Misic et al. BMC Pediatrics(2024) 24:579
https://doi.org/10.1186/s12887-024-05044-y

BMC Pediatrics

RESEARCH

Open Access‘All for the well-being of the infant’:nurses’ perceptions of preterm infants’ eye
examinations: a phenomenographic study
Martina Carlsen Misic1,2*, Emma Olsson1,2, Randi Dovland Andersen3,4 and Agneta Anderzén-Carlsson5,6
Abstract
Background Preterm infants are at risk of complications due to their prematurity and Retinopathy of Prematurity(ROP) is one of them. To discover and treat ROP the preterm infants regularly undergo eye examinations. Nurses are
responsible for the infants’ care during this painful and stressful procedure.
Aim The aim of this study was to explore nurses’ perceptions of preterm infants’ eye examinations.
Methods Data were collected through semi-structured interviews with 10 nurses experienced in participating inpreterm infants’ eye examinations. Data were analysed using a phenomenographic approach.
Results The results showed several perceptions of the eye examinations, and the analysis resulted in four descriptive
categories: Infants are affected by the eye examination; Nurses have comprehensive overall responsibility for the infants;
Parents are important to their infants, but they need support to fulfil their parental role, and Collaboration is important for
the examination’s favourable outcome. The category Nurses have comprehensive overall responsibility for the infants was
regarded as the most comprehensive, covering all the other categories.
Conclusions Nurses felt a great responsibility during a painful and stressful procedure for preterm infants. Infants’
well-being could be better protected by interprofessional collaboration, improved nursing care and involved parents.
Keywords Neonatal, NICU, Nursing, Premature, Preterm, ROP screening*Correspondence:
Martina Carlsen Misic
martina.carlsen.misic@oru.se
1
Department of Paediatrics, Faculty of Medicine and Health, Örebro
University, Örebro, Sweden
2
Faculty of Medicine and Health, School of Health Sciences, Örebro
University, Örebro, Sweden
3
Research Centre for Habilitation and Rehabilitation Models & Services(CHARM), Faculty of Medicine, University of Oslo, Oslo, Norway
4
Department of Research, Telemark Hospital Trust, Skien, Norway
5
University Health Care Research Centre, Faculty of Medicine and Health,Örebro University, Örebro, Sweden
6
Faculty of Health and Social Sciences, Inland Norway University ofApplied Sciences, Elverum, Norway

Background
Preterm infants are born before they are ready to live
outside the womb. The earlier the infant is born, thehigher the risk of various complications [1]. One of thoseis retinopathy of prematurity (ROP), a disease that affects
the immature retina and its vessels. The eye should normally develop in the oxygen-deficient environment in
the uterus, but with preterm birth the eye is exposed toincreased and altered levels of oxygen, which can cause apathological development of the retinal vessels [2].
According to Swedish guidelines, the fundus of theeye is examined in all infants born before 30 weeks gestational age to discover and treat ROP [3]. The examinations are performed regularly until the infants reach full

© The Author(s) 2024. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use,sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) andthe source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in thisarticle are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not includedin the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you willneed to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

Misic et al. BMC Pediatrics(2024) 24:579

term or the retina is fully developed. The frequency of
examinations depends on the stage of ROP and the development of the eye [3]. In Sweden, these eye examinations
are performed using either indirect ophthalmoscopy or
retinal imaging. During indirect ophthalmoscopy, theeyes are held open manually or with an eyelid speculum,
and a bright light is pointed into the dilated pupil while
the ophthalmologist examines the eye with an ophthalmoscope. During retinal imaging, the eye is held open
by eyelid speculums and the fundus are photographed
for later diagnostics [4]. The eye examination can takeplace in the infant’s care room, an examination room, or
the ophthalmology unit depending on the required levelof care. Usually, health care professionals from both theneonatal unit and the eye clinic and the parents are present at the examination to support the infant.
To facilitate the retinal examination, infants receive
mydriatic eye drops to dilate the pupils before the eye
examination. Side effects can be cardiovascular, gastrointestinal, and respiratory [5]. When eyelid speculums areused, the infant usually receives pain-relieving eye drops
before the examination [4].
The eye examination consists of stressful and painful
elements for the infant, including being held in positionand subjected to bright light and sometimes physicalmanipulation of the eye [6]. Despite extensive research
into pharmacological, physical, psychological, and multimodal methods to alleviate infants’ pain during eye
examinations, no effective treatment has yet been identified [7–11].
Nurses at the neonatal unit are responsible for the preterm infants and supervise their care. Nurses have beenshown to experience stress when infants receive inadequate pain relief during procedures and when they are
responsible for an infant’s distress. Neonatal nurses havealso expressed emotional distress when trying to protect an infant from pain and discomfort [12]. Individual
nurses’ perceptions of suffering may also affect how
nurses experience infants´ suffering during a procedure[13]. However, perceptions and attitudes towards painfulprocedures also depend on nurses’ knowledge and awareness of infant pain and preterm infants´ pain signals [14].
In particular, the smallest infants’ pain can be overlooked
and undertreated, since their pain expressions can bevery subtle [15].
In summary, despite research showing that preterm
infants experience pain and distress during eye examinations, no adequate pain management is yet available.
Although nurses are responsible for infants’ care andpain assessment, little is known about their experiences
during the eye examinations. A better understandingof how nurses perceive infants’ eye examinations could
help identify areas for improvement in care during eye

Page 2 of 11

examinations and potentially lead to more effective pain
and stress management.
Aim

The aim of this study was to explore nurses’ perceptionsof preterm infants’ eye examinations.

