1. CAPILLARY BLOOD SAMPLING
AND VENEPUNCTURE IN
CHILDREN AND YOUNG PEOPLE
A WORKBOOK TO ASSIST PRACTITIONERS IN DEVELOPING
COMPETENCE

2. Acknowledgements
We would like to thank the NHS Modernisation Agency for sponsoring the development of this
framework. We are grateful to the following people for their assistance:
Expert Group
Karen Bravery, Practice Development Nurse/Nurse Practitioner, Great Ormond Street Hospital
for Children NHS Trust
Pauline Brown, Lead Nurse IV Therapy, Royal Liverpool Children’s Hospital NHS Trust
Annette K. Dearmun, Lecturer Practitioner, Oxford Radcliff Hospitals NHS Trust
Alison Hegarty, Teacher Practitioner, IV Therapy, Central Manchester and Manchester
Children’s Hospital NHS Trust
Louise Mills, Nurse Practitioner for Intravenous Therapy, Great Ormond Street Hospital for
Children NHS Trust
Sally Ramsay, Nursing Adviser, Ramsay Consulting Ltd
Jo Rothwell, Lead Nurse, IV Therapy, Central Manchester and Manchester Children’s Hospital
NHS Trust
Jane Willock, Senior Lecturer, School of Care Sciences, University of Glamorgan / Practice
Educator – Paediatric Nephrology, Cardiff and Vale NHS Trust
Review group
Anne Casey, Royal College of Nursing
Fiona Smith, Adviser in Children & Young People’s Nursing, Royal College of Nursing
We are also indebted to the following hospitals whose training programmes and other materials
were helpful in developing this document:
Central Manchester and Manchester Children’s University Hospital NHS Trust
Bolton Hospitals NHS Trust
Great Ormond Street Hospital for Children NHS Trust
Hull and East Yorkshire Hospitals NHS Trust
Nottingham City Hospital NHS Trust
Oxford Radcliffe Hospitals NHS Trust
University Hospital of Leicester NHS Trust
Royal Free Hospital NHS Trust
Royal Liverpool Children’s Hospital NHS Trust.
University College London Hospital NHS Trust
University Hospital of Wales, Cardiff and Vale NHS Trust

3. Introduction
This workbook should assist practitioners in developing the knowledge that
underpins safe practice in performing capillary sampling and venepuncture in
children and young people. It should be used in conjunction with the document
Capillary Blood Sampling and Venepuncture in children and young people: An
education and training competency framework (RCN, 2005) and form part of a
programme of learning.
In view of the considerable differences between children of varying ages we
recommend that practitioners develop their competence within specific age
bands according to their area of practice - 0-1 year, 1-5 years, 5 years and
above.
Aims and objectives
To assist practitioners to develop the underpinning knowledge to perform
capillary blood sampling and venepuncture in children and young people
competently
To assist practitioners in identifying gaps in their knowledge where further
study is needed
To assist educators in assessing knowledge and competence.
How to use this workbook
Having blood taken can be a very painful and frightening experience for
children. However, with appropriate preparation and support children can learn
how to cope, and their fear and anxiety can be minimised. This workbook has
its basis in some of the key learning outcomes described in the document
Capillary Blood Sampling and Venepuncture in Children and Young People: A
Competency Framework for Education and Training (RCN, 2005). In each
section there is a brief introduction to the issues followed by self-directed
activities for the student to undertake.

4. PROFESSIONAL AND LEGAL ISSUES
The ability of a nurse to perform capillary blood sampling and venepuncture
can be beneficial to the child or young person. It can result in care being less
fragmented and treatment given in a timely manner. Before training to perform
this enhanced role you should ensure that other aspects of the care you give
to children and young people will not be compromised. The Code of
Professional Conduct (NMC, 2004), Guidelines for Records and Record-
keeping (NMC, 2005) and your trust’s policies and procedures will assist you
in understanding and exercising your professional accountability as you
develop your skills in peripheral venous cannulation.
Activity 1
Read The Code of Professional Conduct (NMC, 2004) and your employer’s
policies related to nurses performing capillary blood sampling and
venepuncture.
Describe what you understand by the term “accountability” when applied to your
actions in taking blood samples from a child or young person.
Describe a situation where it would be inappropriate for you to perform this
procedure.
Gaining consent
Any informed and competent person can authorise a medical procedure once
the implications, side effects and alternatives have been appropriately
explained. Age is not necessarily a major factor for informed consent (British
Medical Association, 2001), and if children are competent to give consent, you
should seek consent directly from them (DH, 2001b). It should not be assumed
that children with learning disabilities are not competent to make decisions;
many children will be competent if information is presented in an appropriate
way (DH 2001b). In most situations it is desirable to have the parent’s consent
in addition to the child’s consent. Consent can be verbal, written or implied by
the child’s actions, such as holding out an arm ready to have blood taken.
Children sometimes refuse to have blood taken because of anxieties over pain
during the procedure, or the thought of the needle going into their arm, rather
than refusal to have the test performed on their blood.
Genuine refusal of treatment is based on awareness of the implications (BMA,
2001), rather than short term discomfort. Where the refusal appears
consistent, valid and informed, but would be likely to result in serious and
avoidable damage to the young person’s health, legal advice should be sought
(BMA, 2001). It is also important to think about the ethical implications – which
course of action will cause the least harm and the most benefit for the child.

