The twelve participants represented both sexes. They had a widespread age and educational level, both at bachelor’s and master’s level. The nurses’ experience from clinical practice in ophthalmology ranged from two to thirty-one years, with a mean of 10 years.
Twelve sub-themes clustered in four main themes emerged from the data: 1) responsibility and safety, 2) motivation and respect, 3) collaboration and 4) reflection and evaluation. The themes and the twelve subthemes are illustrated with quotations in the text and shown in table 1. [See Additional file 1].
Theme 1: Responsibility and safety
The nurses stated they felt safe at different stages in their training, and the ones with the most experience soon saw the injections as a routine instead of a challenge. Regardless of previous experience, all the nurses had moments of insecurity.
Routine versus variation
Most of the nurses expressed that learning a new task gave them increased variety.
You get a larger repertoire and the work gets more varied.
Several of the nurses said that the new task quickly became a routine. One nurse had hoped for a greater challenge and was disappointed.
Every patient can be a challenge in themselves, but I will not claim to have large challenges in the injection room. It’s more of a routine.
Confidence and safety
All the nurses expressed they felt safe administering injections after they had gained some experience. They also appreciated that the training was voluntary and that they could spend the time they needed as one nurse explained:
An important factor was that we were told that we would not be forced through the training, but we could try if it suited us, and then withdraw if it didn’t. Therefore, I felt safe the whole way.
To assess if patients had an eyelid infection was mentioned as a common source of insecurity. It was especially challenging if the patient came directly from a physician examination saying eyelid infection was not present, while the nurse was convinced of the opposite.
A patient came from examination and the journal note written by the physician said that there were traces of blepharitis, but that it was okay to inject. This leaves us nurses a bit…(insecure) if it is blepharitis we should not inject, and this is what we have been trained to think. And at the end it is us who injects the needle into the eye. Off course it is the physician’s responsibility because he says in the note that the injection was approved, but we end up having a bad feeling when we believe it is blepharitis…
Administering injections also brings greater responsibility, and the risk of doing something wrong can lead to insecurity. Several nurses mentioned patients not cooperating for various reasons as challenging. One nurse expressed feeling insecure when having to take responsibility for a patient that could not fully cooperate:
Yesterday we had a patient who claimed she never had received an injection in her left eye and today would be her first time…and this was kind of injection number twenty-four in that eye...they (the patients) are growing old, some are a bit forgetful.
Another nurse explained the danger of doing a patient harm:
Off course I am happy when the patients get to keep their vision, but…it is no fun if you end up puncturing the whole eye, causing a retinal detachment, all because the patient could not lie still.
Theme 2: Motivation and respect
Traditionally administering IVIs is a physician task. Mastering this task gave the nurses a sense of pride and a feeling of contributing to solve some of the departments resource challenges. The nurses also valued to be more involved in the treatment of patients.
All the nurses appreciated learning a new task and highlighted that it added pride because few nurses are trained to do IVIs. One nurse emphasized that was is a privilege being certified to give injections:
I get to be a part of something unique and special.
Another nurse accentuated that learning a new procedure gave higher self-esteem:
I feel that my skills have expanded. Learned a new procedure and mastered a new situation.
All the twelve nurses agreed that the new task gave them increased respect among both patients and colleagues. The expanded repertoire of tasks also increased the responsibility which most of the nurses felt sharpened them and made them better nurses. One nurse explained that she had to take better care of herself to be at her best:
When I’m in the injection room, I’m more aware of my blood sugar. In the outpatient clinic we measure visual acuity and eye pressure and I can feel my belly rumbling, but it’s okay, we keep going. But if I’m in the injection room, I’m more aware of that it affects me negative and that I have to eat something before I continue.
Another nurse said that nurses taking over new tasks and increased responsibility is the future:
You feel the responsibility, but it’s a good kind of responsibility. This is the direction the world goes, we (the nurses) must do more and more “physician tasks”. It’s like this everywhere, with everything. It is a good development because we become more skilled professionally.