Methods
DesignIn this phenomenographic interview study, the phenomenon under study was preterm infants’ eye examinations. A phenomenographic approach aims to describe
the various ways people experience and comprehend aphenomenon in the world around them [16]. This is also
referred to as a second-order perspective [17]. While afirst-order perspective would provide a description of thevarious aspects of infant eye examinations (how something “really is”), a second-order perspective provides
a description of how the different aspects of infant eye
examinations were perceived by the participating nurses.
The reporting of the Study followed The ConsolidatedCriteria for Reporting Qualitative Research (COREQ)[18].
Study setting and recruitment

Nurses working at Swedish neonatal units with > 12months neonatal work experience and who had participated in at least two eye examinations of preterm
infants were invited to participate in the study. Information about the study was distributed to various organizations for paediatric nurses, Facebook groups for Swedish
neonatal nurses, and personal contacts of the authors. A
snowball selection strategy [19] was also used where participating nurses could suggest colleagues who might bequalified and interested in participating.
Data collection

To capture qualitative descriptions of the participants’experiences [20], semi-structured interviews were conducted from February 2021 to May 2022. An interview
guide was developed from a version used in a previous
study addressing nurses’ experiences of caring for nonverbal children in pain [21]. In the current study, thequestions were adapted specifically to preterm infantsand eye examinations. In preparation for the interview,the nurses were asked to recall two eye examinations
they had participated in, preferably one they perceived
as positive and one they considered unfavourable. A pilot
interview was performed to test the interview guide. Nochanges were made to the guide and the pilot interview
was included in the analysis.
All interviews but one were performed online due to
COVID-19 restrictions. The first author performed eightinterviews, and the last author performed two interviews

Misic et al. BMC Pediatrics(2024) 24:579

Page 3 of 11

Table 1 The seven analytical steps described by Sjöström and Dahlgren (2002) as performed in the current study
Familiarization
Compilation of responses

Condensation

Preliminary grouping
Comparison of categories
Naming of the categories
Contrastive comparison

The first author listened to the interviews and corrected the transcripts. All authors read the transcribedinterviews to familiarize themselves with the data.
The most significant parts of the informants’ responses were identified and extracted from four of the transcripts. Eachauthor extracted significant parts individually, and these were compared within the group to confirm that similar parts
were identified. The first author then extracted and compiled significant responses from the remaining transcripts.
The individual answers were shortened to identify their most central parts: the first author condensed the excerpts,
and the co-authors read through the condensed material, compared it with the original statements, and discussed
their understandings to ensure that the substantial meanings were retained.
The first author sorted the condensed meanings into preliminary categories, which all authors discussed on several
occasions.
The preliminary categories were compared to find associations and establish borders between them. The authors discussed and revised these associations and borders in a process to agree on subcategories and descriptive categories.
After thoroughly discussing their collective understanding of the categories, all authors named the final descriptive
and subcategories to highlight their inherent meanings.
The unique character of each descriptive category and the resemblances between them were described.

Fig. 1 Hierarchy of and resemblance between the descriptive categories

with nurses who had ongoing professional relationships
with the first author. Both interviewers are paediatricnurses with neonatal care experience. The last author isan experienced qualitative researcher, and the first author
is a doctoral student. The interviews, which took from17 to 60 min (median = 34 min) were recorded on digital
voice recorders and transcribed by the first author.
Characteristics of participants

Ten neonatal nurses from seven different hospitals volunteered to participate and were included in the study.
Their ages ranged from 27 to 65 (mean 42 years) andtheir working experience in neonatal intensive care
ranged from 5 to 38 years (mean 17 years). Nine nurses
worked at a university hospital and six of the seven university hospitals in Sweden were represented. Only
female nurses chose to participate. Nine had a degreein paediatric nursing and one was undergoing specialist
education at the time of the data collection.
Data analysis

The data analysis followed the steps described by
Sjöström and Dahlgren [17], which are further describedin Table 1. Although the steps are described linearly, theanalysis was iterative and moved back and forth among
the steps.

Results
The nurses’ perceptions of the preterm infants’ eye
examinations resulted in four descriptive categories: [1]Infants are affected by the eye examination; [2] Nurses
have comprehensive overall responsibility for the infants;[3] Parents are important to their infants, but they needsupport to fulfil their parental role; and [4] Collaboration
is important for a favourable examination outcome. The
resemblances between the categories are described inFig. 1 and in Table 2 the categories and respective subcategories are outlined.
Contrastive comparison of the categories

The descriptive categories showed a variety of nurses’
perspectives of the phenomenon under study, all ofwhich were related to the nurses’ focus on the infant’s
best interest. Nurses considered the infant the central
figure in the eye examination, and they perceived theirprimary professional role as advocating for the infant andsafeguarding their well-being. The eye examinations wereperceived to cause infants distress and discomfort, andnursing care was provided to support the infants’ wellbeing. Despite the necessity of nursing care, parents wererecognized as the most important people to the infant,but the parents required support and guidance from thenurses and the ophthalmologists to take an active role.

