ORIGINAL ARTICLE How Sharp is a “Sharp Scratch”? A Mixed Methods Study of Verbal Warnings Issued Before Venipuncture Roshan Vijayan, MBBS*; Gregory Scott, MBBS † ; Wendi Brownlie, NZCS*; Pandora Male, BSc † ; Kian Chin, MBChB* *Milton Keynes Hospital NHS Foundation Trust, Milton Keynes, U.K.; † Imperial College School of Medicine, London, U.K. & Abstract Objectives: Health care providers frequently issue a verbal warning before venipuncture. Communications that induce negative expectations in patients can lead to the “nocebo” response, defined as experiencing greater pain. But is this also true for “sharp scratch”? Methods: The study was conducted across 4 U.K. hospitals. Two separate surveys of health care providers and patients explored the prevalence, phraseology, rationale, and reac- tion to verbal warnings before venipuncture. Blinded adult patients already attending an outpatient department during a 2-week period were randomized to hearing a “sharp scratch” or the verbal cue “ready?” immediately before venipuncture. They were also asked to rate their pain (the primary outcome). Results: 77% of 117 health care providers surveyed issued a verbal warning before venipuncture; 73% used “sharp scratch”. Of 62 patients surveyed, 56% agreed that “sharp scratch” accurately describes venipuncture, and 64% agreed that they prefer “sharp scratch” to no warning. With increasing age, a preference came for an alternative warning to “sharp scratch” (P = 0.039) and to be distracted by conversation (P = 0.002). Of 192 patients in the randomized study, there was no difference in pain between the “sharp scratch” and “ready” groups. The numeric rating scores were 0.74 SD 1.06 vs. 0.88 SD 1.18, respectively. (P = 0.493). Conclusions: Most health care providers use the verbal warning “sharp scratch” before venipuncture. Most patients find this acceptable and prefer it to no warning. An exception may be elderly patients, who may prefer to be distracted by conversation. “Sharp scratch” makes no difference to the pain experienced compared with a verbal cue. & Key Words: pain, pain acute, pain psychological variables INTRODUCTION Venipuncture is the most common invasive medical procedure 1 performed by a variety of health care providers including doctors, nurses, and phlebotomists. It may be a source of significant distress to patients; therefore, it is desirable for clinicians to minimize anxiety and pain engendered by the procedure. The phrase “sharp scratch” is frequently used as a verbal warning to patients immediately before needle insertion. But what is the rationale for such a warning? Warning patients of pain well in advance of needle-related procedures may increase their experience of pain 2–6 . Little is known, however, as to whether this is true for a commonly used verbal warning such as “sharp scratch” issued immediately before needle insertion, despite such warnings being routinely employed in clinical practice in the United Kingdom. While the World Health Address Correspondence and reprint requests to: Roshan Vijayan, MBBS, Department of Plastic Surgery, Queen Victoria Hospital, Holtye Road, East Grinstead, RH19 3DU, U.K. E-mail: roshan.vijayan@gmail.com. Submitted: May 23, 2013; Revision accepted: October 16, 2013 DOI. 10.1111/papr.12159 © 2013 World Institute of Pain, 1530-7085/15/$15.00 Pain Practice, Volume 15, Issue 2, 2015 132–139