5. For a child to be able to consent to a procedure, they must be allowed to
participate in decision making. Encouraging children to make decisions by
giving them information and explanations, and respecting their thoughts takes
more time than just telling them what’s going to happen, and the time factor is
often used as an excuse for not adequately preparing children. However, the
procedure itself may take longer and cause more distress if the child is not
prepared, and their wishes have not been taken into account.
You should explain to the child and carer why the blood needs to be taken.
Ensure verbal or implied consent has been given (written consent is required if
the blood is to be used in research studies). The Oxford Reference Dictionary
(1986) defines consent as “to express willingness or agree (to), to give
permission, voluntary agreement”. Consent must be given willingly, without
duress, force or fraud (Dimond, 1996).
For children to willingly allow someone to do something to them that is
uncomfortable or painful, they must be able to control their anxiety, and trust
the person performing the procedure. Preparing children for procedures and
telling them the truth decreases their anxiety (Price, 1995). Conversely,
withholding information regarding illness and treatment does not protect the
child, they tend to come to conclusions on their own (Perry, 1994) and this can
be more frightening than reality (Action for Sick Children, 1994). In order to
prepare a child for a procedure, they must be given honest factual information
about the procedure so that they have an understanding of what will happen to
them, and what their role is.
Children younger than eight years of age can understand and make logical
decisions about life-changing therapy (Alderson & Montgomery, 1996). In
keeping with the philosophy of partnership in decision making with the child,
and in encouraging their developing autonomy, the child should be informed of
treatment plans, and his or her decisions should be taken seriously
(Brykczynska, 1987).
Activity 2
Think about a child in your care who has had blood taken.
What steps were taken to ensure that the child understood the procedure and
was able to give consent?
PREPARING SELF, CHILD AND FAMILY
Generally younger children respond to painful procedures with more distress
than older children (Broome 1990). They mainly perceive pain as a physical
experience and are generally unable to develop their own psychological
coping mechanisms. These children need their parents and health
professionals to help them cope by providing distraction and comfort as well
as topical pain relief. Older children start to have an understanding of the

6. reasons for blood tests, have greater physical control, and are able to develop
psychological coping mechanisms (Twycross, 1998).
Children’s temperament can play a part in their responses to venepuncture
pain, and influence parents’ decisions to prepare them for painful experiences
(Lee and White-Traut, 1996). Children who are more adaptable and positive in
mood tend to be better prepared than more anxious children, possibly
because parents are hesitant to evoke unpleasant reactions from their
children.
For many children, the fear of needles is the most worrying aspect of attending
hospital. A proportion of children display high levels of fear, pain and
behavioural distress (Duff, 2003). As a nurse you play a major part in
assessing the child’s anxiety and taking steps to minimise any distress.
You can do this by first introducing yourself to the child and carer when you
check identity of the child. Then talk to the child to find out their developmental
maturity and understanding. This is important in planning how to approach the
child when taking blood.
Find out whether the child has had blood taken before. If he/she has, ask them
how they felt about it previously. If this is the child’s first time, find out how the
child responds to injury situations, such as grazes and scratches as this can
be a useful guide to how the child will respond to venepuncture (Goodenough
et al., 2000). Smalley (1999) suggests ways of assessing how the child will
react to having blood taken (box 1); this can provide information when
preparing the child for the procedure.
Box 1
Assessing the child’s coping skills (Smalley 1999).
• How much the child understands about the procedure
• If there are any factors that might influence the child’s level of anxiety
• What previous experiences of needle procedures has the child had
• The child’s social support system / family coping style.
• The child’s cognitive/developmental level
• The child’s coping style and how he/she perceives his or her ability to cope
with the situation.
Activity 3
Describe how you personally cope with unpleasant procedures like going to
the dentist. Compare your coping mechanisms with those of a 3 year old and
an 8 year old.

