Lens on eye care in intensive care units: deficiencies, training, and improvement recommendations – a descriptive observational study

Abstract

Background

Eye care in intensive care unit is often neglected in environments where attention is primarily directed toward life-threatening conditions. Such neglect can result in ophthalmological complications, vision loss, and reduced patient comfort. Although several evidence-based protocols exist, their implementation in daily nursing practice remains unclear in many settings.

Objective

This observational study aimed to assess the eye care practices of intensive care unit nurses and examine the demographic and professional factors influencing these practices. The study further sought to generate data-driven improvement recommendations for clinical practice.

Methods

A descriptive observational study was conducted between December 2024 and April 2025 in the adult internal medicine ICU of a tertiary hospital in the Central Anatolia Region of Turkey. All nurses in the ICU, except those on leave or sick leave, were included, resulting in a sample of 32 participants. Data were collected using two instruments: a structured Demographic Information Form and a 16-item Eye Care Observational Form developed based on evidence-based guidelines. Each nurse was observed in real time during three separate care sessions, with patients selected consecutively during assigned shifts, and the average number of patients observed per shift was 2–3. Data analysis was performed using IBM SPSS Statistics 22.0, applying descriptive statistics, chi-square tests (χ²), and multiple regression analysis to identify significant predictors of correct eye care practices.

Results

It was determined that 68.7% of nurses adhered to hand hygiene in eye care. Nonsterile materials (e.g., wet wipes) were frequently used for eye cleaning, with only 31.2% using sterile gauze and 0.9% using isotonic sodium chloride solution. Furthermore, none of the nurses reported any eye complications in their patients. Level of education in eye care was found to be a statistically significant factor (p < 0.05); nurses with a bachelor’s degree demonstrated better adherence to evidence-based practices.

Conclusion

This study revealed critical deficiencies in eye care practices among intensive care unit nurses and emphasized the role of formal education in improving care quality. These findings support the urgent need to implement standardized eye care protocols and enhance nursing training, particularly in intensive care unit settings. From a health policy perspective, incorporating structured in-service training and protocol-based practices into national intensive care unit nursing standards may help prevent avoidable vision-related complications and align care delivery with international patient safety benchmarks.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-03787-2.

Introduction

In intensive care units (ICUs), life-threatening conditions often take priority, which can result in the neglect of other essential aspects of nursing care. Among these, eye care is frequently overlooked despite its critical role in preventing serious ophthalmological complications. Studies have shown that eye care is omitted in up to 50–62% of ICU settings worldwide [1, 2].

Beyond neglect, the frequent use of sedatives and muscle relaxants in ICUs contributes to incomplete eyelid closure, making patients more susceptible to ocular disorders. While a healthy corneal epithelium serves as a barrier against infections, the onset of eye dryness—common in ICU environments—can lead to superficial keratopathy or punctate epithelial erosion, ultimately causing epithelial damage. As the severity of superficial keratopathy increases, the cornea becomes more permeable and progressively deteriorates [3–6].

The incidence of ocular complications in ICU patients ranges between 20% and 60%, including conditions such as conjunctival chemosis, corneal abrasions, and corneal ulcers. These complications arise not only from inadequate eye care but also from treatment-related factors and the general ICU environment. If left unaddressed, such conditions may result in irreversible vision loss [2, 7, 8, 21, 32]. In recent years, international patient safety initiatives have increasingly emphasized the importance of eye care in critical care settings. Preventable visual impairment due to suboptimal ICU care is now recognized by global health authorities, including the World Health Organization (WHO) and the Joint Commission International (JCI), as a significant patient safety concern [9, 10]. Accordingly, preventive eye care should be considered a fundamental component of holistic ICU nursing practice.

Several interventions—such as isotonic sodium chloride washes, lipid-based ointments, artificial tears, eyelid closure, polyethylene covers, swimming goggles, and paraffin gauze—have been recommended to protect the ocular surface and prevent complications [11–14]. Although eyelid taping is commonly used, it should be performed only when clinically indicated [15]. Therefore, ICU nurses must possess both the knowledge and clinical judgment necessary to conduct appropriate ophthalmological assessments.

Despite the well-documented risks, standardized eye care protocols remain absent in many ICUs, and there is limited observational research on how nurses deliver eye care in real-world practice. While numerous studies have evaluated the effectiveness of specific interventions or compared commercial products [11, 14, 29], real-time assessments of nursing behaviors and care accuracy are scarce [16, 17]. This gap underscores the need to evaluate current practices as a foundation for developing targeted training and institutional protocols.

