The ICU is where critically ill patients with often multiple systemic problems are provided life support during their stay. In the setting of these clinical priorities, ocular complications are often under recognized, especially in patients who are sedated, unconscious, or mechanically ventilated. They are predisposed to ocular surface disorders because normal protective mechanisms such as blinking, tear production and complete eyelid closure may be compromised. This increases the risk of exposure keratopathy, corneal abrasion, microbial keratitis and possibly long term visual loss [1-3]. Exposure keratopathy is one of the most important preventable ocular conditions in ICU patients. The reported incidence varies from 3.6% to 60% depending on the patient condition, level of sedation, mechanical ventilation, use of neuromuscular blockers, environmental factors and presence or absence of preventive eye care protocols . The mechanisms behind this are lagophthalmos, a reduced blink reflex, decreased tear secretion, chemosis, and the low humidity of air-conditioned ICU environments [5]. Without early detection, exposure keratopathy can progress to corneal ulceration and microbial keratitis with consequent avoidable morbidity and risk of permanent visual loss [3,6]. Eye care is a relatively simple and less expensive aspect of ICU nursing care but is often given a lower priority as the clinical focus is on ventilatory support, hemodynamic monitoring, sepsis management and other life-saving interventions. Critical care nurses are continuously at bedside and are therefore in an ideal position to detect early ocular changes, perform preventive measures and initiate timely referral. However, previous studies have demonstrated that ICU nurses may have limited formal education, variable recognition of risk factors, and the availability of standardized eye-care protocols [7,8]. Knowledge, attitude, and practice (KAP) studies help to identify gaps between health-care providers’ knowledge, beliefs and practice in routine clinical practice. KAP assessment in ICU eye care may help to determine whether nurses are aware of high-risk patients, appreciate the importance of preventive eye care and practice practical measures such as eyelid closure assessment, eye cleaning, lubrication, eyelid taping and documentation. Such information is useful to design targeted training and institutional protocols. There are some Indian and international studies which have assessed eye-care practices of ICU nurses. Vyas et al. [1] reported that although 78% of the ICU nurses in Chhattisgarh were aware of the risk of exposure keratopathy, only 5% followed a strict protocol and less than half of them regularly checked eyelid closure or cleaned the eyes. Thomas et al. [2] found that many nursing staff in ICU in Kerala had average knowledge and positive attitudes and practice pattern was only moderate. Ebadi et al. [3] from Iran also found moderate knowledge with better attitudes and practices which highlights the role of continuing education. Although a few studies have evaluated the knowledge and practice patterns of ICU nurses on eye care, the data from South Indian settings are still scarce. Furthermore, few studies have simultaneously evaluated knowledge, attitude, practice patterns and perceived barriers by using a structured questionnaire. The present study gives local evidence from selected hospitals of Tumkur and may help in developing institution specific eye-care protocols, nurse training modules and documentation practices. Hence, the present study was undertaken to assess the knowledge, attitude and practice patterns of ICU nurses regarding eye care of critically ill patients and to explore the barriers that may hinder recognition and provision of appropriate ocular care.

Study Design and Setting: This was a cross-sectional observational study done over a period of two months in the Intensive care units of selected hospitals at Tumkur. This study was carried out to assess the knowledge, attitude and practice patterns of ICU nurses on eye care of critically ill patients. Study Population and Data Source: The source population was comprised of all ICU nurses, of all ages and both sexes, who were directly involved in the care of critically ill patients in the ICU. Eligible nurses were those working in medical, surgical, cardiac, neonatal and other ICU areas who fulfilled the inclusion criteria. Sampling Method and Sample Size: The total number of ICU nurses in the study was 50. Nurses who were directly providing care to patients in the ICU were recruited through purposive sampling. This method was suitable for accessing the target study population, but it is recognized that this approach has the limitation that purposive sampling may introduce selection bias and limit generalizability. Inclusion Criteria: All the ICU nurses who were attending the patients admitted in ICUs and were willing to participate after informed consent were included in the study irrespective of age and gender. Exclusion Criteria: Nurses posted in any other area except ICUs like outpatient departments, operation theatres and general wards were excluded. Nurses who were not willing to give informed consent were also excluded. Study Tool and Questionnaire: Data were collected