Misic et al. BMC Pediatrics(2024) 24:579

Page 4 of 11

Table 2 Descriptive categories and subcategories
Infants are affected by the Nurses have comprehensive overall
eye examination
responsibility for the infants
The examination causes theinfant discomfort
Infants react differently during the examination

Parents are important to their infants, butthey need support to fulfil their parentalrole
Nurses want to be in control to safeguard The examination is stressful for parents
the infant’s well-being
Nurses provide infants with nursing
Parents need information and support to ascare and administer pharmacologicalsist their infant during the examination
treatment
Nurses advocate for the infantParents support their infant in different ways
Nurses become emotionally involved

To achieve the best outcome for the infant, interprofessional and parental collaboration was necessary, which inturn required a shared understanding of the infant’s wellbeing. The nurses perceived themselves as indispensable in facilitating this collaboration. Inherent in all theperspectives of the phenomenon is the nurses’ implicit
notion that nurses have comprehensive overall responsibility for the infants, which is the most complex descriptive category. This includes to safeguard the wellbeing forthe infant and parents in the here and now, while simultaneously facilitate for the ophthalmologist to be able toperform the examination accurately, as this is of crucial
importance for the infant’s future health. Furthermore,
there is a relationship between the descriptive category“Infants are affected by the eye examination” and thedescriptive categories “Parents are important to theirinfants, but they need support to fulfil their parental role”
and “Collaboration is important for a favourable examination outcome” respectively. In addition to nursing care,both parental support and collaboration are important toensure the wellbeing of the infant.
Infants are affected by the eye examination
The examination causes the infant discomfort

Based on how the examination looks and how the infants
react, nurses perceived the eye examinations as unpleasant for the infants. It was also described as stressful andchallenging. Even if the infant managed the examination
well, it was still perceived as a difficult situation.
I do not know if I have ever seen an ROP examination that has been top notch since they are tough.
(Nurse 3)
Some nurses explicitly mentioned the examination as
painful for the infants, particularly when the eye was
directly manipulated or when a speculum was used
to hold the eye lids open. The use of the speculum wasdescribed as “horrible” and “uncomfortable” for the
infants.
The perceptions of different examination methods
varied, and although the ‘horrible’ eyelid speculum wasused during the RetCam examinations, some nurses

Collaboration is important for a favourable
examination outcome
Communication and joint
understanding are crucial
The attitude of the ophthalmologist affects the atmosphere of the examination

recognized this method as more convenient for the
infant, as it led to quicker and safer examinations.
The challenging part [of the eye examination] takes
approximately thirty seconds in an eye with severe
ROP changes. So, thirty seconds or ten minutes, you
can understand that the [shorter] time perspective isthe winner [comparing the time to use RetCam with
conducting a manual examination]. (Nurse 4)

Infants react differently during the examination

The infants displayed different reactions both during different stages of the eye examinations and in comparison
to other infants. However, common reactions during theexaminations were changes in physiological parameterssuch as a reduction in oxygen saturation and heart rate.
Infants could also require more oxygen throughout theexaminations.
His oxygen saturation fluctuates a lot due to his very
sick lungs, but during the examination it becomeseven worse. (Nurse 3)
Nurses also observed different behavioural expressionsof discomfort, such as crying, tensing arms or legs, or
becoming ‘floppy’. Nurses also formed an impression of
the infant as stressed.
I knew her well and noticed that she was twisting and got a bit distressed. She moved her arms.
Despite holding her, one could feel that she was restless. (Nurse 10)
Different factors affected how the infant responded to theeye examinations; some nurses mentioned the infants’levels of sickness and maturity, and they noted that thesame infant could react differently to examinations at different times.
Well, my experience is that infants react during eye
examination on different levels, but there is always
some sort of reaction. (Nurse 1)

Misic et al. BMC Pediatrics(2024) 24:579

After the eye examination, the infants were often perceived as tired and in need of recovery time, especiallyafter examinations that nurses regarded as unfavourable.
And you can also see that the infants are exhausted
afterwards, they are unstable. (Nurse 5)
It was not only the examination that was perceived toaffect the infant’s well-being. The eye drops given before
the examination could also have negative side effects,
such as increased heart rate, digestive problems, and sensitivity to light.
Despite the general perception that the infants usually reacted negatively to the examination, there werealso reports of infants who did not seem to react. Some
infants slept through the examination or were perceived
as calm and physically stable.
She was calm and stable regarding oxygen saturation, heart rate, and blood pressure, and she was not
at all affected during the examination. (Nurse 9)

Nurses have comprehensive overall responsibility for the
infants
Nurses want to be in control to safeguard the infant’s wellbeing

The nurses felt responsible for the infants’ well-being
during the examination since they regarded themselves
as knowing the infant best. They wanted to be in controlof the infant’s status, both by controlling equipment suchas respiratory support and monitoring the infant’s physiological parameters and expressions.
I trust myself, and I also feel that I am [the one
responsible]. If, for example, the baby is on CPAP ora ventilator, then I want to be in control to ensurethat everything is still in place and the mask has not
slid out of position. I want to be there [in a central
position], so I really can see and not have the [ophthalmologist’s] hands in the way. (Nurse 8)

Nurses provide the infant with nursing care and administerpharmacological treatment

Nursing care was perceived as crucial to the infant’s ability to cope with the examination. The nurses believedthat their nursing care could make a significant difference
for the infant during the examination and that such carehelped the infants get through the examination. The goalof their nursing care was to leave the infant with enoughstrength to recover after the examination.