To make a difference
Several of the nurses expressed they accomplished something good by contributing to raise patient’s quality of life and saving the department resources came as a bonus. One nurse explained why she felt more important when she was certified to give injections:
I feel I do a better job when I am in the injection clinic, than when I am doing other tasks. I feel like I make a difference when I administer injections.
Another nurse highlighted the importance of helping patients to a better quality of life:
I think it is exciting when I hear… (good news about the patient’s vision), because some patients actually get better visual acuity, and I think this is great…or at least they keep their visual acuity. It is fantastic to hear that they have better vision, or that they stopped seeing skewed lines. I think this is very rewarding.
A desire to learn more
More than one nurse mentioned that it would have been satisfying learning more, both theory of ophthalmic diseases and diagnostics. Two reasons recurred when the nurses explained why they wanted to learn more; to satisfy own curiosity and to be able to answer questions from patients:
It’s really as easy as learning to handle the slit lamp properly. Understand what it is you see. It’s easier to explain it to the patient when you have seen it yourself. They ask a lot. How does it look? Why is it like that?
The patients often asked about their diagnosis and prognosis. Not being able to answer, but referring to a physician that could, took away some of that pride the nurses felt drifting the clinic.
It’s a bit discouraging when the patient’s ask a lot of questions that I cannot answer, all I can say is that they should ask again in three months at your next appointment with the physician.
Theme 3: Collaboration
The nurses agreed that collaborating with different health care personnel could be both rewarding and demanding, as could cooperating with fellow nurses as a team. A stable nurse team would provide safety for patients who do not have to meet a new physician at every appointment.
Some days were busier than others, with over thirty patients receiving treatment the same day. On days like these, several of the nurses talked about the importance of working with the people that they had good chemistry with. Working as a team gave them the opportunity to seek support if something went wrong. One nurse explained what she would do if she ran into problems:
We are very good talking things through, we nurses. If some things are difficult, I discuss it with my colleagues.
In the injection clinic they cooperate with fellow nurses, physicians, secretaries, and ophthalmologist referring patients to the clinic. Communication between those involved was not always easy and represented a new form of cooperation, in which the nurses had no former experience.
Taking over a physician task
All participants agreed that the new task gave the nurse’s job satisfaction and better self-esteem. Because of the group dynamic, the confidence was especially highlighted in the focus group interview where they all agreed that their skills were as good as the physicians when it came to inject anti-VEGF intravitreally. One nurse stated short and concise:
The point is that we (the nurses) do it better than the physicians.
Another nurse added with a smile:
The physicians feel their role is more serious, they don’t go along with the joke and the good vibe in the room. Us nurses we can have fun with the patient, but for the physicians it’s just a serious procedure.
Theme 4: Reflection and evaluation
All nurses had reflections on how to improve the training program and the injection clinic in general. Evaluation of the training program resulted in shorter and more intensive training.
The training program
The nurses were overall satisfied with the training program. Some wished for continuous learning in the workplace with frequent lectures on ophthalmic diseases, training in filling out the outpatient clinic form and regular controls of the injection technique. One nurse stated:
I would love to get a refresher along the way, I think that would be useful. Some theoretical repetition of blepharitis, for instance, and the rules when the patients need to postpone their injections. But the injections itself I think I have had plenty of training in.
Most nurses preferred another nurse as a supervisor instead of a physician.
I believe it’s much better when a nurse is the one giving instructions, I feel they think more about everything. What does the nurse in training need to know, observe, and try, and what progression should the nurse have?
All the nurses had opinions on what would make the day run smoothly. Journals with missing information and too many patients at the injection list could cause stress. When they had to clarify questions with a physician, this was time-consuming as explained by one nurse:
The physician will talk to the patient and time flies, and I have already prepared the patient and I am standing there waiting with the syringe in my hand. Several times I think that I must give the patient anesthetic eyedrops all over again.
Suggestions for improvement
Several suggestions on how to improve the injection clinic came up during the interviews. Giving a physician responsibility for answering questions was something all the nurses wanted. Some wanted more time per patient, but another nurse preferred the opposite, shorter time between patients. One nurse who wished for more time said:
I want to talk more with the patients.