Helping Patients Overcome Needle Fear
In a busy and sometimes understaffed dialysis clinic, needle fear can be a frustrating challenge. Patients who need extra time and care for cannulation disrupt the schedule for all subsequent patients assigned to that chair—which can have a domino effect on other chairs. Due to HIPAA, you can’t call on fellow patients’ compassion by explaining the cause of the delay. So, patients who have somewhere to be and must wait or who want “their” chair can become angry, and then everyone’s day can go downhill.
Your challenge is to be quick—and compassionate—while helping patients overcome their very real fears. In this course, we describe three levels of needle fear and offer practical, quick strategies for each level to keep your clinic schedule intact and your patients feeling supported and cared for.
As you may have seen in your patients, there may be a continuum of reactions to hemodialysis needles.
Patients who are new to HD and have a venous access may have no idea what a vascular access is or how it works—and may be unable to learn, due to uremia and fear. Some are not told—even by the vascular surgeon who created an access—that two of the biggest needles they have ever seen will be placed at each treatment. Needless to say, this can be an unpleasant shock.
Never assume that patients who have a fistula or graft had (or retained) any primary HD access education. Plan to start at the beginning with the basics and build from there. Explain what an access is and why the large needles are required. Over a series of treatments, teach access protection, self-assessment, and routine care, and then switch to “needle anatomy”—the hub, the eye, the clamp… Let a patient handle a capped or blunt needle to demystify it and start the informal desensitization process.
Fungal peritonitis also takes longer to diagnose. Early PD catheter removal improves patients’ chances of being able to return to PD. With the PD catheter in place, mortality rates for fungal peritonitis have been reported at 50-91%. Unfortunately, patients on antibiotics for bacterial peritonitis are at high risk of developing a secondary fungal peritonitis—so, your clinic policy and procedures may include antifungal prophylaxis.
It’s tempting to encourage PD in part by (truthfully) mentioning that it is a needle-free option. This really is a selling point for some patients—unfortunately to the extent that some may have a more difficult time adjusting to HD when PD no longer works, or even refuse to switch to HD until it’s too late.
Using phrases like, “Those big, giant hemo needles,” or “all that blood,” can poison the well for patients. Yet, in a lifetime with end-stage kidney disease, patients may need to use multiple different options. If you can be mindful and stay neutral in your language about treatment options, you may well save your patient’s life down the road.
How can you help? The tips below form a basic toolbox you can pull tactics from to quickly meet the needs of your patients who don’t like needles. (I.e., all of them).
Patients who view nursing staff as caring, empathetic, and friendly feel more comfortable (Duncanson, 2023). This small intervention can go a long way: teamwork and positive communication can improve a clinic atmosphere and boost patient confidence.
If you say you will do something, do it—or apologize if it is not possible. If you promise you won’t do something, don’t do it. Respect patient choices about their bodies, their lifestyle, and how they want to be treated. Know your audience. Teasing that one patient may enjoy could dismay or devastate another
Ensure each patient’s comfort:
- For optimal needle control and patient eye contact, pull up a rolling stool and sit down to cannulate.
- Avoid making patients hyperextend their arms. Instead, have them scoot over in the chair so you can easily reach. (This tactic also gives patients an active role in their cannulation, which is part of consent). Place a pillow under the arm for support.
- Ask “Are you comfortable?” If not, suggest shifting in the chair to be closer to you. One patient said,
“You want someone that is gonna pick up on the way you’re feeling about it and do what they can to make you feel comfortable about what’s about to happen. And then normally the rest just works.”
- Find out your patients’ level of needle fear (Duncanson, 2023). When a patient says something about feeling scared about cannulation, listen. A patient explained,
“I think in the beginning people need to be asked a lot more, ‘Are you scared of needles?’, ‘Do you understand what’s going to happen to you?’…I think that’s the key for people coping.”
- Validate the patient’s perspective. Depending on the answer, you might say, “Yes, those really are big needles.” Or, “It should only hurt for a moment when I place them; after that you shouldn’t feel them.”