Page 5 of 11

Because of our different understanding of the infants
and their needs for support and holding [comparedwith professionals from the eye clinic], we can help
and comfort them during the very tough situation of
the eye examination. This is true whether the ophthalmologist uses lights only or uses RetCam: one
can make a great difference solely with nursing care.
(Nurse 7)
Preparations before the eye examination were recognized
as an essential aspect of nursing care and an important
prerequisite for the infant’s well-being during the examination. These could include swaddling, changing the diaper, and feeding. During the examination, holding theinfant was described as crucial to assist the infant and to
make them feel safe and supported through the examination. Despite this positive aspect of holding, it could
sometimes be perceived as restraining the infant, especially when it was important for the infant to keep still forthe examination to be safe.
Another aspect of nursing care considered important
for the well-being of the infant was their positioning.
Most infants disliked being placed on their backs during the examination. By positioning infants on their side,even more seriously ill infants could get through the eye
examination while remaining relatively stable. The nurses
also said it was important to take breaks when the infant
showed signs of exhaustion, decreased oxygen saturation,or low pulse during the examination. Infants were given
extra support after the examination, such as by being
held skin-to-skin by a parent or by having fewer otherprocedures the same day.
The infant’s perceived experience of the examination as
hard and stressful could lead to a change of routines. Bychanging the place of the examination to the arms of theparents, for example, the nurses experienced an immense
improvement for the infants. This led to nurses having
more positive feelings towards the examination and perceiving that the infants handled the examination betterand recovered sooner. ‘We are so positive now; we thinkthat it goes so much better and that feels great’ (Nurse 5).
Nevertheless, it was also perceived as important that theexamination should be safe for the infant as well as ergonomic for the ophthalmologist.
Adaptations of the environment such as dimmed lights
and a reduction of noise in the room where the examination took place were other nursing care actions to support the infants. The nurses always tried to keep a calmand quiet environment, but this was perceived as especially important during eye examinations. By reducing
the lights, nurses felt that the activity in the room automatically slowed down. As the infants were perceived assensitive to light due to the mydriatic eyedrops, the room
was kept dark after the examination as well. AlthoughMisic et al. BMC Pediatrics(2024) 24:579

the infants were given optimal conditions, however, thenurses sometimes perceived that it was not enough to
support them.
We swaddle, we give [oral] glucose, we help by holding the head, the setting is quiet and calm, but the
infant is still not settled, maybe unstable in oxygen
saturation, screams, and is sad and sweaty. (Nurse
6)
Besides nursing care, the nurses also supported theinfants by administering pharmacological treatments.
The infants sometimes received oral glucose before andduring the eye examination and in combination with apacifier. Other pharmacological support, such as sedatives or analgesics were not prescribed routinely, butwere offered to infants when needed. Some nurses
debated the necessity of providing more pharmacologicalsupport during the eye examination.
Nurses advocate for the infant

The nurses considered themselves as the voice of theinfants. As such, it was their obligation to advocate forthe infant during the eye examinations. When an infant
was not doing well, they spoke up and stopped the ophthalmologist from proceeding with the examination.
I noticed the condition of the infant and spoke up.
I acted as the child’s advocate; it feels like my mostimportant role in such a situation. (Nurse 9)
There was a strong belief among the nurses that theparents of the infant should be present to support theirinfant during the eye examinations. They believed thatthe role of the parents was irreplaceable, and they therefore worked to enable the parents to be there for theirinfant even when it was difficult for the parents to copewith the situation.
Nurses become emotionally involved

The eye examinations affected the nurses emotionally. In
general, they were perceived as a troublesome procedure
for the infants. When the examinations were perceived togo smoothly and favourably for the infant, the nurses felt
content and satisfied.
It is for the infant. I want the infant to be content,
and when I notice that the infant is doing well, then I
feel well, too. (Nurse 8)
The nurses wanted to do what was best for the infants,
but although they did their very best, they felt it was
not enough if the examination turned out to affect the
infant badly. Nurses also felt frustrated when they felt the

Page 6 of 11

ophthalmologist did not listen to them and went ahead
with the examination in a way that was not in line withthe condition of the infant.
When the examination was perceived as unfavourable
for the infant, nurses could have feelings of failure. They
empathized strongly with the infant in discomfort, and it
was difficult for them to see the infants crying and suffering. Nurses usually felt sad after examinations they perceived as having caused the infant to suffer, and they tried
to cope with this by helping the infant and parents withextra support afterwards.
It tears you up; you almost feel it yourself when they
start having decreases in their oxygen levels and do
not feel well afterwards. I feel it in my whole body,
because when you work with these [vulnerable
infants] you want to do what is best for each infant.
(Nurse 7)
Because the examination could cause pain and discomfort to the infant, the nurses sometimes questioned thenecessity of the eye examinations, but mostly they agreed
that it was an important and necessary procedure for thesake of the infants’ long-term well-being.
Parents are important to their infants, but they needsupport to fulfil their parental role
The examination is stressful for parents

The examinations were perceived as difficult for theparents to endure and sometimes the parents could not
manage to be present. When the examination made theinfant suffer, parents were perceived as feeling sad andmiserable, which made it hard for them to support theirinfant.
I have experienced, during an unfavourable examination that they [the parents] can’t stand staying
at bedside and instead they say ‘I´ll go and sit overthere for a while’, the staff stands closest to the infant
instead. (Nurse 5)

Parents need information and support to assist their infantduring the examination

Nurses felt it was important that parents were informed
about the examination to be able to participate and support their infant. They also considered it essential toprepare parents for what to expect during the examination. The nurses felt they had more knowledge and control than the parents and so they could predict how the
infant might react during the examination. They perceived it as important to share this knowledge with theparents to support them in being active participants inthe care of their infants. Parents were informed aboutMisic et al. BMC Pediatrics(2024) 24:579

how the examination was performed, how they could
provide support, and how their infant might react during
the examination. The parents also received information
about the findings in the eyes directly from the ophthalmologist before, during, and after the examination, which
the nurses felt was beneficial.
The nurses’ perceived that it was important to encourage the parents by telling them that they had an important role in supporting the infant. For the well-being of
the parents, the nurses felt it was better for the parents tosee the examination with their own eyes than to have it
described to them afterwards.
To recite the course of the examination to them feels
totally worthless. They need to see what is done totheir infants. (Nurse 1)

