Nurses Reveal Why Neonatal IV Care Stays Reactive Instead of Proactive

In the smallest patients in medicine, the difference between a routine infusion and a life-threatening complication can come down to a thin plastic catheter and the judgment of the nurse watching it. A new qualitative study published in Pediatric Research suggests that in neonatal intensive care units, decisions about vascular access are made largely after problems occur rather than before them, a pattern the researchers describe as reactive rather than proactive care. The finding, drawn from interviews with neonatal nurses across three Dutch tertiary centers, offers a rare behavioral window into why device failure, repeated needle sticks, and avoidable harm persist in a field where the technical science of catheters has advanced considerably.

Vascular access is the circulatory lifeline of neonatal intensive care. Premature and critically ill infants depend on intravenous lines for nutrition, medications, and fluids, often for weeks at a time. Yet the devices that deliver these therapies fail frequently. Peripheral intravenous catheters in neonates are prone to infiltration, dislodgement, phlebitis, and occlusion, and each failure means another painful insertion attempt in an infant whose veins may be barely visible. Previous work by the same research group, including retrospective cohort studies such as the ABBA project, documented the scale of device-related complications and the factors associated with them. What remained poorly understood was the human and organizational side of the problem: how nurses actually decide when to insert, monitor, escalate, or abandon a line.

To answer that question, Matheus van Rens of Radboud University Medical Center and colleagues conducted semi-structured interviews with twelve neonatal nurses involved in vascular access and infusion therapy across three tertiary neonatal intensive care units in the Netherlands. The team analyzed the transcripts using reflexive thematic analysis, a method that treats the researcher’s perspective as an active ingredient in interpretation rather than a bias to be eliminated. Sample adequacy was guided by the concept of information power, an approach that determines whether enough interviews have been conducted based on the richness of the data and the specificity of the study aims, rather than by a fixed numerical target.

Four themes emerged from the analysis, and together they sketch a system that consistently rewards reaction over anticipation. The dominant finding was that vascular access care was characterized by reactive decision-making, with escalation to more secure or more appropriate devices typically occurring only after a complication had already appeared. Nurses described delayed escalation, repeated peripheral intravenous attempts, and inconsistent monitoring practices across all three centers. In other words, a catheter often had to fail before the team reconsidered whether a different strategy was needed from the start.

Behind this reactive pattern, the interviews revealed a web of interacting pressures. Organizational factors, including workload, staffing constraints, and the absence of structured decision-support embedded in daily workflows, shaped how much attention vascular access received at any given moment. Knowledge varied between individual nurses, and so did the implementation of existing guidelines, producing inconsistency both within and between units. The researchers also identified relational factors: parents were largely left out of decisions about vascular access, despite growing evidence from family integrated care research that involving parents in neonatal care improves outcomes for infants and families alike.

Perhaps the most striking theme was a persistent gap between risk awareness and clinical action. The nurses interviewed clearly understood which infants were at high risk of catheter failure and could articulate the consequences of repeated attempts. Knowing, however, did not translate into doing. This disconnection echoes classic patient safety literature, including James Reason’s models of human error, which emphasize that accidents rarely stem from individual carelessness alone but from systems that allow known risks to go unaddressed. The study’s authors frame their findings in exactly this spirit, pointing to organizational and behavioral factors that reinforce reactive practice regardless of individual competence or good intentions.

The technical literature has long documented the consequences of this gap. Studies of peripheral intravenous catheter failure in adult and pediatric populations have described the problem as accepted but unacceptable, a phrase coined by researchers reviewing the burden of device failure in hospitals. In neonates, multicenter observational studies have reported substantial complication rates for peripheral cannulation, and consensus tools such as the neonatal DAV-expert algorithm developed by European vascular access groups now exist to guide the selection of the most appropriate venous access for each newborn. The Dutch study suggests that the bottleneck is not a lack of technical knowledge or decision tools, but the absence of structures that trigger their use at the right moment.

The authors argue that the way forward lies in structured, anticipatory approaches integrated directly into clinical workflows. Rather than relying on individual nurses to remember to reassess a line or to escalate concerns through informal channels, units could build anticipatory planning into routine care, ensuring that the choice of device, the monitoring plan, and the escalation pathway are considered together at the moment of insertion and revisited systematically thereafter. The team has previously proposed a patient-centered framework based on the 7-Rights of vascular access, and the new findings support the idea that such frameworks must be embedded in practice rather than left as optional guidance.

The implications extend beyond the neonatal unit. Catheter-related bloodstream infections in intensive care were dramatically reduced in landmark studies when checklists and standardized bundles transformed culture and behavior, demonstrating that structured interventions can convert awareness into consistent action. The Dutch researchers point to similar potential in neonatal vascular access: if the reactive cycle of failure and rescue can be interrupted by anticipatory planning, the payoff could include fewer painful procedures, fewer infections, shorter stays, and more consistent care across centers. Practice variation in neonatal care is well documented, and standardizing the behavioral and organizational dimensions of vascular access may be as important as standardizing the technical ones.

The study also carries a methodological lesson for patient safety research. By listening to nurses rather than measuring devices, the investigators surfaced factors that retrospective audits of complication rates could never capture: the hesitation to escalate, the uneven distribution of knowledge, the silence of parents at the bedside. The authors acknowledge the limitations inherent in qualitative work, including the interpretive nature of thematic analysis and the potential identifiability of interview data, which is why the underlying datasets are available only on reasonable request. Yet the consistency of the four themes across three separate tertiary centers lends weight to the central conclusion. Vascular access care in neonatal intensive care, the nurses suggest, is shaped by interacting organizational, behavioral, knowledge-related, and relational forces that quietly reinforce reaction over prevention. Recognizing those forces, the researchers argue, is the first step toward designing workflows in which the smallest patients receive lines that are planned, monitored, and escalated with the same rigor that the technology itself deserves.

Subject of Research: Nurses' decision-making and reactive versus proactive practice in neonatal vascular access care

Article Title: Reactive rather than proactive: nurses’ perspectives on decision-making in neonatal vascular access

Article References: van Rens, M. F., Huis, A., Hugill, K., van der Lee, R., & de Boode, W. P. (2026). Reactive rather than proactive: nurses’ perspectives on decision-making in neonatal vascular access. Pediatric Research. https://doi.org/10.1038/s41390-026-05570-8

Image Credits: AI Generated

DOI: 10.1038/s41390-026-05570-8

Keywords: neonatal intensive care, vascular access, nursing decision-making, peripheral intravenous catheters, patient safety, qualitative research, thematic analysis, catheter failure, escalation delays, family integrated care, clinical workflows, Pediatric Research