- Ask patients what they prefer, to help build rapport (Duncanson, 2023). If someone is new to your clinic—or to you—ask about cannulation and tape preferences. Would the patient like you to explain what you’re doing? Count down to a puncture (or not)? Does your patient prefer to “get it over with” quickly, or appreciate a slower process?
- Present yourself as cool, calm, and collected. Don’t let patients see you as rushed or stressed or pressured; these could reduce their confidence in you—which could then reduce your own confidence in yourself. Aim for a positive loop, where you encourage each other. “We’ll get through this together!”
- Essential oils. Patients who inhaled fragrance from lavender essential oil had significantly less anxiety and pain—and more comfort than controls (Ozen N et al, 2023).
- Music. Patients who listened to music during cannulation had significantly less pain than those who heard white noise (Inayama E et al, 2022). Many patients have Smartphones and earbuds, and you can suggest that they try music.
- Suggest a meditation app. Some are free on YouTube with images, and others are guided meditations with sound only.
- Offer a stress ball or other squeeze toy. Your clinic may have a bag of these. Or, staff who attend local meetings or national conferences can often pick these up for free.
- Acknowledge that dialysis is a big challenge, but they can claw themselves out of the pit they’re in and rise up and find strength.
- Pointing out that they have done hard things before, and can use those coping skills.
- Note that it’s never too late to make positive changes.
Patients who are not comfortable with HD needles (and who is?) may be reacting, in part, to a loss of independence due to ESKD. Autonomy—feeling in control—is critical for all humans to grow and thrive (Ryan RM, Deci EL, 2000). Needle fear can reduce the chance of making a treatment choice that can preserve autonomy. At 47%, needle phobia was the most prevalent self-reported barrier to self-care or home HD (Duncanson E, 2021).
The Conditions for Coverage for Dialysis Facilities give patients the right to participate in all aspects of their care—including learning how to self-cannulate (CfC, 2008). Of course, it takes extra time to teach patients. But, refusing to teach and allow patients to place their own needles can lead to complaints, a state survey, and a citation. And, patients who do learn how feel more confident and say things like: “Everyone who can see and reach their access needs to learn to stick themselves. It’s like brushing your teeth! Once you learn it you will never let Mom (or anyone else) do it for you” (Sondergaard H, 2018).
Watch this video of children self-cannulating—if they can do it, many of your patients can, too.
Learn more about how to teach patients in the SPARK course on Rope Ladder and Buttonhole Cannulation.
For your patients: Learn about managing needle fear in one of the Ready Set Home eClasses on Home Dialysis Central.
Did you know that fear and catastrophizing (e.g., fearing that a bad cannulation will lead to loss of a limb) significantly amplify pain (Rogers AH, Farris SG, 2022), while inducing positive emotions—like feeling safe, happy, and content—significantly reduce pain? (Mikkelsen MB et al, 2024). It’s science! Even in someone with a normal level of needle discomfort, fear and distress from a bad day can make future treatments more challenging. Of course, we can’t promise everyone a perfect cannulation every time.
An estimated 80% of U.S. HD patients start HD with a CVC. When patients start without a catheter, their new fistulas may be very delicate. If cannulations go poorly, the access may need rest or revision and the patient will be unable to receive a treatment (Lok CE et al, 2025).
Depending on residual kidney function, diet, and lab results, underdialysis can be an emergency andthe patient may need a CVC placed as a bridge. Consider how many hours of HD your patient received and express concern to the nephrologist if you believe your patient needs more to remain stable.
Even with a working access, a standard 2-day treatment gap increases the risk of sudden cardiac death by 45% (Bleyer AJ et al, 1999). In the 12 hours before a Monday or Tuesday treatment, the risk of sudden death is triple (Bleyer AJ et al, 2006).
Empathize
When you know a patient had multiple needle attempts or an infiltration, put yourself in that patients’ shoes for a moment. Think about the trepidation that arises from having to do something that may feel like self-torture or self-mutilation (Fielding, 2023). As one patient said, “They should be concerned that you are a human being and you are still alive. Instead, they come in there and punch you like you would punch a tyre. They bruise you all over like that with no concern at all.”
Plan ahead
When you know that a patient has a new fistula or is difficult to cannulate, avoid a rush by asking the patient to come in a bit early, if possible. This can buy you a little extra time to do a thorough access assessment and support the patient’s emotional and physical comfort.