Parents support their infant in different ways

When the parents were informed and had previously participated in eye examinations, they could take on a more
active parental role in supporting their infant. As parents
gained experience in participating in the care of theirinfant, nurses perceived that providing support during
the examination came more naturally to them.
The nurses described how the parents comforted theirinfants by holding them and talking or singing calmly.
Occasionally parents could also administer the oral glucose and offer the pacifier to the infant. Because nurses
felt that the parents should be the infants’ main support
during the examination, they were willing to change their
nursing role to support the infant through supporting theparents.
When the examination was performed in the arms of
the parents, the nurses perceived it as positive for boththe parents and the infants. The parents then became
more included and took a more active role supporting
the infant. The nurses felt that the infants became muchcalmer, which shortened the examination time.
Even if it is a challenge and exhausting for the infant– challenging because an eye examination is still atough procedure – they recover more rapidly when
comforted and supported by their parents. (Nurse 4)
Likewise, the nurses experienced it as more favourable
for both infants and parents when the examinations took
place in the family care room. The infant did not have to
be moved into another room, and the parents were perceived to feel safer in the environment they had createdwith their infant at the unit.
Previous experiences during the neonatal care could
affect the parents in ways that the nurses perceived
as negative for the infant. This could cause a clash in

Page 7 of 11

perspectives between what nurses and parents thought
the infant needed.
Collaboration is important for a favourable examination
outcomeCommunication and a joint understanding are crucial Collaboration was described as positive interaction
between nurses, parents, and ophthalmologists to perform the examination in the best possible way for the
infant. Communication was crucial to the interaction
between the nurses and the ophthalmologists, and by
sharing information they could create a joint understanding of the infant’s situation. Since the ophthalmologists
did not have primary knowledge about preterm infants,
the nurses considered themselves responsible both for the
infant’s well-being during the examination and for leading
the team. The nurses expressed a need for ophthalmologists to learn how best to care for preterm infants andimprove their well-being during the examination.
The collaboration around the infant during the examinations also included other colleagues. When the infants
were more fragile and vulnerable, more staff were needed
to support them. In such cases an explicit distribution of
responsibilities was agreed upon; for example, one staff
member might be responsible for keeping the breathingtube in place, another for monitoring the infant’s physiological measures, a third for supporting the parents andthe infant, and a fourth for assisting the ophthalmologist
by holding the infant’s head.
The nurses believed it was favourable when the ophthalmologists brought their own assistant from the eye
clinic to help them. Nevertheless, sometimes the nurses
regarded themselves as the ophthalmologist’s assistant by
being responsible for creating favourable conditions forthe examination.
The nurses’ experiences of collaborating with ophthalmologists were mostly favourable.
However, there were times when the interaction was
experienced as unfavourable.
The triangle of us [the nurse, the ophthalmologist,
and the parent] does not really come together to help
the infant. So, the collaboration between the three ofus did not work optimally. (Nurse 2)

The attitude of the ophthalmologist affects the mood of theexamination

The nurses mostly reported the ophthalmologists as acting professionally and responding to the infant’s wellbeing. The examining ophthalmologists were often
known to the nurses from previous examinations, which
generated a feeling of security.

Misic et al. BMC Pediatrics(2024) 24:579

It was generally perceived as negative when the different professionals’ perspectives collided, for example,
when nurses and ophthalmologists did not have a sharedunderstanding of the examination situation. The examination could also be perceived as less favourable for the
infant when nurses felt the ophthalmologist did not listen
to them and prioritized finishing the examination overthe infant’s well-being.
He was not very cautious and did not listen [to thenurse]. He just wanted to turn up and do what hewas supposed to do and then leave. It felt like hedidn’t give a shit about whether it was okay for the
infant or not. (Nurse 10)
When the nurses wanted to further develop their caring
routines during the eye-examinations, the ophthalmologists were not always positive about the change and questioned whether the examination could still be performed
correctly and whether the infant’s well-being was more
important than the outcome of the examination. However, some ophthalmologists were reported to support
the development of new routines for the well-being of theinfant. In addition, the nurses talked about ophthalmologists who themselves had initiated to perform the eye
examination with the infant placed skin-to-skin with oneof their parents.
The nurses expressed a desire for the ophthalmologist
to perform the examination quickly and with infant’s bestof interest in focus. However, sometimes they observedthat ophthalmologists were stressed by a large workload
and having many infants to examine within a limited
time. The stress caused by these circumstances was perceived as negative for the outcome of the examination,
as it threatened the infant’s well-being, especially when
the ophthalmologist did not want to take breaks that the
infant needed. However, some nurses considered thatearlier negative experiences could affect the ophthalmologists’ understanding about why an examination mightneed to be stopped.

Discussion
Nurses found ROP eye examinations to be uncomfortable and stressful for the infant. Their overall goal during
the eye examination was to support the well-being of theinfant and they considered nursing care, which was theirmajor responsibility, very important. They also emphasized the importance of the parents as an irreplaceablesupport for the infants during the procedure. A favourable examination for the infant required collaboration
among the professionals and the parents. The ophthalmologist’s attitude was also reported as essential to thesuccess of the procedure.