using a structured self-administered questionnaire prepared in Google Forms format. The questionnaire was developed based on previously published KAP studies on ICU eye care [1,2] and modified according to the local ICU setting. The questionnaire was reviewed by experts from ophthalmology, critical care, and nursing fields for content relevance, clarity, and face validity. A small pilot administration was performed to assess clarity and feasibility before final data collection. Formal psychometric validation and reliability testing using Cronbach's alpha were not performed, and this has been acknowledged as a limitation. The questionnaire included demographic variables such as age, gender, nursing qualification, ICU experience, and ICU setting. It further contained knowledge, attitude, practice, and barrier-related sections. The full questionnaire has been attached as an appendix/supplementary file. Questionnaire Domains: The knowledge domain included 7 multiple-choice questions related to possible eye complications in ICU patients, high-risk ICU patients, high-risk admitted patients, reasons for exposure keratopathy, management of exposure keratopathy, prior special training in eye care or administration of eye medications, and correct direction of adhesive tape application for eyelid closure. The attitude domain included 7 questions regarding hand hygiene before and after eye care, response to incomplete eyelid closure, need for routine eye examination in ICU patients, need for eye protection during nursing care procedures, perceived importance of eye care for ICU patients, effect of nursing staff education on prevention of eye disorders, and effect of eye care on prevention of eye disorders among ICU patients. The practice domain included questions on last assessment of lid closure, frequency of eyelid closure assessment, frequency of eye drop instillation in exposure keratopathy, method and frequency of cleaning eyes, performance of eyelid taping for incomplete closure, adherence to a fixed eye-care protocol, and source of the protocol. The barrier section included lack of time, shortage of staff, excessive documentation, low priority, and lack of knowledge and skill regarding eye care. Scoring system: Correct responses were scored as 1 and wrong responses as 0 for knowledge questions. The highest possible knowledge score was 7. For the attitude questions, a positive answer was scored as 1 and a negative answer as 0, so the maximum attitude score was 7. Practice items were scored according to recommended and appropriate eye-care practice with the maximum possible practice score being 7. Scores were classified as good, average and poor using percentage based grading. Good performance was defined as scoring 70% or more of the maximum possible score, average performance as 40-69% and poor performance as less than 40%. To avoid arbitrary classification, the same classification was used throughout the knowledge, attitude and practice domains. Data collection method: After getting approval from Institutional Ethics Committee, eligible ICU nurses were approached during duty hours. Written informed consent was obtained prior to participation. The questionnaire was administered anonymously through Google Forms and participants were given sufficient time to complete it. No investigation and intervention was done for the patient. Statistical Analysis: Data were entered into Microsoft Excel and analyzed using statistical software. Categorical variables were expressed as frequency and %. Continuous variables were reported as mean ± standard deviation. The mean KAP scores of the trained and untrained nurses were compared using an independent t-test. The chi square test or Fisher’s exact test, as appropriate, were used to test associations between categorical variables. Statistical significance was considered at p-value <0.05.

A total of 50 ICU nurses participated in the study. The mean age of participants was 33.8 ± 5.8 years. There were 22 females (44.0%) and 28 males (56.0%). Most participants held a B.Sc. Nursing degree (n = 40, 80.0%), while 10 nurses (20.0%) had a diploma in nursing. Half of the participants (n = 25, 50.0%) had 1-5 years of ICU experience. Prior formal training in eye care was reported by 18 nurses (36.0%). Table 1. Demographic Characteristics of ICU Nurses (n = 50) Variable Number Percentage Total participants 50 100.0 Mean age 33.8 ± 5.8 years - Female 22 44.0 Male 28 56.0 B.Sc. Nursing 40 80.0 Diploma Nursing 10 20.0 ICU experience <1 year 10 20.0 ICU experience 1-5 years 25 50.0 ICU experience >5 years 15 30.0 Prior eye-care training 18 36.0 Knowledge Assessment Good knowledge was observed in 12 nurses (24.0%), average knowledge in 31 nurses (62.0%), and poor knowledge in 7 nurses (14.0%). Most participants were aware that sedated and mechanically ventilated patients were at risk of exposure keratopathy. However, fewer nurses correctly identified multiple contributing factors such as incomplete eyelid closure, reduced blink reflex, and dry ICU environment. Table 2. Knowledge Score Distribution (n = 50) Knowledge Category Number Percentage Good 12 24.0 Average 31 62.0 Poor 7 14.0 Attitude Assessment Good attitude was observed in 26 nurses (52.0%), average attitude in 20 nurses (40.0%), and poor