Ease the pain
Approaches that reduce the physical pain of cannulation can also ease fear and anxiety—creating a positive feedback loop. NOTE: The need for needle analgesia may not be permanent. When patients get used to the needles and their level of fear drops, they may find that the few seconds of pain are not worth the inconvenience of using a messy cream. Depending on your clinic’s policies and procedures, alternatives for needle pain relief may include products such as:
Vapocoolant spray (OTC)
Read label for distance from skin and seconds of spray time. NOTE: May or may not be sterile. Disinfect accordingly.
+ Works quickly, but superficially.
– Can cause frostbite if mis-applied. Do not contaminate the cannulation area.
Lidocaine cream (OTC): do not exceed 4%
Read label for application details as they may vary.Use approved brand(s) only. NOTE FDA warnings (FDA 2024).
+ Inexpensive. Placebo effect may ease pain.
– Warn patients: 1). OTC brands may have more than 4% lidocaine. 2). Don’t wrap OTC cream with plastic wrap. Either can cause seizures, dyspnea, and arrythmias.
EMLA® Rx lidocaine + prilocaine
Start 2 hours before HD and then wash the access are.
Apply 1/8” thick dime-sized blob to each cannulation area.
Cover with plastic wrap.
Remove plastic and wash arm again, disinfect per policy, cannulate (Core Curriculum for the Dialysis Technician, 7th ed).
+ Effective for shallow and deep accesses.
– Expensive
– Requires Rx.
– Must be applied 1-2 hours prior to cannulation and wrapped to keep cream off clothes and penetrate skin.
Intradermal Lidocaine
Make a wheal per clinic policy and patient’s prescription.
+ Works quickly (1-3 minutes) to numb cannulation area.
– Expensive
– Requires Rx.
– Extra punctures (and burning) are not helpful for needle phobia.
– Difficult to inject over superficial, small, and/or new AVFs.
– Vasoconstriction makes cannulation difficult (BC Renal 2021).
Build your skills
Recognize your limitations. Traumatic experiences at the clinic can cause or worsen cannulation fear. If you don’t feel confident about an access, don’t try: ask for help and watch. Ask the patient what the other nurses say about the access. Is it deep?
“I had about 6 or 7 jabs in one session. It took him over an hour. The trauma of that experience just, it shook me up. I didn’t go in that Wednesday…I was still bleeding 2 days later. That’s where my anxiety, my fear has stemmed from.”
Know when to stop trying
If you see signs of patient distress, stop cannulation until you can address them. Continuing while a patient is upset can harm trust, confidence, and rapport (Duncanson E, et al 2024).
“I have quite a strict policy in the unit that people [nurses] have to ask for help. And if they really don’t think they can do it, then they get somebody. And so, we’ve kind of developed that culture in the unit anyway. And we don’t have such a problem, but there is in other places and you’ll get patients coming back and telling you stories about, different nurses that have just absolutely butchered their arms. And that’s one of the reasons why people have phobias. It’s not necessarily that initial cannulation, it’s that ongoing, bad experience kind of stuff” (Duncanson E, et al 2024).
“I have a very large fistula on my left arm right above my elbow. It is about 6” long and 2” thick. I work with young children and one day I made the mistake of wearing a short-sleeved shirt. One of the kids got so scared he started to cry. There is nothing more damaging to your self-image than to have a child cry just by looking at you. Now I wear long-sleeve shirts to work no matter what.”
Patients notice each other’s fistulas and may worry out loud, “Will my arm look like that?!” In a clinic, reassure the patient you are talking to AND anyone else who may have overheard that every access is a lifeline, and we respect them. It may be worth adding that—contrary to many TV and magazine ads—none of us is perfect. We all have our battle scars. Some cope by:
- Covering an access with a stretchy, non-constricting gardening sleeve
- Making up a story, like “a shark bit me”
- Using questions as an opening to teach others about dialysis and transplant
Of the three levels of needle fear, a specific blood-injection-injury (BII) type phobia (DSMIV-DSMV) is the most severe and can interfere most with healthcare, particularly dialysis. In dialysis clinics, where patients may watch fellow patients experience infiltrations, difficult cannulations, or even exsanguination, needle phobia may well be a rational response to trauma—and these patients may benefit from therapy if they can access it. This is not hysteria, it’s realistic fear and self-protection. The higher the degree of BII phobia, the more likely it is that patients will have a correspondingly high degree of distress (McMurtry 2016). These are some distress reactions and the behaviors you may see (Alsbrooks K, 2022 and McMurty C, 2016).
