensuring that the person’s perception of the procedure aligns with reality. Price (2022) pointed out the importance of preparing patients for treatment, noting that optimal preparation is beneficial in the short term and can positively influence patients’ attitude to healthcare interventions.

TIME OUT 2

Read about social stories on the Carol Gray Social Stories website (carolgraysocialstories.com/social-stories/what-is-it). How could using social stories assist you in preparing a service user for venesection? If the person rehearses their story out loud – for example explaining why they need venesection and what it may be like for them – what could you learn from this?

Informed consent

Gaining informed consent is essential before proceeding with any healthcare intervention in any setting and with any patient (NMC 2018). However, Goldsmith et al (2013), who undertook a study on informed consent in people with learning disabilities undergoing blood tests in general practice, reported that consent procedures were frequently inadequate.

In the UK, in accordance with the Mental Capacity Act 2005, a person is assumed to have capacity to make decisions about themselves – including consenting to a procedure such as venesection – unless they are assessed as lacking that capacity. This is just as valid in the field of learning disabilities as in any other field of nursing (Adams et al 2018). As explained in the Mental Capacity Act 2005 Code of Practice (Department for Constitutional Affairs 2007), to be considered as having capacity to make a decision the person must be able to:

  • Understand information about the decision to be made.

  • Retain that information in their mind.

  • Use or weigh that information as part of the decision-making process.

  • Communicate their decision (by talking, using sign language or any other means).

The process of gaining informed consent from a person with a learning disability for venesection should include the provision of information about the procedure, the rationale for it and its benefits and risks (Goldsmith et al 2013).

The information, while remaining objective, must be presented in a way that will reassure the person, not frighten them. With some service users this will be a straightforward process, but with others groundwork will be required to prepare them effectively and ensure they are in a position to give informed consent (Adams et al 2018, Malik and Giles 2020). It is important to reassure the person that they can withdraw their consent, and that the procedure can be stopped, at any point.

A step-by-step explanation of the procedure can reassure the person and prepare them psychologically and emotionally, thereby increasing the likelihood of their consent. It can be useful to pause the description between each step to gauge the person’s understanding and respond to their concerns. For example, they might ask ‘will it hurt?’, and the nurse may want to warn them that ‘it may scratch when the needle goes in’ or ‘you will see the blood coming out but you won’t feel it’.

Reasonable adjustments

Disability is one of the nine characteristics protected by the Equality Act 2010, under which public sector organisations are required to make ‘reasonable adjustments’ – that is, they must change their approach to service provision to ensure disabled people are not discriminated against.

Equality for people with learning disabilities does not necessarily mean that they must be treated in exactly the same way as people without learning disabilities (Philips 2019) but rather that they must be treated fairly, which is why the term equity is often used instead of equality.

People with learning disabilities may require reasonable adjustments, for example longer appointments (Guidelines and Audit Implementation Network 2010). The nurse, therefore, needs to determine how to meet the person’s needs in a way that ensures their right to an equitable service is respected, which can be summed up as adopting a person-centred approach to care (MacArthur et al 2015). Depending on the person’s traits and needs, there may be a range of reasonable adjustments that can be put in place to increase the likelihood of a successful outcome and positive experience for the person. If undertaking venesection is essential, for example for diagnostic purposes, but the person is likely to react to the procedure in a way that could pose a significant risk to them and/or to the healthcare professional, sedation may need to be considered as a reasonable adjustment (Wolff and Symons 2013).

Needle phobia and procedural pain

According to McMurtry et al (2015), approximately 10% of the world’s population has some degree of fear of needles, described as a continuum from ‘little fear’ (which can increase anxiety levels) to ‘significant distress’ (which can negatively affect care and potentially lead to suboptimal health outcomes). McLenon and Rogers (2019) noted that the psychological effects of procedures involving needles, such as fear and anxiety, can lead to the avoidance of such procedures. Wolff and Symons (2013) suggested that people with learning disabilities may be at increased risk of developing needle phobia, and in some instances severe needle phobia, since they may be unable to understand the function of needles and only associate them with pain. Further, procedures that have caused pain or discomfort in the past can result in the person experiencing anticipatory distress (Hudson et al 2015, Li et al 2021).