attitude in 4 nurses (8.0%). Most participants agreed that regular eye care helps prevent ocular complications and supported the inclusion of eye assessment in routine ICU nursing care. Table 3. Attitude Score Distribution (n = 50) Attitude Category Number Percentage Good/Positive 26 52.0 Average 20 40.0 Poor 4 8.0 Practice Assessment Only 13 nurses (26.0%) demonstrated good eye-care practices. Seventeen nurses (34.0%) reported following a written eye-care protocol. Regular eyelid closure assessment was reported by 28 nurses (56.0%), routine eye cleaning by 22 nurses (44.0%), and eyelid taping for incomplete closure by 26 nurses (52.0%). Table 4. Practice Patterns Among ICU Nurses (n = 50) Practice Parameter Number Percentage Good practice score 13 26.0 Followed written eye-care protocol 17 34.0 Regular eyelid closure assessment 28 56.0 Routine eye cleaning performed 22 44.0 Eyelid taping for incomplete closure 26 52.0 Association Between Training and KAP Scores Nurses who had received prior eye-care training had significantly higher knowledge and practice scores compared with those without training. Attitude scores were also higher among trained nurses, but this difference was not statistically significant. Table 5. Association Between Prior Eye-Care Training and KAP Scores Domain Trained Nurses Mean ± SD Untrained Nurses Mean ± SD p-value Knowledge 14.3 ± 2.6 11.8 ± 3.1 0.002 Attitude 6.2 ± 0.8 5.5 ± 1.1 0.060 Practice 13.6 ± 3.2 10.4 ± 3.5 0.001 Association of Demographic Factors with KAP Scores No statistically significant association was observed between overall KAP performance and age group, gender, educational qualification, or ICU experience. Prior eye-care training was the only factor significantly associated with better overall KAP performance. Table 6. Association of Selected Factors with Overall KAP Performance Factor Association with KAP Score p-value Age group Not significant 0.214 Gender Not significant 0.486 Educational qualification Not significant 0.178 ICU experience Not significant 0.092 Prior eye-care training Significant 0.003 Barriers to Eye-Care Implementation The most common barrier was lack of time due to workload, reported by 23 nurses (46.0%). Lack of standardized eye-care guidelines was reported by 15 nurses (30.0%), while inadequate training or lack of knowledge and skill was reported by 12 nurses (24.0%). Table 7. Barriers to Proper Eye-Care Practice Barrier Number Percentage Lack of time due to workload 23 46.0 Lack of standardized guidelines 15 30.0 Inadequate training/lack of knowledge and skill 12 24.0

The present study was aimed to assess the knowledge, attitude and practice patterns of ICU nurses regarding eye care of critically ill patients in selected hospitals in Tumkur. The main finding was that nurses had fair knowledge and overall favorable attitudes, but their actual practices of eye care were irregular with minimal protocol-based care. This highlights a clinically significant knowledge-to-practice gap in ICU eye care. The demographic profile revealed that most of the participants were B.Sc. Nursing graduates and half of them had 1-5 years of ICU experience. This indicates acceptable professional exposure of study population to critically ill patients. However, eye care in ICU is a specialized area of nursing care and experience in routine ICU care alone may not guarantee adequate competence in ocular assessment. This may also contribute to the suboptimal eye-care practices despite moderate knowledge. Only 24.0% of nurses had good knowledge and 62.0% of nurses had average knowledge in the knowledge domain. Most nurses knew about the risk of exposure keratopathy in sedated and mechanically ventilated patients. Fewer participants, however, could identify multiple contributing mechanisms such as incomplete eyelid closure, reduced blinking, reduced tear secretion and dry ICU environment. Similar findings were reported by Vyas et al. [1] who reported that awareness about exposure keratopathy was there among ICU nurses but protocol based implementation was poor. Thomas et al. [2] also demonstrated that although most nurses correctly identified patients at high risk, there were gaps in their understanding of the full pathophysiology and preventative measures. The nurses’ attitude towards eye care was better than their knowledge and practice as 52.0% of the nurses had a good attitude. This indicates that most of the participants were aware of the importance of eye care and were willing to help in preventive practices. A positive attitude is hopeful, because it gives a positive base for interventions based on training. Similar findings were reported by Ebadi et al. [3] who found that ICU nurses generally had positive attitudes towards eye care despite moderate knowledge levels. The largest gap was in the domain of practice. Only 26.0% of nurses indicated good practice and only 34.0% indicated they followed a written eye-care protocol. Routine cleansing, taping for incomplete eyelid closure and assessment of eyelid closure were not performed consistently. Clinically this is important because keratopathy, exposure and abrasions of the cornea are largely preventable when simple nursing interventions are consistently carried out. According to Vyas et al. [1], only 5% of ICU nurses adhered