- Crashing into dialysis emergently
- Keeping a CVC and declining to get a fistula or graft*
- Skipping treatments (Fielding C et al 2022)
- Refusing vaccines
- Disassociating: Flat affect, 1000-yard stare, no interaction
- Refusing to switch to HD when PD stops working†
- Shaking
- Hyperventilating
- Crying
- Behavioral resistance: being argumentative or combative)
- Pallor
- Sweating
- Hypotension
- Fainting
* In a study, 36% declined a fistula or graft—mainly due to fear (Arenas MD et al, 2024). You may have encountered patients who have fistulas or grafts, but will not consent to cannulation, though we could not find studies on this.
† Among 551 Australian patients, 37% said needle fear had an impact on their treatment choice (Shanahan L et al, 2019).
Among the general public who have access to healthcare and typically get blood draws, IVs, and injections, needle phobia is relatively common. An estimated 20 to 30% of 20-40 year olds (fewer with age) have which can be a barrier to seeking routine dental and health care like lab tests and procedures (McLenon et al, 2018). As many as 20% may skip vaccines out of fear.
In contrast, a patient with a working venous access has at least 312 large-bore needles placed each year (Duncanson E et al, 2021). It is no surprise that 88% more HD patients than the general public report needle fear: 47% vs. 25% (Duncanson EL et al, 2023). One paper notes that, “Cannulation for HD is an unpleasant, abnormal and unique procedure associated with pain, abnormal appearance, vulnerability, and dependency.” Patients know that cannulation is essential to get their treatments—at least, if they accept use of a venous access (Fielding C et al, 2022).
Unfortunately, needle phobia can reduce quality of life and survival on HD. Patients worry about successful cannulation, bodily intrusion, disfigurement—and reactions from others, pain, and anxiety (Duncanson EL, 2023).
As with needle pain, you have a toolbox you can call on to help patients cope—with the addition of some phobia-specific tactics outlined below.
Find hope. Patients need hope to get past their fears (Hammer K et al, 2009). Have patients who are in a dark place talk to others who have made it through and have things to live for. Patients can help each other.
Try to connect with patients who are avoidant. It’s okay to tell someone that they look “a little shut-down,” and to offer to get the social worker. Patients’ feelings may not be what you think they’re about—but it can still help a patient to show that you care.
A patient with clinically significant anxiety or a panic disorder may need to see a mental health practitioner who can prescribe an antianxiety medication to take before treatment.
If a patient tells you that they have a history of fainting due to needle phobia, take steps to protect safety and short-circuit the physiological response they typically have.
- Center the patient in the middle of the chair to prevent falling.
- Start treatment with the patient’s feet up.
- If tolerated, consider using the Trendelendburg position preemptively at the start of treatment.
- Teach applied tension: squeezing and releasing large muscle groups, especially in the lower body, without dislodging the needles. This can serve as a distraction and may force more blood into the brain.
Check in with phobic patients to see if their level of fear has changed. Some patients receive “informal desensitization” by virtue of seeing and experiencing needles multiple times each week. If your clinic permits it, offer the patient a blunt needle and tubing to take home and handle to speed the process along. They can look at it, handle it, tap the point against their arms, open and close the clamps… They may find over time that their phobias become much more manageable.
As you have now learned, there are three main levels of needle fear. This course has equipped you with a toolbox full of brief, effective approaches and interventions to help soothe fears, ease concerns, teach key concepts, and equip your patients to cope with the needles that are necessary for them to have hemodialysis treatments with a fistula or graft. As you see them make progress toward acceptance—and hopefully self-cannulation—point out how far they have come. Cheer on their successes and take pride in the role you played in helping them to make progress.