The nurse may need to consider using a pain assessment tool during venesection to monitor the person’s pain levels, so that they can respond appropriately and quickly to the person’s changing needs. Pain assessment tools are routinely used with adults with learning disabilities and/or an inability to communicate verbally (Doody and Bailey 2017). Pascolo et al (2018) advocated the use of pain assessment tools during procedures involving needles performed in children with and without learning disabilities. Relaxation techniques, distraction or topical anaesthetic cream may be useful for managing procedural pain in some patients, but there is little evidence that they are effective in people with learning disabilities (Doody and Bailey 2019, Meindl et al 2019).

Equipment

Equipment should be gathered in advance of the procedure and time should be spent showing it and explaining its purpose to the person. Box 1 lists the equipment required to perform venesection.

Box 1.

Equipment required to perform venesection

  • Tourniquet

  • Alcohol wipe or other appropriate skin cleanser

  • Vacuum tube holder

  • Needles – including spares in case one is damaged

  • Unlabelled blood sample tubes and specimen bags

  • Sharps bin

  • Apron

  • Non-sterile examination gloves

  • Alcohol gel

  • Lint-free gauze

  • Plasters or dressings

(Adapted from Skarparis and Ford 2018)

TIME OUT 3

Watch this video on performing venesection at www.youtube.com/watch?v=SHx_P08m3_Y How do you think the procedure needs to be adapted if the patient has a learning disability? What would you do differently? What would you do that is not shown in the video?

Performing the procedure

Table 1 shows a step-by-step procedure for performing venesection in a person with a learning disability.

Table 1.

Step-by-step procedure for performing venesection in a person with a learning disability

Step Task Rationale
Step 1Wash your hands. The skin should be bare below the elbow to ensure hands and wrists can be washed thoroughlyTo reduce the risk of pathogens on your skin which, in turn, reduces the risk of cross-infection
Put on an apronTo reduce the risk of cross infection
Step 2Ensure blood sample tubes and specimen bags are within easy reach and located on the non-dominant hand sideTo keep the dominant hand free for inserting and supporting the needle while insitu
Ensure the sharps bin is within easy reach and located next to the dominant handTo reduce the risk of needlestick injury
Step 3Check again that the person consents to the procedure and remind them they can withdraw their consent at any pointTo reassure the person that the procedure will be stopped if they no longer want to undergo it
Step 4Check that the person is seated comfortably and ask them to roll up their sleeve or remove clothing that may restrict access to the arm, assisting them if necessary. Support the arm by placing a pillow underneathTo ensure the person is physically comfortable
Step 5Assess the skin and veins in both arms, observing for skin discolouration, bruising, breaks and oedemaTo select a suitable needle puncture site
Select a suitable needle puncture site. The site most commonly used for venesection is the antecubital fossa (the small triangular depression in the pit of the elbow where the humerus is connected to the radium and ulna)The veins in the antecubital fossa are easily accessible and inserting a needle in these veins is less painful for the person than in other areas (Brooks 2017)
Step 6Apply the tourniquet. It should be placed approximately at a four-finger width above the selected site. If the selected site is the antecubital fossa, this is midway up the upper arm (Figure 1)To increase the pressure in the vein
Check the radial pulse. If no pulse is felt, loosen the tourniquetTo ensure the tourniquet is not too tight
Step 7Palpate the veins at the selected site and locate a vein that is bouncy to the touch and refills after being depressed. Take time to select the best possible veinTo ensure the procedure is not unnecessarily prolonged
Remind the person that it can sometimes be difficult to take blood and reassure them that if this is the case the procedure will be stoppedTo assist in alleviating the person’s anxiety or distress
Step 8Release the tourniquetTo decrease the pressure in the vein
Clean the selected site in a backward and forward motion for 30 seconds with the alcohol wipe (or another appropriate skin cleanser) and leave the site to dry for a further 30 seconds. Do not touch the site again after thisTo reduce the risk of pathogens being present on the person’s skin and entering their bloodstream via the needle puncture site
Reapply the tourniquetTo increase the pressure in the vein
Step 9Disinfect your hands with alcohol gelTo reduce the risk of pathogens being present on your skin, which in turn reduces the risk of cross-infection
Once your hands are dry, put on the non-sterile examination glovesTo protect the person and yourself, as recommended by the World Health Organization (2009), since the procedure involves direct patient contact and potential exposure to blood, for example if the puncture site bleeds more than expected
Step 10Remove the needle’s protective cover, Check the tip of the needle to ensure it is not bent or damagedTo prevent unnecessary pain
Step 11Immobilise the vein by applying traction below it. Use light pressure to pull the skin backwards slightlyTo ensure smoother access to the vein
Step 11
Step 12
Explain to the person that they will feel a slight scratchTo prepare the person for the needle prick
Insert the needle at an angle of 30° (Figure 2). The angle of 30° is approximate and will vary slightly depending on the size of the vein and how deeply it is lying in the skinTo reduce the risk of missing or going through the vein
Step 12
Step 13
When you feel the needle has punctured the vein, or when you observe a flashback of blood, reduce the angle of insertionTo reduce the risk of going through the vein
Gently push the needle slightly into the veinTo avoid the needle becoming dislodged. Doing this gently reduces the risk of piercing the vein from side to side and therefore reduces the risk of bruising
Draw blood and collect the samples in the correct order. Always follow local policy regarding the order of blood draw. According to the World Health Organization (2010), the order of blood draw should be as follows:
  • 1. Blood culture tube