Implementing eye care interventions based on standardized clinical guidelines and evidence-based practices has been shown to help patients progress through critical illness without developing ocular complications. Such practices also preserve visual function and improve post-discharge quality of life. Routine ocular assessments and nursing interventions aimed at protecting the ocular surface are especially effective in preventing exposure keratopathy, conjunctival edema (chemosis), and corneal abrasions. Preserving visual function supports physiological recovery, facilitates patient interaction with their surroundings, and enhances psychosocial adaptation and rehabilitation. Consequently, improving ICU nurses’ knowledge and awareness of eye care should be viewed as a strategic priority for enhancing the quality and comprehensiveness of patient care. Interventional studies have demonstrated that structured educational programs significantly improve ICU nurses’ knowledge, skills, and adherence to evidence-based eye care protocols, leading to lower complication rates and improved patient outcomes [18–20].

According to clinical nursing standards and ICU practice guidelines, nurses play a central role in the prevention, early detection, and management of ocular complications in critically ill patients. International and regional organizations such as the American Association of Critical-Care Nurses (AACN), the European Federation of Critical Care Nursing Associations (EfCCNa), and the Royal College of Nursing identify ocular protection as an essential nursing responsibility in ICU practice [21, 22, 30, 31].

Although eye care is formally included within ICU nursing responsibilities, it is often underperformed due to the prioritization of life-saving interventions. Evidence, however, shows that integrating standardized eye care protocols into routine care planning can effectively prevent severe ocular surface complications such as exposure keratopathy [23, 33].

Numerous studies support the widely held view that structured training programs for ICU nurses substantially enhance both theoretical knowledge and practical skills in eye care. This, in turn, contributes to the prevention of corneal and ocular surface disorders, improves clinical outcomes, and supports nurses’ professional development [23]. While randomized controlled trials continue to evaluate the effectiveness of individual eye care products or procedures, there remains a marked shortage of observational research examining bedside nursing practices and the contextual, institutional, or individual barriers that influence eye care implementation. Additionally, qualitative data exploring nurses’ perceptions, attitudes, and daily challenges in providing eye care are limited. This lack of real-world insight perpetuates the gap between evidence-based guidelines and actual clinical practice [16, 18, 24].

In countries such as Türkiye and other middle- to low-income countries (LMICs), the level of knowledge and practical competence among ICU nurses in eye care has been reported to be relatively low, with protocol-based approaches rarely implemented. For example, an international comparative study conducted in 2017 found that most ICU nurses in Türkiye and Palestine relied on personal knowledge rather than structured protocols for eye care [25]. Similarly, a 2023 study from the West Bank revealed that only 0.7% of nurses demonstrated good knowledge, and just 25.7% exhibited good practices—primarily due to the absence of institutional protocols [26]. These findings highlight the urgent need for region-specific training programs and policy interventions in critical care nursing.

This study was conducted in Türkiye, an upper-middle-income country where ICUs often face systemic challenges such as low nurse-to-patient ratios, high patient acuity, and inconsistent access to standardized care protocols. Such barriers are common across many LMICs and can hinder the delivery of evidence-based care. Therefore, the insights from this study may be applicable to other countries operating under similar constraints and may contribute meaningfully to the global nursing literature on critical care practices [18, 27].

In light of these gaps, the present observational study was designed to determine whether ICU nurses employ evidence-based eye care protocols and to examine how socio-demographic and professional factors influence their practices. The study also sought to generate actionable findings to guide the development of targeted educational interventions and policy updates. Specifically, the research addressed the following questions:

1. To what extent do ICU nurses’ eye care practices comply with current standards and protocols?

2. How do nurses’ socio-demographic and professional characteristics influence the quality and appropriateness of their eye care practices?

Methods

Study design and participants

The study was designed as an observational descriptive study to systematically evaluate real-time nursing practices related to eye care in critically ill patients without manipulating the clinical environment. This design enables researchers to document naturally occurring behaviors and assess practice patterns as they exist in real-world settings. Observational descriptive studies are particularly suitable when the aim is to explore clinical behaviors, identify practice gaps, and inform protocol development—especially in settings where intervention may not be ethical or feasible due to patient vulnerability, such as intensive care units [35, 36].

In line with this approach, the present study was conducted between December 2024 and April 2025 in the adult internal medicine intensive care unit (ICU) of a tertiary hospital located in the Central Anatolia Region of Türkiye.

The target population consisted of 32 nurses who were actively providing care in the internal medicine ICU during the study period and met the study’s eligibility criteria. Due to the small and accessible size of the population, a total population sampling method (also known as consecutive sampling) was employed. This method involves including all eligible participants who meet the inclusion criteria during the study period and is commonly recommended in clinical and nursing research involving small, accessible populations, as it minimizes sampling bias and enhances representativeness [33, 34].

Inclusion criteria for participants were: (1) actively working as a nurse in the internal medicine ICU, and (2) voluntary participation with written informed consent.