Page 8 of 11

Infants are affected by the eye examination

The nurses described some elements of the examination,such as the use of the eyelid speculum and manipulation of the eye as painful, but not the examination itself.
Instead, they used words such as “discomfort” or “stress”
when describing their experiences of infants undergoingeye examinations. This is somewhat different from previous research, which on a more general level has claimed
that eye examinations could be painful for the infant [6].
Perhaps the thought of participating in a routine procedure that causes pain is challenging for nurses, making
them use less loaded expressions when describing theirperception of the infants’ experience as a coping strategy.
However, such coping mechanisms could lead to bias intheir assessments of infants’ pain [22]. Previous research
indicates underassessment of infants’ pain may be due
more to factors such as the infants’ inability to express
pain or previous knowledge of the infants from other caring situations [23] than to nurses’ biases. Since infants are
not able to self-report their pain and distress, other indicators are needed. Korhonen et al. [13], suggested the useof physiological parameters such as alterations in oxygen
saturation and heart rate along with behaviours such as
crying and moving. The nurses in this study described
how such indicators of pain helped them to interpretwhen the child was in pain, adding to our knowledge on
pain associated with eye examinations in preterm infants.
Nurses have comprehensive overall responsibility for the
infants

As in other previous studies of the nursing role during
ROP examinations of preterm infants, these nurses felt
an overall responsibility for the outcome of the eye examinations. In fact, it was found to be the most comprehensive way of thinking about eye examinations. The nursing
role has been identified as preventing ROP through nursing care and taking responsibility for the infant before,
during, and after the eye examinations, and supportingand counselling the families [24]. However, the particular role and overall responsibility of the neonatal nurse iscomplex and remains not only during eye examinations.
Nurses in neonatal units need to have special competencies that are crucial for providing safe and high-quality
care [25].
The nurses in this study became emotionally involved
and mentioned feelings of failure when they perceived
distress in the infants as they considered preventing such
distress a part of their overall responsibility. This is comparable to earlier research in which nurses expressed feelings of stress and personal pain when they felt the infantsin their care were not doing well [12]. These findings
indicate a need for further investigation into the stress of
neonatal nurses to identify what actions might be taken
to prevent and alleviate these feelings.

Misic et al. BMC Pediatrics(2024) 24:579

Parents are important to their infants, but they needsupport to fulfil their parental role

The parents were perceived as invaluable partners during
eye examinations. This could be because parents are now
usually recognized in neonatal care units as primary caregivers to their infants. Several pillars of family-centredcare in this setting, such as the principles of informationsharing, support, collaboration, and empowerment, arementioned in the findings of this study. In family-centredcare, parents are supported in caring for their infants,
usually with positive outcomes for both the infants andthe parents [26]. When the parents are present in the
neonatal unit and regarded as members of the team, they
become even more involved in the care of their infant
and take on a more active role [27], which was in linewith the current findings. Involving parents has also beenfound to improve the infants’ pain management [28],and parents want and need to participate in their infants’
pain management [29]. The nurses in the current study
strongly supported the positive effect of parental involvement in their infant’s care and pain management, butthey also reported that some parents could not manage
being at the eye examinations. Therefore, supporting parents to stay at their infant’s bedside was another aspectof the nurses’ responsibility to provide the best circumstances for infants undergoing eye examinations, as outlined in this descriptive category.

Collaboration is important for a favourable
examination outcome
The setting of the eye examination includes interprofessional collaboration between the nurses and ophthalmologists, but the nurses highlighted that the collaborationneeded to be based on a mutual understanding andrespect for each other’s competences. This is in line withtheoretical framework on interprofessional collaboration,
where collective action has been called for to addresscomplex tasks and for team members to respect and trust
each other [30].
Ophthalmologists in a previous qualitative study
expressed discomfort with examining preterm infants
and reported that stress and the set-up of the examination could make it burdensome. Nevertheless, they said
they were committed to the task and needed the nurses’
help with preparations for the examination [31]. Whenthe nurses in the current study discussed their collaboration with the ophthalmologists, they demonstrated anunderstanding of these aspects. Neonatal care includes
several types of interprofessional collaboration, both in
the daily work at the unit and in other units; therefore,
these nurses have much experience of collaboration. In
the future, however, the particular topic of collaboration
during eye examinations could be explored more in detail

Page 9 of 11

to facilitate collaboration focused on the best interests of
the infant.
Implications for education

The various ways of understanding preterm infants’ eye
examinations, can provide a base for nurses’ learning andeducation. Nurses need knowledge and skills within theareas identified in this study. They need knowledge andeducation about pain and how preterm infants express
pain, the nursing care and pharmacological treatment
during eye examinations and how to best support parents
in these situations. Furthermore, they need knowledge
about the ophthalmologist’s procedures and experiencesfrom performing eye examinations, as well as knowledge
and skills in how to best facilitate collaboration. All thisknowledge is needed for the wellbeing of the infant.
Strengths and limitations of the work