7. Unless play preparation is required, assessment of the child’s coping
behaviour should not take too long as the anticipation phase of the
venepuncture is the worst part of the procedure for some children (Caty S,
Ellerton ML and Ritchie JA, 1997). Providing information is important so that
the child will know why the procedure is needed and what he or she will see,
feel, hear and smell. If the procedure is more painful than the child expects,
this may lead to anticipatory anxiety with future procedures. For young
children you may need to show them on a teddy or doll and allow them to play
with safe equipment. Children with extreme anxiety should have the procedure
postponed if it is not urgent, in order to spend some time with the play
specialist or child psychologist, getting used to handling safe blood taking
equipment and working through their fears with dolls and teddies.
Needle phobia
‘Needle phobia is a term used in practice to describe an anticipatory fear of
needle insertion.’ (Thurgate C, Heppell S, 2005). If pain and anxiety are poorly
managed, there can be significant negative consequences. The child’s
memory of traumatic venepuncture experiences can lead to extreme anxiety
and physiological responses such as venous constriction during later
procedures (Vessey JA et al., 1994). Although in many people needle phobia
can be traced to a negative experience they had when they were younger,
some children and young people may have been conditioned by the fears of
relatives or friends concerning needle procedures (Smalley 1999). Children
who display signs of needle phobia should be referred to a play specialist and/
or child psychologist.
Restraint
If a child is wriggling and screaming, you can assume they have not consented
to the procedure. Restraining a child means forcefully holding them against
their will; holding a child still is done with their cooperation, and some children
feel more secure when they are gently held. Being restrained can be more
distressing for a child than the pain involved in the procedure (Collier &
Robinson 1997). Restraining a child for venepuncture should be the last
course of action envisaged for an essential and urgent sampling of blood, or
establishment of venous access. When the rights of the child are considered it
becomes clear that alternatives to restraining should be available and used
(Royal College of Nursing, 2003b). Only when the child’s safety and well-being
may be compromised by delay should restraining be the preferred option.
When appropriate, nurses and parents may gently hold a child’s arm in
position during venepuncture and this, in conjunction with other techniques,
may be comforting for the child as well as help to ensure the child’s safety. If
holding the child still is ever undertaken, its ill-effects may be minimized by
preparing the parent and child as far as possible in the situation. The child can
also subsequently be given further information and offered the chance to
discuss events so that they may be able to begin to make sense of what has
occurred. Very young children can be held securely, but not too tightly.

8. Wrapping a young child or infant in a light blanket while cuddling and talking to
them may be comforting as well as providing effective restraint.
On occasion, in the intractable but non-urgent situation, sedation might be
considered as a safe and alternative technique (Scottish Intercollegiate
Guideline Network, 2002).
‘All healthcare staff working with children should understand the importance
and benefits of distraction techniques and know how to use them effectively.
They are not interventions to be carried out just by a play specialist.’ (Pearch,
2005)
Activity 4
Find and read two articles about restraining children. This should include the
document Restraining, holding still and containing children (RCN, 2003)
Describe the steps you would take to keep a five year old still during capillary blood
sampling or cannulation.
Pain relief
You should take active steps to reduce any pain during capillary blood
sampling or venepuncture.
Ametop gel and Emla cream
Other than in emergency situations where time is important, local anaesthetic
cream should be offered to all children and young people. Ametop gel and Emla
cream are two preparations providing local anaesthesia. They act by causing a
reversible block to conduction along the nerve fibres. Both should be applied in
accordance with the manufacturer’s instructions.
Emla is not licensed for use in children under 1 year, whereas Ametop is licensed
for use in children over who are 1 month older than their expected date for
delivery.
For both Emla cream and Ametop gel a thick layer should be applied to intact skin
and covered with an occlusive dressing, preferably by the person performing the
procedure in order that the appropriate sites can be identified. Side effects can
include erythema, itching and oedema of the site.