Exclusion criteria included: (1) being on leave or not involved in direct patient care during the observation period.

All eligible nurses were included in the study; therefore, the sample size was equivalent to the population size (n = 32). This approach allowed for a comprehensive and unbiased assessment of ICU nurses’ eye care practices and ensured the full representation of the target population.

A priori power analysis was not conducted, as the study involved total population sampling (n = 32) in a small, well-defined clinical setting. According to Polit and Beck (2021), power analysis may be omitted in studies where the entire accessible population is included, particularly in descriptive observational research within healthcare settings [35].

All participating nurses had received general training on eye care as part of their undergraduate nursing education. However, this training did not typically include specialized instruction on eye care practices for critically ill patients. Moreover, the institution where the study was conducted did not have a standardized eye care protocol or defined frequency for eye care practices. Each intensive care nurse was typically responsible for the care of two to three patients per shift. The intensive care setting housed patients who were sedated and mechanically ventilated, thus increasing the risk of complications associated with reduced blinking, incomplete eyelid closure, and impaired protective reflexes, which are common in such clinical situations.

Data collection instruments

Data were collected using two structured tools developed by the researchers based on a comprehensive review of national and international literature and existing clinical guidelines on eye care in intensive care settings:

Demographic information form

This form included 12 items designed to capture the participants’ socio-demographic and professional characteristics. Variables included age, sex, level of education, total years of professional experience, years of ICU experience, shift type (day/night), weekly working hours, average number of patients per shift, in-service training on eye care, and current eye care practices. The form was used both to describe the sample and to explore potential associations between demographic factors and eye care performance.

Eye care observation form

The Eye Care Observation Form was developed to systematically evaluate ICU nurses’ adherence to evidence-based eye care practices during routine clinical care. The checklist consisted of 16 items, reflecting critical procedures including: hand hygiene, use of sterile equipment, patient preparation, cleaning techniques, eye inspection, application of protective agents (e.g., ointments or saline), eyelid closure, documentation, and physician notification.

The items were derived from a thorough review of international guidelines (e.g., Royal College of Nursing, AACN) and peer-reviewed literature [11–14, 21]– [22], ensuring both relevance and standard alignment.

Each item was scored dichotomously (0 = Not Performed, 1 = Performed), yielding a total score range of 0–16 per observation. As each nurse was observed during three separate care sessions, their total possible score ranged from 0 to 48. For multi-component items (e.g., “Hands are washed and gloves are worn”), a score of 1 was only assigned if all components were fully completed; partial compliance was scored as 0 to maintain strict evaluation criteria.

The form was reviewed for content validity by a panel of nine experts (including critical care nurses, ophthalmologists, and academic nurse educators). Based on their feedback, revisions were made to improve item clarity and structure.

A pilot test with five ICU nurses was conducted to assess item clarity, usability in real-time care, and feasibility. The results confirmed the form’s applicability and ease of use in clinical observation.

Since all observations were performed by a single trained researcher, inter-rater reliability was not applicable. However, intra-rater consistency was ensured through structured training in the use of the observation form and the use of clearly defined behavioral indicators. Observations were conducted in real time using the finalized version of the form, following a standardized protocol.

Content validity

To ensure content validity, the Eye Care Observation Form was evaluated by a panel of nine experts, including four academic nurse educators (professors and associate professors), three ophthalmology specialists, and two ICU nurses. Based on their feedback, revisions were made to improve item clarity and structure. The final version was pilot tested with five ICU nurses to confirm clarity, feasibility, and usability before data collection commenced. Although a formal Content Validity Index (CVI) calculation was not performed during the initial instrument development, the expert panel provided detailed item-by-item feedback to refine the checklist. The absence of CVI quantification is acknowledged as a limitation; however, future studies are recommended to incorporate formal CVI calculations to further strengthen the instrument’s psychometric robustness. For transparency, a summary of the 16 checklist items—covering key domains such as hand hygiene, use of sterile equipment, patient preparation, cleaning technique, ocular inspection, application of protective agents, eyelid closure, documentation, and physician notification—is presented in the Methods section to enable replication in future research.

Reliability

To enhance intra-rater reliability and consistency, all observations were conducted by a single trained researcher using clearly defined behavioral indicators. The researcher maintained a non-participatory role and adhered to a standardized observation protocol. Additionally, a pilot test was conducted to ensure that checklist items were unambiguous and consistently interpreted, thereby reducing observer bias. Unexpected or unlisted behaviors were recorded in a separate “Observer Notes” section.

Since all observations were conducted by a single trained researcher, inter-rater reliability was not applicable in this study. The observer received prior training in the standardized use of the observation checklist, which was developed based on national and international guidelines. A pilot test was conducted before data collection to ensure the clarity of checklist items and consistency in interpretation. This strategy helped to ensure procedural fidelity and enhance the reliability and consistency of all recorded observations.