  • 2. Non-additive tube

  • 3. Coagulation tube

  • 4. Clot activator tube

  • 5. Serum separator tube

  • 6. Sodium heparin tube

  • 7. Plasma separator tube

  • 8. Ethylenediaminetetraacetic acid (EDTA) tube

  • 9. Oxalate/fluoride tube

To reduce the risk of cross contamination between tubes that contain additives. That risk may be negligible with the use of closed blood sampling systems and vacutainers (Bazzano et al 2021)
Step 14Release the tourniquetTo decrease the pressure in the vein
Step 14
Step 15
Remove the needle and activate its safety mechanism. Immediately dispose of it in the sharps binTo reduce the risk of needlestick injury
Using a clean piece of lint-free gauze, apply firm fingertip pressure to the needle puncture site for approximately one minute or until bleeding stops. The person can do this themselves if appropriate but must be encouraged to keep their arm straightTo reduce the risk of bruise or haematoma formation
Step 16Gently turn the blood sample tubes upside down up to ten times (recommendations vary according to blood sample tube and additives)To ensure the additives are mixed with the blood without causing damage to the blood cells and making the samples unusable
Step 17Label the blood sample tubes with the person’s details while you are still at the person’s sideTo avoid a mix up of samples or patient details. Blood tube samples should only be labelled once blood has been drawn to avoid inadvertent use with the wrong service user

(Adapted from Dougherty 2008, Dougherty and Lister 2015, National Institute for Health and Care Excellence 2017, Skarparis and Ford 2018)

Each step includes a brief description of the tasks involved and the rationale for them. It is important that the nurse is proficient in applying and removing the tourniquet, not only to ensure that the procedure is as smooth as possible, but also because this will reassure the person, so time should be dedicated to practising this skill.

TIME OUT 4

Imagine you have successfully performed venesection in a service user. What, in your view, are the benefits to the person of reflecting with you on the procedure?

Providing post-procedural care

Once the procedure has been completed, it is essential to ensure the person’s comfort and peace of mind by allowing them time to compose themselves, offering to assist with readjusting clothing, asking them how they feel and complimenting them on how well they have done. That time can also be used to reflect on the procedure with the person, give them an opportunity to explain how they felt and discuss any further concerns.

Making the person feel listened to and understood, and reassuring them that the procedure has been successful, may increase their confidence and willingness to undergo healthcare interventions in the future. The nurse will also need to observe the puncture site to ensure the bleeding has stopped and explain to the person that there may be some bruising. Involving the person in deciding whether to apply a plaster or dressing – which is not necessarily needed – can increase their sense of being in control.

Once the nurse is certain that the bleeding has stopped and the person is comfortable, they can remove their gloves and dispose of waste. The blood tube samples must be placed in the correct specimen bags and left at the appropriate collection point as per the local policy.

Conclusion

When working with people with learning disabilities, the clinical aspects of a procedure such as venesection are often more straightforward than the psychological and emotional preparation of the person. People with learning disabilities may be anxious at the idea of undergoing venesection and they may find the procedure painful or distressing.

Getting to know the person and understanding their traits and needs will enable learning disability nurses to make reasonable adjustments to reduce the person’s anxiety, pain or distress and make the procedure a positive experience. These steps will ensure that the blood test is successful, potentially improve treatment and outcomes for the person and positively influence their attitude to healthcare interventions.

TIME OUT 5

Identify how performing venesection in people with learning disabilities applies to your practice and the requirements of your regulatory body

TIME OUT 6

Now that you have completed the article, reflect on your practice in this area and consider writing a reflective account: rcni.com/reflective-account

Figure 1.

Tourniquet placement

ldp.2022.e2186_0001.jpg
Figure 2.

Needle insertion

ldp.2022.e2186_0002.jpg

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