9. Emla cream should be applied at least 60 minutes before the cannula is inserted.
It is effective for up to 5 hours, but this only lasts for 10 – 20 minutes after
removing the cream.
Ametop gel should be applied 30 minutes before anaesthesia is required for
venepuncture. It must be removed after 45 minutes, although its effect will last for
4 - 6 hours.
Ethyl Chloride
Nerve impulses cannot be generated in an area of skin cooled to below 10°C,
however, adjacent pain receptors are stimulated which produces the sensation
of freezing. The application of a cold substance to the skin (e.g. ice or ethyl
chloride spray) can act as a local anaesthetic (Tortora, 1997). Ethyl chloride
when sprayed onto the skin for 5 - 10 seconds quickly evaporates and cools
the skin down to below 10°C. However, it is not recommended for use in
children under the age of five.
If you ask the child, they will usually tell you when their skin is cold and numb
enough. Armstrong P, Young C, and McKeown D (1990) recommended ethyl
chloride as a method of producing instant skin anaesthesia and DeJong et al.
(1990) reported that its efficacy when used for peripheral intravenous
cannulation in children is comparable with Emla cream.
There have been reports of solvent abuse with ethyl chloride (Broussard et al.,
2000, Yacoub et al., 1993) leading to confusion, hallucinations, ataxia, short
term memory impairement, cardiac dysrhythmias, respiratory arrest and death.
Care should be taken to avoid inhalation, and it should be stored in a secure
place.
Nitrous oxide (Entonox®)
Although distraction techniques and topical anaesthesia are more usual for
relieving the distress of venepuncture, in some cases nitrous oxide has been
shown to be effective. However, Nitrous oxide mixture is reported to be less
effective for pain relief during venepuncture in children under the age of four
years, than in older children (Gall O, Annequin D, Benoit G, Glabeke EV,
Vrancea F, Murat I, 2001).
When nitrous oxide is combined with oxygen in a 50:50 concentration,
analgesia rather than anaesthesia is produced and respiratory depression is
avoided (Fisher & Harrison, 2000). It has a rapid onset of about four minutes
(Fisher & Harrison, 2000) and produces effective, short acting pain relief (Beh
et al., 2002). It should be used with care by staff that have undergone specific
training in its use and side effects.

10. Activity 5
List the ways in which pain during capillary blood sampling and venepuncture is
minimised in your clinical area.
What are the advantages and disadvantages of these methods of pain relief?
Describe how you would use each of these to best effect.
Activity 5a
If you will be taking blood from neonates and infants describe the differences in
their care and pain relief.
PERFORMING CAPILLARY BLOOD SAMPLING AND VENEPUNCTURE
CAPILLARY BLOOD SAMPLING
The main advantages of capillary blood sampling are that it prevents the need
for venepuncture, requires small amounts of blood and is a relatively quick
procedure. However, there are some disadvantages: Heel punctures are the
most common painful invasive procedure performed on neonates; skin trauma
can result in bruising, haematoma or scarring. More extreme complications
can be infection leading to cellulitis and osteomyelitis as the result of too deep
or repeated punctures. If an incorrect technique is used, it can lead to
localised swelling, tenderness or increased hypersensation.
When choosing a site you should remember that the posterior curvature of the
heel must not be used as this can result in growth disturbances of the hind
part of the foot. In neonates, the fingers can be damaged by capillary
sampling and this should be avoided.
On occasions a second site needs to be punctured to obtain adequate blood
for analysis. If the puncture site is `milked', this can result in a haemolysed
sample, giving abnormal and inaccurate potassium levels.

11. SELECTING A SITE
The following are some key points to remember when choosing a site.
• Heel pricks should only be performed on babies under four months of
age.
• The technique cannot be performed on poorly perfused, oedematous,
inflamed or swollen tissues
• Never obtain a sample from the fingers of neonates as they will become
damaged due to their delicate nature.
• Do not use a previous puncture site as the blood flow will be reduced and
tissue damage can occur to the finger or heel.
• When obtaining a sample from the heel the most medial or lateral portion
of the heel should be identified. Punctures should never be made on the
posterior curvature of the heel below the Achilles tendon, where the bone
is closest to the skin or the arch of the foot. Poor procedural technique
can result in growth disturbances of the hind part of the foot.
Correct puncture site for a heelprick:

12. Correct puncture site for a fingerprick:
VENEPUNCTURE
SELECTING A VEIN
Only a small amount of the needle needs to enter the vein before the blood
can be drawn but many children feel anxious that the whole needle will go into
them, or the health professional will have to ‘wiggle’ it around to get the blood
out.
Once the procedure has begun, it should be carried out as calmly, efficiently
and as quickly as possible; for many children, including the oldest age group,
the threat may not be over until the needle has been removed from the vein
(Caty et al., 1997). In addition to preparation before the procedure, children’s
distress can be further reduced if they are told what is happening during the
procedure and what sensations they will feel (Broome 1990, Caty et al., 1997).
If the child has had blood taken previously, ask them where their best vein is,
or where they prefer it to be taken from. Spend time selecting the most
appropriate vein so that the first attempt will be successful. Talk to the child
and encourage them to help in choosing a vein. You may need to apply the
tourniquet briefly or get the carer to squeeze the child’s arm while you look for
an appropriate vein.

13. The best veins for venepuncture are usually around the antecubital fossa
region (the median cubital, basilic and the median cephalic veins), although
these may be difficult to locate in well nourished infants and care needs to be
taken to avoid the brachial artery (Das & Sharma, 2002). With young infants,
transillumination of the palm of the hand with an otoscope can help in
identifying suitable veins for venepuncture (Goren A, et al., 2001) Children
with spina bifida and little or no sensation in their legs and feet may prefer the
veins in the feet to be used.
If it is likely that the child will need a peripheral venous cannula, if possible
smaller veins should be used in order to preserve larger veins for cannulation.
If topical anaesthetic cream is being used it should be applied to at least two
potential sites, just in case the first attempt fails. When it has been in place for
a suitable length of time you need to remove it and clean the area before re-
examining for suitable veins.
Activity 6
Look at the veins on your arms, hands and feet. Which of your veins would be most
suitable to use if you needed to give a blood specimen?
Observe health professionals on your ward / unit taking blood by peripheral
venepuncture. Make a list of the sites used, and the advantages and disadvantages
of these sites.
COLLECTING BLOOD SAMPLES
Blood sampling for diagnostic testing is an important aspect of care and
treatment. It can confirm a diagnosis; indicate that treatment is working and
may lead to treatment changes. Results must, therefore, be reliable and
results available as soon as possible. When taking blood samples you will be
the first link in a chain.
The specimen must arrive the laboratory in a good condition. Your hospital’s
laboratory service should give clear instructions on sample requirements and
when blood should be taken.
Specimen bottles vary according to the test required. You should familiarise
yourself with the more commonly used bottles. When drawing samples you
should ensure they are collected in the correct order to prevent samples that
need to clot are not contaminated by an anti-coagulant.
It is essential that specimens are labelled correctly. This is the responsibility of
the person collecting the sample. You should label the specimen immediately
after collection.

14. Activity 7
In your ward or department
Locate and read information regarding laboratory tests.
Locate information on types of specimen bottles and identify where the
different bottles are kept.
TROUBLESHOOTING
There are many situations where capillary blood sampling and venepuncture
can prove difficult, even to the experienced practitioner. It is important to
recognize when you are experiencing difficulties and to summon assistance
from someone else. Your hospital should have a policy outlining the number of
failed attempts at venepuncture, usually two or three, that you can have before
asking someone else to perform the procedure.
Potential problems include:
Improper tourniquet placement – too high/low/loose/tight leading to
insufficient engorgement of the vein.
Failure to release the tourniquet – when the needle has been placed
sufficiently, may cause bleeding outside the vein as the result of increased
intravascular pressure.
A “stop start” approach – when beginner’s lack confidence. This can injure
the vein and cause bruising.
Inadequate vein stretching – allowing the needle to push the vein aside.
Opposite wall penetration – may not be immediately obvious. If you suspect
this has happened act quickly in an attempt to save the vein. Without removing
the tourniquet, retract the cannula slightly until blood flashback appears again
indicating the cannula is in the vein lumen. Quickly advance the cannula into
the vein and remove the cannula.
Lack of backflow – suggests vasospasm. This is common in young patients
who are anxious.
Occasionally the patient, especially teenagers, and parents may experience
light headedness. They may even faint. It is possible that you may be so
focused on the procedure that you don’t realise. Even when you are learning,
try to be aware of the child’s reaction to the procedure.