Procedures

Prior to data collection, institutional permission and ethical approval were obtained. The researcher contacted the internal medicine intensive care unit (ICU) nursing administration to explain the study’s purpose, scope, and methodology, and requested access to potential participants. All eligible ICU nurses (n = 32) were approached individually during their shifts, provided with detailed information about the study, and invited to participate. Written informed consent was obtained from all who volunteered.

Data collection was carried out in the clinical setting of the adult internal medicine ICU without disrupting patient care. First, each participant completed the “Demographic Information Form” in a quiet area designated by the unit supervisor, typically during shift breaks. This form was completed once per participant.

Following that, the researcher, acting as a non-participant observer, directly observed the nurses’ routine eye care procedures performed on critically ill patients who were sedated and connected to mechanical ventilators. Each nurse was observed at least once during both the day shift (08:00–16:00) and the night shift (16:00–08:00). Specifically, each nurse was observed at least once during the night shift. Observations were conducted at the patient’s bedside in real-time and recorded simultaneously using the 16-item “Eye Care Observation Form.”

Each observation form was collected by the researcher immediately after the observation was completed. All data were anonymized; no identifying information related to the nurses or patients was recorded. Because nurses worked two shifts (8am-4pm, 4pm-8pm), each nurse was observed three times per shift, for a total of six times. A total of 192 observations were made across the entire sample, creating a diverse data set that represents a wide variety of care scenarios and minimizes the risk of duplication. Patients were selected consecutively during nurses’ assigned shifts to ensure that all eligible cases were observed in sequence. The average number of patients observed per shift was recorded as 2–3.

To prevent information contamination, each nurse was observed caring for different patients during separate procedures. No nurse was observed more than once for the same patient. Observations were recorded independently and anonymously in real-time, without any influence or feedback from the researcher.

Ethical considerations

Ethical approval for this study was obtained from the Nuh Naci Yazgan University Scientific Research Ethics Committee (Approval Number: 2024/003 − 001, Approval Date: November 15, 2024) and from the tertiary hospital where the research was conducted.

All participants were fully informed about the purpose, scope, and procedures of the study. Participation was entirely voluntary, and each nurse signed a written informed consent form prior to data collection. Participants were assured that their identities would remain anonymous, and all data would be handled with strict confidentiality.

To minimize the risk of perceived coercion, all eligible nurses were approached individually by the researcher in private, outside of staff meetings or managerial presence. Nurses were explicitly informed that participation was completely voluntary and would not affect their job performance evaluations, work assignments, or professional relationships. This approach was used to ensure informed consent was given freely, without any external pressure.

The study was conducted in accordance with the ethical principles of the Declaration of Helsinki [37] and followed the ethical publication guidelines of the International Committee of Medical Journal Editors [38].

Data analysis

The choice of statistical tests was guided by the type and distribution of the variables, as assessed by the Shapiro–Wilk normality test for continuous data. All data were analyzed using IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics, including frequencies, percentages, means, and standard deviations, were used to summarize the demographic and professional characteristics of the sample and the observed eye care performance scores.

Chi-square tests were used to examine associations between categorical independent variables (e.g., education level, ICU experience) and adherence to evidence-based eye care practices. When expected cell counts were below 5, Fisher’s Exact test was applied to ensure the validity of the results.

Multiple linear regression analysis was conducted to identify independent predictors of correct eye care practices. The dependent variable was the total eye care adherence score, while independent variables included age, gender, professional experience, ICU experience, weekly working hours, in-service training status, and educational status. Only variables found to be statistically significant in the preliminary univariate analyses were entered into the multiple regression model.

Prior to regression analysis, assumptions of multicollinearity, homoscedasticity, linearity, and normality of residuals were tested. Multicollinearity was evaluated using Variance Inflation Factor (VIF), with all values below 2, indicating no concerns. Homoscedasticity and linearity were assessed through residual plots and showed no significant deviations. Normality of residuals was verified using the Shapiro-Wilk test and Q-Q plots, confirming an approximately normal distribution.

The regression model was statistically significant (p < 0.05), explaining 32.2% of the variance in eye care adherence scores (Adjusted R² = 0.322).

Control for the Hawthorne effect

Given the observational nature of the study, the potential for Hawthorne Effect—where participants alter their behavior due to awareness of being observed—was acknowledged as a limitation. To minimize this bias, the researcher adopted a passive, non-interfering role during observations and conducted observations across multiple shifts and different patients to reduce predictability.

However, no additional blinding or concealment techniques were feasible due to the clinical setting and ethical considerations. Therefore, the Hawthorne Effect remains a possible threat to internal validity. Future research could consider longer adaptation periods, the use of covert observation methods where ethically permissible, or triangulation with other data sources to further mitigate this bias.

