Survey and participants

The Harris Poll conducted the online survey from 11 to 28 December 2023. The questionnaire was designed by The Harris Poll in consultation with subject experts, after which survey invitations were sent to vetted, consenting respondents registered with the company in online panels. In the US, ethical approval is not required for anonymous surveys.

Survey invitations were sent to a general population sample that reflects the US adult population (aged ≥18 years). Within this sample there were specific subgroups comprising parents, older adults and caregivers; additional survey invitations were sent to parents and older adults to maximise representation of these subgroups. Survey invitations were sent separately to registered nurses, a subgroup that was not included in the general population sample.

The survey sample and description of each group are shown in Box 1.

The survey questions varied slightly across the five groups to enable the general population and older adults to report their firsthand experiences; parents and caregivers to provide their own perspectives and those of their children or individuals in their care; and nurses to provide their direct or observational experiences. Respondents could only select one option in response to the questions. Questions relevant to the results of the survey reported in this article are shown in Box 2. Demographic data were also collected but are not reported here.

Statistical analysis and data weighting

Descriptive statistics were reported and comparisons included crosstabs run with t-tests with overlap, but without continuity correction or separate variance, with a significance threshold set at P<0.05. The sampling precision was measured using a Bayesian credible interval, with a 95% credible interval width of ±2.8 percentage points.

For groups B-E, the margin of error was ±5.9 for parents (n=502), ±4.9 for older adults (n=687), ±5.4 for caregivers (n=648) and ±10.9 for nurses (n=106). Data were weighted using ‘raking’ by age, gender, race or ethnicity, US region, education, marital status, household size, household income, parental status (of children aged <10 years) and propensity to be online. The increase in margin of error due to weighting was considered. Quantum v5.8 software was used for the data analysis.

Number of needle insertion attempts

Most respondents in groups A-D (collectively referred to as ‘patient groups’ in the rest of this article) and in the nurse group (group E) experienced more than one needle insertion attempt during a single procedure. Of the patient groups respondents, older adults experienced the highest percentage of ≥10 needle insertions in IV cannulation and blood withdrawal. More than half of nurse respondents reported attempting or observing ≥3 needle insertions for IV cannulation and for blood withdrawal (Table 1).

Most respondents in the general population group had experienced ≥3 needle insertion attempts in a single hospital stay; respondents in the older adults group reported the highest percentage of ≥10 needle insertion attempts. For nurses, the highest percentage of needle insertion attempts was 4-10 (Table 2).

Acceptability of multiple needle insertion attempts

The highest percentage of maximum number of acceptable needle insertion attempts for IV cannulation among the patient group respondents was one attempt. For blood withdrawal, the highest percentage among the general population, parents’ and caregivers’ groups was two attempts, but the highest percentage in the older adult group was one attempt (Table 3).

Nurses’ perspectives on multiple needle insertion attempts aligned with those of respondents in all other groups, as evidenced by 90% of them agreeing with the statement ‘Patient preference would be to have only one vascular access device for all infusions and blood collections throughout their hospital stay’ (Table 4).

Complications

The most common complication reported by patient and nurse respondents was ‘blown or damaged vein or blood vessel’ followed by ‘blood clot’ and ‘cannula-related infection’ (Table 5).

Satisfaction

Across all patient groups, respondents’ satisfaction rates with IV cannulation and blood withdrawal practices were lower when at least one complication had occurred than when no complications had occurred; the reduction between satisfaction rates (specifically ‘very satisfied’) when a complication had occurred was greatest in the older adult group (Table 6). This is reflected in nurses’ agreement with the statements ‘Repetitive [needle insertions] negatively impact patient experience’ and ‘Alternatives are needed to reduce the number of [needle insertions] patients encounter’ (Table 4).

Awareness of and interest in alternative methods

Most patient group respondents were unaware of alternative methods of blood withdrawal and IV cannulation, specifically needle-free blood collection and ultrasound guidance. For example, among the general population group (n=2,006), 83% (n=1,659) did not know about these alternative methods. However, there was a strong interest across all groups in the use of these alternative methods once respondents became aware of them through completing the survey. Respondents in the caregivers’ group were particularly interested in alternative methods, with 82% (n=527/641) indicating they were ‘very interested’ or ‘somewhat interested’ in needle-free blood collection and 78% (n=503/641) indicating they were ‘very interested’ or ‘somewhat interested’ in ultrasound guidance for IV cannulation.

Around 97% (n=103/106) of nurse respondents were ‘very interested’ or ‘somewhat interested’ in needle-free blood collection, and 95% (n=101/106) were ‘very interested’ or ‘somewhat interested’ in ultrasound guidance for IV cannulation.