A major strength of this study is its focus on the nurses’
perspectives on eye examinations in preterm infants,
which adds to our knowledge of various professionals’
perspectives. The nurses in this study worked in different
hospitals and had different experiences, which is anotherstrength as it allowed us to capture different perspectives
on, and perceptions of, the phenomenon under study.
The sample size was rather small, but nevertheless, we
obtained a variation of perceptions, adding to the opportunity for a contrastive comparison of the descriptive
categories and to find a resemblance between them. In
phenomenographic research a range of 10–30 participants are typically considered large enough to capture
sufficient variation [32]. In the future, it would be valuable to add to current knowledge by researching the perspectives of parents and other staff at the neonatal unit.
As the phenomenographic approach strives to investigate
the phenomenon within a homogeneous group [33], we
did not consider it appropriate to include other perspectives in this study.
The nurses were asked to prepare themselves before theinterview by thinking of two cases they had experienced,
preferably one positive and one negative. This design created variation within the phenomenon, which is desirable in a phenomenographic design and could be seen as
a strength [16]. However, not all nurses imagined individual cases, but reported more generally on what they
perceived as more or less favourable eye examinations,which could be considered a limitation.
The first author, who performed most of the reviews
had limited experience of interviewing, which could be
regarded as a limitation; however, the interview guide
was thoroughly discussed, and the interviews were
continually reviewed and followed up on by the otherresearchers to control the quality of the interviews and toMisic et al. BMC Pediatrics(2024) 24:579

supervise the interviewer, which increases the credibilityof the study.
Despite some researchers stating the importance toadhere to the advances in methodology [34], we decided
to follow the analysis steps by Sjöström and Dahlgren [17], which for example differ from more recent
approaches, as they do not use the concept of ‘outcome
space’. Instead, the last step in the approach describedby Sjöström and Dahlgren [17] is to describe the uniquecharacter of each descriptive category and the resemblances between categories. Nevertheless, we interpretthat as being similar to what in later research is referred
to as an outcome space. Sin [33] for example, states thatan outcome space is accommodating both the uniqueessence of each category and the relationships between
them [33]. In this article the relationship and hierarchy
between the categories was presented in Table 2; Fig. 1.
Recommendations for further research

Neonatal nurses participate in advanced care of preterm
infants and assist in various painful and stressful procedures. Further research is therefore needed to explore
how nurses experience these situations and to further
develop the nursing care and support these nurses. The
perspectives of other members in the team around theinfant are also of interest for future research; since theperspectives of ophthalmologists have already been studied, there is a need for more knowledge about the parents’ experiences. Furthermore, as previous research has
shown that eye examinations generate pain and stress ininfants, additional research is needed to improve nursing care of the infants during these examinations. Future
research might also include an observational study using
video technology to capture infants’ expressions of pain
during different phases of the examination, the workof the nurses, and the collaboration among all parties
present.
Implications for policy and practice

The nurses’ reported perceptions showed that infants’
pain might vary during eye examinations, that the parents’ presence was important, that the nurses felt a huge
responsibility, and that a well-functioning collaborationis needed for a favourable outcome for the infant. Thisknowledge is of great value for nurses, but also for ophthalmologists and other health care professionals participating in eye examinations of preterm infants. These
results may also be applicable to other painful procedures
performed in neonatal care. Furthermore, the findings
bring useful insights for managers. If they are to develop
the care of preterm infants during eye examinations, theyneed to consider various aspects of care and support for
all involved parties.

Page 10 of 11

Conclusions
The nurses in this study perceived themselves as having
overall responsibility for preserving the well-being of theinfant and for the eye examination to be successful. By
providing nursing care, supporting parental participation
and by interprofessional collaboration they believed thatthe well-being of the infant could be safeguarded.
Acknowledgements
The authors would like to thank the nurses participating in this study for
generously sharing their experiences.
Author contributions
The contributions of the authors according to the CrediT, contributor roles
taxonomy. MCM: Conceptualization, Investigation, Formal Analysis, Writing
original draft. EO: Conceptualization, Formal Analysis, Writing – review andediting. RDA: Conceptualization, Formal Analysis, Writing – review andediting. AAC: Conceptualization, Investigation, Formal Analysis, Writing –review and editing. All authors reviewed the manuscript.
Funding
This study was supported by ALF funding, Region Örebro County.
Open access funding provided by Örebro University.
Data availability
The datasets used and/or analysed during the current study are available fromthe corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
In Sweden ethical approval is not needed for this kind of study, however wesent in an application and received a favourable advisory statement from theSwedish Ethical Review Authority (Dnr 2020–05984). Prior to participation, theparticipants received written and verbal information about the study and that
their participation was voluntary and that they could withdraw from the study
at any time. Written informed consent was collected from the participants
before the interviews. The study was conducted according to the Declarationof Helsinki [35]. During the analysis, the data were kept in a safe databasehosted by Region Örebro County. Quotations used in the Result sections
were translated as closely to the original statements as possible but edited toreduce the risk of exposing the identities of the participants or the families.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Received: 16 April 2024 / Accepted: 30 August 2024

References
1. Platt MJ. Outcomes in preterm infants. Public Health. 2014;128(5):399–403.
2. Hartnett ME. Advances in understanding and management of retinopathy ofprematurity. Surv Ophthalmol. 2017;62(3):257–76.
3. Holmstrom G, Hellstrom A, Granse L, Saric M, Sunnqvist B, Wallin A et al. New
modifications of Swedish ROP guidelines based on 10-year data from the
SWEDROP register. Br J Ophthalmol. 2019.
4. Moral-Pumarega MT, Caserio-Carbonero S, De-La-Cruz-Bertolo J, TejadaPalacios P, Lora-Pablos D, Pallas-Alonso CR. Pain and stress assessment after
retinopathy of prematurity screening examination: indirect ophthalmoscopy
versus digital retinal imaging. BMC Pediatr. 2012;12:132.
5. Kremer LJ, Reith DM, Medlicott N, Broadbent R. Systematic review of mydriatics used for screening of retinopathy in premature infants. BMJ Paediatr
Open. 2019;3(1):e000448.

Misic et al. BMC Pediatrics

6.
7.
8.
9.
10.