Results

The findings of this observational study, conducted to determine the eye care practices of nurses working in the ICU, are presented subsequently.

Table 1: demographic characteristics of ICU nurses

Table 1.

Distribution of nurses based on their demographic characteristics

Variables	Groups	n	%
Age	22–27	9	28,1
	28–32	13	40,6
	33 and above	10	31,3
Gender	Female	23	71,9
	Male	9	28,1
Education Level	Associate Degree	5	15,6
	Bachelor’s Degree	27	84,4
Professional Experience	Up to 5 years	25	78,1
	5 years and above	7	21,9
ICU Experience	Up to 5 years	24	75,0
	5 years and above	8	25,0
Weekly Working Hours	40 h	20	62,5
	48 h	12	37,5
In-Service Training on Eye Care	Received	15	46,9
	Not Received	17	53,1

Table 1 presents the demographic and professional profile of the 32 nurses observed in the adult internal medicine ICU. Female nurses constituted the majority of the sample (71.9%), reflecting typical gender distributions in nursing populations globally. The educational background of the participants was predominantly at the bachelor’s degree level (84.4%), indicating a relatively high level of formal nursing education in the sample. Age distribution showed that most nurses (40.6%) were between 28 and 32 years old, with nearly equal representation in younger (22–27 years, 28.1%) and older (33 years and above, 31.3%) groups.

Professional experience was generally limited, as 78.1% of participants had been practicing nursing for five years or less. A similar pattern was observed in ICU-specific experience, with 75% of nurses having five or fewer years in critical care settings. This relatively limited experience may influence familiarity with ICU-specific eye care protocols.

Regarding workload, 62.5% of the nurses worked 40 h per week, while 37.5% worked 48 h, suggesting a moderately high work demand. Of note, only 46.9% had received in-service training specifically related to eye care, highlighting a potential gap in ongoing professional development in this specialized area. Understanding this demographic context is essential for interpreting subsequent compliance and practice data.

Table 2: nurses’ compliance with eye care procedure steps

Table 2.

Nurses’ compliance with eye care procedure steps

Eye Care Steps	Performed		Not Performed
	n	%	n	%
Hands are washed, and disposable gloves are worn	132	68,7	60	31,3
Patient identity is verified	180	93,7	12	6,3
Explanation is provided to the patient	0	0,0	192	100,0
Patient is positioned appropriately for the procedure	132	68,7	60	31,3
Eye patches, if present, are removed	192	100,0	0	0,0
Dried secretions and ointments are cleaned using warm distilled water, 0.9% isotonic sodium chloride solution, or tap water	60	31,2	132	68,8
The eye is cleaned with a single motion from inner to outer canthus	150	78,1	42	21,9
Separate sterile swabs are used until the eye is clean	72	37,5	120	65,5
Inspection with bright light for redness, chemosis, or corneal opacity is performed	0	0,0	192	100,0
Complications such as exposure keratopathy, corneal abrasion, chemosis, lagophthalmos, or microbial infections are evaluated	0	0,0	192	100,0
Lubricant ointment/artificial tears/sterile isotonic sodium chloride solution is applied to the conjunctival sac	174	90,6	18	9,4
Eyelashes are checked to prevent corneal abrasions	66	34,4	126	65,6
Eyes are closed if necessary, and horizontal taping is used for closure	108	56,25	84	43,7
Gloves are removed, and hands are washed	132	68,7	60	31,3
Procedures are documented	192	100,0	0	0,0
Identified situations are reported to the physician	168	87,5	24	12,5

Table 2 details nurses’ adherence to specific eye care procedural steps based on 192 observations. Although some steps showed satisfactory compliance, several critical deficiencies were apparent.

Hand hygiene and glove use, fundamental infection control measures, were performed correctly by 68.7% of nurses prior to eye care procedures, indicating room for improvement. Patient identity verification was notably high (93.7%), reflecting well-established safety protocols.

However, none of the nurses explained the eye care procedure to the patients (0%), which might relate to patients’ sedated status but raises concerns regarding communication and patient-centered care practices.

Patient positioning for eye care was appropriate in 68.7% of observations, a critical step for ensuring safe and effective care. Tape removal prior to procedure was universally performed (100%), showing consistent adherence to preparatory standards.

Eye cleaning techniques varied significantly: only 31.2% used sterile or recommended solutions (warm distilled water, isotonic sodium chloride, or tap water), while the majority used wet wipes, a practice potentially inconsistent with infection prevention guidelines. Most nurses (78.1%) wiped from the inner to outer canthus in a single motion, adhering to correct technique, but only 37.5% used separate gauze pads for each swipe, which may increase risk of contamination.