Awareness of risks and self-advocacy

The survey asked patient groups about their awareness of the risks associated with needle insertion for IV cannulation or blood withdrawal. Most patient group respondents were unaware of and ‘surprised to learn about’ the following statements:

As an example, among the general population group (n=2,006), 78% (n=1,569) were ‘surprised’ to learn about the 50% failure rate and 70% (n=1,413) were surprised to learn that not all nurses receive specialised training for these interventions. However, a high percentage of all patient group respondents indicated they would better advocate for themselves and those in their care since learning about these issues through the survey. For example, in the general population group, 89% (n=1,778) agreed that they were ‘more aware of the challenges surrounding [needle insertion]’, 85% (n=1,700) agreed they would ‘be a better advocate for [themselves] in future hospital stays’ and 69% (n=1,381) agreed they would ‘plan to ask more questions whenever [they] receive [needle insertion]’.

When speaking about advocating for those in their care, 87% (n=649) of the general population group agreed that they will better advocate for the person in their care, 86% (n=645) reported they were more aware of the particular risks surrounding needle insertion for the person in their care, and 84% (n=632) agreed they would plan to ask more questions when the person in their care received needle insertion.

Effects of multiple needle insertion attempts on patients

Many of the patient group respondents in this survey had experienced repeated needle insertion attempts. This aligns with the broader literature which has identified high venous access failure rates in clinical settings, leading to delayed treatment and increased length of hospital stays (Armenteros-Yeguas et al 2017, Shokoohi et al 2020).

The results also indicate a gap between current practice and patients’ expectations about the maximum acceptable number of needle insertion attempts. For example, only around 20% of patient respondents stated that three or more needle insertion attempts for a single procedure was acceptable (Table 3), yet around 40% reported experiencing this number of attempts (Table 1). In addition, complications related to needle insertion were commonly reported by all respondent groups and negatively affected patients’ satisfaction levels. Nurse respondents reported higher rates of complications than the patient group respondents, which could be attributed to the fact that most of these nurses worked in acute care settings and may therefore treat patients who require immediate and/or frequent medical interventions. Furthermore, the nurse respondents may be more likely to recall patients who require complex care than those who require routine care.

Despite experiencing complications, there was low awareness of the risks associated with needle insertion among all patient groups. However, after being informed about these risks in the survey, patient group respondents agreed they would better advocate for themselves in future hospital stays.

Effects of multiple needle insertion attempts on healthcare systems

The results provide unique insights from nurses on the effects of multiple needle insertion attempts on healthcare systems. For example, almost all nurse respondents agreed that delays to patient treatment caused by difficult venous access are a problem; most agreed that problems relating to gaining and maintaining vessel access take up too much nursing time and contribute to workflow inefficiencies. These results are supported by previous research which linked difficult IV access to delayed patient care and increased healthcare costs (Shokoohi et al 2020, Gala et al 2024). Moreover, evidence suggests that multiple needle insertion attempts can adversely affect patients’ trust in healthcare professionals, as repeated attempts can be perceived as a lack of competence (Cooke et al 2018).

Alternative methods

Although awareness of needle-free blood collection and ultrasound guidance was low among the patient group respondents, most displayed a high level of interest in these methods once they were made aware of them and many of these respondents indicated that they would advocate for their use in future.

Technologies that reduce the need for multiple needle insertion attempts can minimise patient trauma and improve overall patient satisfaction (Brass et al 2015, van Loon et al 2018, Rodríguez-Herrera et al 2022). Advanced technologies such as ultrasound-guided or needle-free insertions, which could reduce complication rates, present a significant opportunity for improved practice (Franco-Sadud et al 2019, Walsh and Fitzsimons 2023).

Combining technological advancements with new care models is essential to facilitate sustainable implementation and practice change. Acito et al (2024) demonstrated that implementing needle-free blood collection technology delivered by dedicated providers can transform practice and care in terms of improvements in staffing constraints, operational efficiency and continuity of patient care.

Implications for practice and recommendations for nurse leaders

While changing culture and practice can be challenging, the results of this survey suggest that most nurses are aware of the challenges associated with multiple needle insertion attempts and are interested in the use of technologies to improve practice and patient care. Based on the survey results, the authors identified the following implications for practice and recommendations for nurse leaders:

Limitations

The results of opt-in surveys are susceptible to error due to coverage errors, self-selection bias, non-responses and issues with the question wording or response options and post-survey weighting or adjustments. The reliance on self-reported data introduces potential biases, such as recall and social desirability biases. In addition, the survey used non-probability sampling, which may limit the generalisability of the results to the broader population.