15. RISKS AND HAZARDS
INFECTION CONTROL
Healthcare associated infection affects an estimated one in ten NHS hospital
patients each year. Over 60% of blood infections are introduced by
intravenous feeding lines, catheters or similar devices. This is because micro-
organisms on the patient’s skin (either those naturally present or those
acquired whilst in hospital) can gain entry to deeper tissues or the bloodstream
when a cannula or catheter is inserted into a vein.
Hand hygiene is widely acknowledged to be the single most important activity for
reducing the spread of disease, yet evidence suggests that many health care
professionals do not decontaminate their hands as often as they need to or use
the correct technique which means that areas of the hands can be missed.
Activity 8
Find the Wipe it Out campaign on the Royal College of Nursing website
www.rcn.org.uk
Read the section on hand hygiene and check your hand-washing technique.
Needlestick injury
Blood sampling is potentially hazardous for the practitioner. Between 1997 and
2002 there were 1,550 reports of blood-borne virus exposures in health care
workers, of which 42 per cent were nurses or midwives.
Needlestick injuries can occur during and after the procedure if the child is
distressed or if sharps disposal policies are not adhered to. You have a
responsibility for minimising the risk to yourself and others of needlestick
injury, by ensuring sharps are used safely and disposed of carefully.

16. Capillary blood sampling and venepuncture have a higher risk of causing
injury. To minimise the risk you should ensure the following:
• sharps are not passed directly from hand to hand
• handling is kept to a minimum
• needles are not broken or bent before use or disposal
• syringes or needles are not dismantled by hand and are disposed of as a
single unit
• needles are never re-sheathed
• you take personal responsibility for any sharps they use and dispose of them
in a designated container at the point of use. The container should conform to
UN standard 3291 and British Standard 7320
• sharps containers are not filled by more than two thirds and are stored in an
area away from the public
• sharps trays with integral sharps bins are in use
• sharps are disposed of at the point of use
• sharps boxes are signed on assembly and disposal
• sharps are stored safely away from the public and out of reach of children
• you are aware of inoculation injury policy.
Activity 9
Find a copy of the Royal College of Nursing document Good Practice in
Infection Prevention and Control: guidance for nursing staff.
www.rcn.org.uk
Describe the key actions you would take to prevent infection to patients
and staff when performing capillary blood sampling or venepuncture.
Accidental arterial puncture – this can result from a poor cannulation technique
causing pain and spasm. If the artery has been puncture the blood will be
brighter, fast flowing and may spurt. You should remove the cannula
immediately, apply pressure for 5 minutes, assess and dress the site and
observe the limb frequently.
Blood spillage – You should follow your hospitals’ policy.

17. Activity 10
Reflect on your learning and knowledge so far and undertake the following:
Identify the areas where you feel your knowledge is at a level where you can
practice safely.
Identify areas where you need more information and support in developing your
knowledge and skill.
Consider what actions you will take to continually develop your skill in peripheral
intravenous cannulation.
FURTHER LEARNING
Your expertise in capillary blood sampling and venepuncture in children and
young people will develop gradually and you will become more confident in
your practice. From your learning so far, including any supervised practice
you have undertaken, you should have a good understanding of the
knowledge and skills you will need to practice safely in this area.
The RCN fully supports members in raising concerns regarding the care
of children and young people, and the protection of their rights as
individuals.
If you feel compromised - for example if training provided by your
employing organisation is inadequate and you are not getting the help
you need - contact RCN Direct on 0845 772 6100 or ring your local RCN
Office (contact numbers can be found in your RCN Diary and Members
Handbook).

18. REFERENCES AND SUGGESTED READING
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19. Department of Health (2003a), Getting the right start: National Service Framework for
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behaviors during stressful healthcare encounters, Maternal-Child Nursing Journal, 22
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22. Useful websites
www.actionforsickchildren.org.uk Action for Sick Children
www.dfes.gov.uk Department for Education & Skills
www.dh.gov.uk Department of Health (England)
www.epic.tvu.ac.uk Evidence-based practice in Infection Control
www.hse.gov.uk Health and Safety Executive
www.icna.co.uk Infection Control Nurses Association
www.npsa.nhs.uk National Patient Safety Agency
www.nahps.org.uk National Association of Hospital Play Staff
www.nmc-uk.org Nursing and Midwifery Council
www.nes.scot.uk NHS Education for Scotland
www.rcn.org.uk Royal College of Nursing
www.skillsforhealth.org.uk Skills for Health
www.rcpch.org.uk Royal College of Paediatrics and Child Health