A striking gap was observed in ocular assessment: no nurse inspected for redness, conjunctival chemosis, corneal opacity, or other complications using bright light, nor evaluated for exposure keratopathy or other eye conditions, representing a major omission in nursing assessment responsibilities.

The majority applied lubricants or artificial tears appropriately (90.6%), but only about one-third (34.4%) checked eyelash positioning to prevent corneal abrasions, and just over half (56.25%) closed the eyes with horizontal taping when necessary, reflecting inconsistent practice standards.

Documentation of procedures was complete in all cases (100%), and 87.5% reported abnormal findings to physicians, indicating effective communication despite the aforementioned assessment shortcomings.

Table 3: comparison of eye care practices across three observations by demographic and professional characteristics

Table 3.

Comparison of nurses’ eye care practices across three observations based on demographic and professional characteristics

Variables	Groups	Observation 1			Observation 2			Observation 3
		Did not do n(%)	Did n(%)	p	Did not do n(%)	Did n(%)	p	Did not do n(%)	Did n(%)	p
Age	22–27	2(22,2)	7(77,8)	0,764	7(77,8)	2(22,2)	0,208	9(100,0)	0(0,0)	0,089
	28–32	2(15,4)	11(84,6)		6(46,2)	7(53,8)		10(76,9)	3(23,1)
	33 and above	1(10,0)	9(90,0)		4(40,0)	6(60,0)		10(100,0)	0(0,0)
Gender	Female	4(17,4)	19(82,6)	0,660	12(52,2)	11(47,8)	0,863	20(87,0)	3(13,0)	0,255
	Male	1(11,1)	8(88,9)		5(55,6)	4(44,4)		9(100,0)	0(0,0)
Educational Levels	Associate Degree	4(80,0)	1(20,0)	0,000*	4(80,0)	1(20,0)	0,190	5(100,0)	0(0,0)	0,434
	Bachelor’s Degree	1(3,7)	26(96,3)		13(48,1)	14(51,9)		24(88,9)	3(11,1)
Professional Experience	0–5 year	4(16,0)	21(84,0)	0,912	14(56,0)	11(44,0)	0,538	24(96,0)	1(4,0)	0,049*
	6 years and above	1(14,3)	6(85,7)		3(42,9)	4(57,1)		5(71,4)	2(28,6)
ICU Experience	0–5 year	3(12,5)	21(87,5)	0,399	14(58,3)	10(41,7)	0,306	22(91,7)	2(8,3)	0,726
	6 years and above	2(25,0)	6(75,0)		3(37,5)	5(62,5)		7(87,5)	1(12,5)
Weekly Working Hours	40 h	3(15,0)	17(85,0)	0,900	12(60,0)	8(40,0)	0,314	19(95,0)	1(5,0)	0,273
	48 h	2(16,7)	10(83,3)		5(41,7)	7(58,3)		10(83,3)	2(16,7)
In-service Training Status for Eye Care	Trained	2(13,3)	13(86,7)	0,737	8(53,3)	7(46,7)	0,982	13(86,7)	2(13,3)	0,471
	Untrained	3(17,6)	14(82,4)		9(52,9)	8(47,1)		16(94,1)	1(5,9)

Bold values indicate statistically significant results (p < 0.05)

Table 3 examines differences in eye care adherence across three sequential observations, analyzed by key demographic and professional variables.

Educational level demonstrated a significant impact on adherence during the first observation, with nurses holding bachelor’s degrees performing significantly better than those with associate degrees (p < 0.05). This suggests that higher formal education correlates with better protocol compliance.

Professional experience showed a significant positive association in the third observation period (p = 0.049), indicating that accumulated experience may enhance practice quality over time or through repeated exposure to observational scrutiny.

Other variables—including age, gender, ICU experience, weekly working hours, and prior in-service training—did not reach statistical significance in influencing eye care adherence at any observation point. Nonetheless, some non-significant trends suggested potential minor influences warranting further exploration.

These results imply that foundational education may play a more decisive role than years of experience or continuing education in influencing eye care behaviors in ICU nurses within this sample.

Table 4: multiple regression analysis of predictors for eye care practice adherence

Table 4.

Results of the multiple regression model for the impact of independent variables on eye care practices

Variables	B	Std. Error	Beta	t-value	p-value
(Constant Term)	-1.477	1.452	-	-1.018	0.319
Age	0.012	0.039	0.06	0.318	0.753
Gender	-0.316	0.343	-0.172	-0.924	0.365
Professional Experience	0.432	0.44	0.215	0.982	0.336
Intensive Care Experience	-0.046	0.388	-0.024	-0.118	0.907
Weekly Working Hours	0.129	0.361	0.075	0.358	0.724
In-service Training Status	0.067	0.298	0.04	0.224	0.825
Educational Status	0.806	0.272	0.529	2.966	0.007*

Bold values indicate statistically significant results (p < 0.05)

Table 4 presents a multiple linear regression analysis assessing the combined effect of demographic and professional factors on the total eye care adherence score.

