Eyes on Newborns: How NICU Staff's Attention and Emotions Shape Neonatal Pain Assessment

Abstract

Background: Assessing pain in neonates is crucial for their management but is inherently subjective. This study investigated the effects of visual attention, gaze patterns, and empathic responses of neonatal healthcare professionals on their assessments of neonatal pain.

Methods: Conducted at the Department of Neonatology, University Medical Center Hamburg-Eppendorf, we employed eye-tracking to monitor staff's responses to videos depicting neonates experiencing non-noxious thermal, brief noxious, and prolonged noxious stimuli. Videos were presented in two formats: full body view, providing contextual information, and face-only view, lacking contextual details. Pain assessments were measured using a Faces Pain Rating Scale (FPRS), exploring the impacts of contextual cues, professional experience, and job roles.

Results: The study found brief and prolonged noxious stimuli eliciting significantly higher FPRS scores compared to non-painful stimuli, with the full body view resulting in higher pain ratings than the face-only view. The mouth region attracted focused attention. Nurses generally reported higher pain scores and exhibited larger pupil diameters compared to physicians, suggesting a stronger empathic response.

Conclusion: This research highlights the essential role of visual cues and empathic responses in neonatal pain assessment, demonstrating how professional roles and stimulus presentation format impact evaluations, and underlining the need for standardised protocols to improve neonatal pain management accuracy.

Significance: The study emphasises the importance of visual cues and empathy in neonatal pain assessment, highlighting the roles of healthcare professionals and stimulus presentation formats. It addresses challenges in understanding neonatal pain, advocating for standardised protocols. Using eye-tracking technology, the research explores how professionals' visual attention and empathy affect pain evaluations, suggesting more objective assessment methods.

Keywords: NICU; emotion; eye‐tracking; newborn; pain assessment; pupil diameter; visual attention.

FIGURE 1

Experimental setup, pain rating procedure, and gaze pattern: (A) Experimental setup: Participants were seated comfortably in a height‐adjustable office chair, positioned 53 cm in front of a computer screen (LG Electronics INC, 24BK550Y, 1920×1080). An eye‐tracker (Tobii pro fusion 2500 Hz, Tobii technology, Sweden) was mounted from below, indicated by the red rectangle. The setup was maintained under standardised lighting conditions. (B) Pain rating procedure: Prior to the experiment, participants received instructions on using the eye‐tracking device and had the opportunity to practice. They were instructed to watch videos of newborns and rate the pain level using a face rating scale ranging from 1 (no pain) to 6 (worst possible pain). Pain ratings were provided immediately after each video. Fixation crosses were presented on the screen before and after each video to ensure attention was directed to a neutral standard position. (C) Exemplary gaze pattern: This panel displays an exemplary eye‐tracking gaze pattern observed during the pain assessment of a newborn exposed to a prolonged noxious stimulus. The hexagons represent individual gaze points, while the colouring indicates the fixation frequency. Consent from the parents has been obtained for the publication of this image.

FIGURE 2

Multivariate linear regression analysis results for pain rating. We present the multivariate linear regression analysis results investigating the factors influencing participants' FPRS pain ratings. The analysis considered participant characteristics (profession, work experience, ward), aspects of the presented stimulus (context, stimulus intensity), and participants' gaze behaviour (total fixation duration for each Area of Interest). The diamonds in the figure represent the estimated effect of each factor on the FPRS score, while the error bars depict the corresponding 95% confidence intervals. Statistical significance is denoted by black colour.

FIGURE 3

Visual attention measures and time to entry saccade analysis: distribution of total visit duration in percent as a measure of viewer visual attention (A), the number of fixations, visits, and saccades (B), and the time to entry saccade as a measure of the order of perception (C) per area of interest (B) and context of presentation.

FIGURE 4

Association of average pupil diameter by professional group and stimulus presented: the violin plot depicts the mean pupil diameter for each rating on the FPRS, stratified by the profession of the viewer and the context of presentation. The violin plot provides a visual representation of the distribution of pupil diameters, with a wider region indicating a higher density of data points. Additionally, a linear regression line is included for each profession, with a dotted line representing physicians and a solid line representing nurses.

FIGURE 5

Results of multivariate linear regression analysis of pupil diameter: this figure displays the results of a multivariate linear regression analysis investigating the effects of several variables on pupil diameter. The variables examined include the context of presentation (full body view vs. face view), the pain rating on the FPRS, the professional group, and the participants' professional experience. The graphical representation presents the estimated effects of each variable on pupil diameter using diamond markers, while the corresponding 95% confidence intervals are shown.