Reactive rather than proactive: nurses' perspectives on decision-making in neonatal vascular access

Neonatal vascular access is essential for life-sustaining therapies but is associated with frequent device failure, repeated procedures, and patient harm. Although technical aspects have been widely studied, less is known about how organisational and behavioural factors influence decision-making.

We conducted a multicentre qualitative study across three tertiary neonatal intensive care units in the Netherlands. Semi-structured interviews were conducted with 12 neonatal nurses involved in vascular access and infusion therapy. Data were analysed using reflexive thematic analysis, with sample adequacy guided by information power.

Four themes were identified. Participants described vascular access care as predominantly characterised by reactive decision-making, with escalation commonly occurring after complications rather than through anticipatory planning. Delayed escalation, repeated peripheral intravenous attempts, and inconsistent monitoring were reported across all centres. Participants described organisational pressures, variability in knowledge and implementation, and limited parental involvement as factors influencing these patterns. A persistent gap between risk awareness and clinical action emerged from the interviews.

Participants suggest that vascular access care is influenced by interacting organisational, behavioural, knowledge-related, and relational factors that may reinforce reactive practice. Promoting anticipatory vascular access care through structured, workflow-integrated approaches may improve consistency, reduce avoidable harm, and support safer vascular access care.

Identifies a predominantly reactive pattern of vascular access care within neonatal nurses' accounts across three tertiary NICUs. Identifies organisational, behavioural, knowledge-related, and relational factors that may contribute to delayed escalation beyond technical considerations. Extends existing literature by providing insight into factors that may contribute to repeated peripheral catheter failure and delayed escalation in routine practice. Supports consideration of structured, anticipatory vascular access approaches integrated into clinical workflows to reduce avoidable harm and improve patient safety.