The model explained 32.2% of the variance in adherence scores (Adjusted R² = 0.322), indicating moderate explanatory power.

Educational status was the only statistically significant independent predictor of eye care adherence (β = 0.806, p = 0.007), reinforcing the importance of higher formal education in promoting evidence-based nursing practices.

While professional experience (β = 0.432) and weekly working hours (β = 0.129) showed positive beta coefficients, these did not achieve statistical significance, suggesting possible trends that require further study.

Discussion

This study examined the eye care practices of nurses working in the intensive care unit (ICU) using real-time observation and evaluated factors influencing these practices. The findings indicate that nurses generally adhered to basic hygiene protocols such as hand hygiene and patient identification verification. These results align with similar adherence rates reported in the literature for fundamental nursing practices [1, 2]. However, critical steps such as eye examination and assessment of complications were entirely neglected (0%). The complex nature of the ICU environment, workload, and the monitoring of sedated patients impede comprehensive eye care [3, 7].

A fundamental cause of deficiencies in ICU nurses’ eye care practices lies in the insufficient emphasis on eye health and care within nursing education. Literature consistently highlights that nurses generally have inadequate knowledge regarding eye care, which translates into clinical practice shortcomings [16, 17, 24]. Protecting eye health in critical care requires specialized knowledge and skills, yet nursing curricula allocate limited time and practical training to this area [18, 23]. Studies conducted in Turkey report that most nurses lack sufficient knowledge to recognize and prevent eye complications and fail to perform eye examinations [16, 17]. Similarly, research from other countries also documents educational deficiencies and their clinical consequences [16]. This gap represents a serious patient safety concern and aligns with findings identifying knowledge and practice deficits as key barriers in eye health management by nurses [3, 4, 16].

In-service training programs are recognized as critical tools to address this knowledge gap. However, the effectiveness and scope of existing programs are often inadequate, with theoretical content insufficiently integrated with practical applications [19, 24]. Structured and interactive training programs have been shown to significantly enhance nurses’ knowledge and practical skills, reducing eye complications [18]. This underscores the necessity of updating educational content and increasing practical, case-based learning opportunities.

Sterile material use was low (31.2%), with frequent use of inappropriate materials such as non-sterile wet wipes for eye cleaning. Such practices increase infection risk in critically ill patients and are leading causes of corneal irritation and infections [7, 11, 28]. The literature typically attributes insufficient sterile material usage to inadequate nurse training. Ghattas et al. (2025) demonstrated that structured training significantly improves sterile material use and general eye care practice [18].

Educational level emerged as the strongest predictor of adherence to eye care protocols. Nurses with bachelor’s degrees adhered more consistently, indicating that higher educational attainment and clinical knowledge directly impact practice quality [17, 18, 39, 40]. Correspondingly, the literature frequently emphasizes the influence of nurses’ academic education on professional competency and patient care quality [41, 42]. In contrast, variables such as age, ICU experience, and in-service training did not show significant effects, suggesting that existing in-service programs may be limited in content and delivery, insufficiently bridging theory and practice [19, 24]. Some studies report that short, theory-heavy, and non-interactive training negatively affect learning outcomes [43, 44]. This highlights the importance of structuring education as regular, case-based, and practically oriented programs [18, 45].

Improving ICU eye care requires the development and implementation of standardized, evidence-based protocols. Such protocols provide a framework for nurses to conduct routine eye assessments, identify complications early, and use appropriate sterile materials [11, 14, 29]. Additionally, structured, interactive in-service education must support both theoretical knowledge and practical skills [18–20].

There is no universally accepted standardized eye assessment scale specifically for ICU eye complications; however, various clinical protocols and scoring systems exist that evaluate parameters such as eyelid aperture, corneal condition, and tear status. The absence of a specific, standardized eye assessment scale complicates the evaluation of eye care effectiveness in ICUs [16, 18, 32]. Consistently, our study lacked the use of a standardized eye assessment scale and observed no performance of eye examination or complication assessment despite their critical importance. This indicates deficiencies in nurses’ monitoring of eye health and complication detection, as well as the lack of systematic follow-up of eye care.