11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

(2024) 24:579

Rush R, Rush S, Ighani F, Anderson B, Irwin M, Naqvi M. The effects of comfort
care on the pain response in preterm infants undergoing screening forretinopathy of prematurity. Retina. 2005;25(1):59–62.
Disher T, Cameron C, Mitra S, Cathcart K, Campbell-Yeo M. Pain-Relieving
interventions for Retinopathy of Prematurity: a Meta-analysis. Pediatrics.
2018;142(1).
Francis K. What is best practice for Providing Pain Relief during Retinopathy ofPrematurity Eye examinations? Adv Neonatal Care. 2016;16(3):220–8.
Sun X, Lemyre B, Barrowman N, O’Connor M. Pain management during eye
examinations for retinopathy of prematurity in preterm infants: a systematic
review. Acta Paediatr. 2010;99(3):329–34.
Pirelli A, Savant Levet P, Garetti E, Ancora G, Merazzi D, Bellieni CV, et al.
Literature review informs clinical guidelines for pain management during
screening and laser photocoagulation for retinopathy of prematurity. Acta
Paediatr. 2019;108(4):593–9.
Thirunavukarasu AJ, Hassan R, Savant SV, Hamilton DL. Analgesia forretinopathy of prematurity screening: a systematic review. Pain Pract.
2022;22(7):642–51.
Green J, Darbyshire P, Adams A, Jackson D. It’s agony for us as well: neonatal
nurses reflect on iatrogenic pain. Nurs Ethics. 2016;23(2):176–90.
Korhonen A, Haho A, Polkki T. Nurses’ perspectives on the suffering of preterm infants. Nurs Ethics. 2013;20(7):798–807.
Nimbalkar AS, Dongara AR, Phatak AG, Nimbalkar SM. Knowledge and attitudes regarding neonatal pain among nursing staff of pediatric department:
an Indian experience. Pain Manag Nurs. 2014;15(1):69–75.
Gibbins S, Stevens B, Dionne K, Yamada J, Pillai Riddell R, McGrath P, et al.
Perceptions of health professionals on pain in extremely low gestational age
infants. Qual Health Res. 2015;25(6):763–74.
Marton F. Phenomenography — describing conceptions of the world aroundus. Instr Sci. 1981;10(2):177–200.
Sjöström B, Dahlgren LO. Applying phenomenography in nursing research. J
Adv Nurs. 2002;40(3):339–45.
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative
research (COREQ): a 32-item checklist for interviews and focus groups. Int J
Qual Health Care. 2007;19(6):349–57.
Johnson TP. Snowball Sampling: Introduction. Wiley StatsRef: Statistics Reference Online2014.
Patton MQ. Qualitative research & evaluation methods: integrating theory
and practice. Thousand Oaks, Calif.: Sage; 2015.
Andersen RD, Nakstad B, Jylli L, Campbell-Yeo M, Anderzen-Carlsson A. The
complexities of nurses’ Pain Assessment in Hospitalized Preverbal Children.
Pain Manag Nurs. 2019;20(4):337–44.
Prkachin KM, Solomon PE, Ross J. Underestimation of pain by health-careproviders: towards a model of the process of inferring pain in others. Can J
Nurs Res. 2007;39(2):88–106.

Page 11 of 11

23. Pillai Riddell R, Racine N. Assessing pain in infancy: the caregiver context. Pain
Res Manag. 2009;14(1):27–32.
24. Kalyan G, Moxon S. The role of neonatal nurses in the Prevention of Retinopathy of Prematurity. Indian Pediatr. 2016;53(Suppl 2):S143–50.
25. Talus E, Seppänen H, Mikkonen K, Palomaa AK, Pölkki T. The competenceof neonatal intensive care nurses: a systematic review. Nurse Educ Today.
2023;128:105892.
26. Franck LS, O’Brien K. The evolution of family-centered care: from supporting
parent-delivered interventions to a model of family integrated care. BirthDefects Res. 2019;111(15):1044–59.
27. Thernström Blomqvist Y, Ågren J, Karlsson V. The Swedish approach to nurturing extremely preterm infants and their families: a nursing perspective. Semin
Perinatol. 2022;46(1):151542.
28. Pierrat V, Marchand-Martin L, Durrmeyer X, Vasante L, Burguet A, CambonieG, et al. Perceived maternal information on premature infant’s pain duringhospitalization: the French EPIPAGE-2 national cohort study. Pediatr Res.
2020;87(1):153–62.
29. Ullsten A, Andreasson M, Eriksson M. State of the art in parent-delivered
Pain-relieving interventions in neonatal care: a scoping review. Front Pediatr.
2021;9:651846.
30. D’Amour D, Ferrada-Videla M, San Martin Rodriguez L, Beaulieu MD. The
conceptual basis for interprofessional collaboration: core concepts andtheoretical frameworks. J Interprof Care. 2005;19(Suppl 1):116–31.
31. Bain LC, Kristensen-Cabrera AI, Lee HC. A qualitative analysis of challenges and successes in Retinopathy of Prematurity Screening. AJP Rep.
2018;8(2):e128–33.
32. Stenfors-Hayes T, Hult H, Dahlgren MA. A phenomenographic approach toresearch in medical education. Med Educ. 2013;47(3):261–70.
33. Sin S. Considerations of quality in Phenomenographic Research Introduction.
Int J Qualitative Methods. 2010;9.
34. Åkerlind GS. Common misunderstandings of phenomenographic research inhigher education. High Educ Res Dev. 2024;43(1):1–16.
35. World Medical A. World Medical Association Declaration of Helsinki:
ethical principles for medical research involving human subjects. JAMA.
2013;310(20):2191–4.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.