Failure to inform patients about eye care procedures, which are sometimes invasive and uncomfortable, constitutes an ethical violation and highlights a need for development in patient safety culture [46]. The literature emphasizes that effective communication enhances patient satisfaction and care quality while reducing safety incidents [47]. Although most ICU patients are unconscious or sedated and cannot actively participate in informed consent, this does not exempt healthcare providers from conducting transparent and ethically compliant care. Every intervention, especially potentially distressing ones like eye care, must be managed carefully within the scope of patient safety and ethical responsibility [10, 37]. Informing the patient is a fundamental part of respecting patient rights and dignity regardless of their level of consciousness. Even unconscious patients deserve careful and respectful handling of interventions to protect their dignity and prevent unnecessary harm [37, 38]. Moreover, this process increases healthcare workers’ awareness and accountability, ultimately improving care quality [10]. The 0% rate of patient information observed in our study is a serious ethical deficiency and underscores the need to improve nurses’ communication skills. It also signals the necessity of strengthening patient rights and ethical care standards within ICU settings.

Strengths and limitations of the study

This study contributes to the limited body of literature on eye care practices among nurses in intensive care units (ICUs). Instead of relying on self-reported data, real-time direct observation was used, which enhanced the reliability of the findings. Each nurse was observed multiple times during different shifts, increasing the consistency and credibility of the results. Furthermore, the inclusion of demographic and professional variables allowed for a detailed examination of how factors such as educational level and professional experience influence differences in eye care practices. Conducting the study in an actual clinical setting also ensured that the findings reflect real-world practice conditions.

The study also has certain limitations. Firstly, it was conducted in a single institution and within only one ICU, with a relatively small sample size (n = 32), which restricts the generalizability of the findings to other ICUs, regions, or countries with different healthcare systems, training protocols, or cultural practices. Although the sample size was sufficient for observational depth, it may have reduced the statistical power to detect significant relationships between variables, especially in the multiple regression analysis. Similarly, some small-scale observational studies in the literature have been conducted with a limited number of nurses and have reported similar generalizability limitations due to sample size [48]. Secondly, the absence of a standardized institutional eye care protocol limited the ability to evaluate nurses’ practices against a clear benchmark. The study also focused solely on nursing practices without including patient outcome data (e.g., incidence of ocular complications), which would have strengthened the clinical relevance of the findings. Moreover, no exploration was made into the underlying reasons for certain deficiencies (e.g., lack of ocular assessments or use of non-sterile materials), which may relate to factors such as training, workload, or resource availability. Finally, because the observations were conducted overtly, the Hawthorne effect may have influenced nurse behavior; however, this effect likely diminished over repeated observations. The lack of a standardized ophthalmological assessment tool further limited the evaluation of actual patient ocular health status.

Conclusion

This study revealed significant deficiencies in ICU nurses’ eye care practices. Critical steps such as eye assessment and patient education were frequently omitted, and the use of sterile materials was inadequate. Educational level emerged as the most influential factor in practice quality, while in-service training and experience showed no significant effect. These findings highlight the need for greater emphasis on eye care in nursing education and clinical practice. Establishing standardized protocols and supporting nurses through case-based training are essential for protecting ocular health in critically ill patients.

Recommendations

Improving eye care practices in intensive care units requires a multifaceted approach. First, standardized and evidence-based eye care protocols specific to ICU settings should be developed to ensure consistency and safety in practice. Nursing curricula at both undergraduate and postgraduate levels must integrate eye care content, combining theoretical instruction with practical training. Additionally, in-service education should be structured as regular, case-based, and interactive programs that reflect real clinical challenges. Ethical and patient-centered care must also be prioritized, with efforts to ensure that even sedated or unconscious patients are treated with respect and informed when appropriate. Finally, the development and implementation of standardized eye assessment tools tailored to ICU patients is essential to improve evaluation, monitoring, and documentation processes.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

ICU

Intensive Care Unite

Author contributions

ATY and ÖC contributed to the design and planning of the study. Data were collected, analyzed, and interpreted by ATY. ATY and ÖC equally contributed to the drafting, revision, and approval of the manuscript. All authors read and approved the final version of the manuscript.

Funding

This research project did not receive any financial support from public, commercial, or non-profit funding agencies.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Nuh Naci Yazgan University Scientific Research Ethics Committee (Approval Number: 2024/003 − 001). At the request of the ethics committee, the present study was conducted under the Declaration of Helsinki and the Committee on Publication Ethics (COPE). To observe ethical considerations, the participants were provided with comprehensive information about the study goals and process. All participants provided written informed consent in all stages of the study. The confidentiality of the participants was carefully protected at all stages, from data collection to the publication of the manuscript.

Consent for publication

Not applicable.

Artificial intelligence (AI) use disclosure

The authors used AI-assisted language support (ChatGPT) solely to improve the fluency and grammar of the English text. No AI tools were used in study design, data collection, data analysis, or interpretation. The authors take full responsibility for the manuscript’s content and conclusions.

Competing interests

The authors declare no competing interests.