to a strict protocol and less than half checked for eyelid closure. Despite better awareness, Thomas et al. [2] also reported variability in eye-care practices. Therefore, the current findings are in line with the evidence that the ICU eye-care practices are still inconsistent in many settings. Previous eye-care training was significantly associated with better knowledge and practice scores. Trained nurses had better knowledge scores than untrained nurses and they also had better practice scores. This finding underscores the need for structured and repeated training programs. Ebadi et al. [3] emphasized on interrelationship of knowledge, attitude and practice and that can be strengthened by the continuing education. Likewise, compliance with eye-care measures has been reported to be improved by protocol-based education and demonstration of nursing skills [10,11]. The study also identified key implementation barriers. The most prevalent barrier was lack of time due to workload. In busy ICUs, nurses often focus on ventilatory care, administration of medications, hemodynamic monitoring, emergency procedures, and documentation. So eye care may be overlooked unless it is part of the routine nursing checklists. The other major barrier was the lack of standardized guidelines. Without written protocols, nurses are left to their own experience, advice from colleagues or instructions from ICU doctors, which leads to variability in practice. Inadequate training and lack of knowledge and skill were also major barriers. Nurses may be uncertain about how often to lubricate, how to tape the eyelids, and when to refer to ophthalmology. These barriers are in line with previous studies. Mohammadi et al. [8] identified competing priorities, lack of knowledge and system-level constraints as factors influencing the provision of eye-care in ICUs. Güler et al. [7] and Oh et al. [9] also found that eye care is often given low priority compared with hemodynamic and ventilatory care, unless supported by protocols and documentation. Thus, improvement of eye care in the ICU should not only include individual training, but also institutional systems such as written guidelines, documentation charts, and regular audits. The novelty of this study is the local assessment of ICU eye-care KAP among nurses in Tumkur Hospitals. Similar studies have been done in India and abroad, but local data are important as nursing workload, availability of protocols, training exposure, and ophthalmology referral systems differ between institutions. The results provide pragmatic information for the development of local eye care protocols in the ICU and targeted training programmes. This study has important clinical implications. Preventive eye care in ICU patients does not require costly equipment. Regular assessment of eyelid closure, sterile cleaning, lubrication, eyelid taping and timely referral can decrease preventable ocular morbidity. We believe that the inclusion of eye care in routine ICU nursing charts and daily checklists may improve compliance. Sustainable implementation would require collaboration of ophthalmologists, intensivists and nursing educators. LIMITATIONS OF THE STUDY There were some limitations of this study . First, the study was conducted in selected hospitals of Tumkur and the sample size was small, thus findings may not be generalizable to all ICU settings. Second, purposive sampling might have led to selection bias. Third, the practice assessment was based on self-reported responses which may overestimate the actual practice due to social desirability bias. There were no direct observational audits undertaken. Fourth, although the questionnaire was adapted from previous studies and reviewed for content and clarity, it was not validated psychometrically nor tested for its reliability (e.g., Cronbach’s alpha). Future research should include larger multicentric samples, validated tools, direct observation of practices, and pre- and post-training assessment.

The study revealed that ICU nurses had fair knowledge regarding eye care in critically ill patients and generally positive attitudes, but the actual practice was inconsistent. Only a minority of nurses demonstrated good practice and written eye-care protocols were not routinely followed. There was significant association between knowledge and practice scores with previous eye-care training. Structured training can improve delivery of eye-care in the ICU. The main barriers were lack of time due to workload, lack of standardized guidelines and inadequate training or lack of knowledge and skills . These findings should be interpreted with caution given the small sample size, selected-hospital setting, purposive sampling, and self-reported practice assessment of the study. The findings, however, underscore the need for locally applicable eye-care protocols, nursing education, routine documentation, and periodic audits to improve ocular care in critically ill ICU patients. RECOMMENDATIONS • A standardized ICU eye-care protocol should be developed and implemented. • Eye care should be incorporated into routine ICU nursing checklists. • Regular training and continuing nursing education sessions should be conducted. • Ophthalmology referral criteria should be clearly defined. • Periodic audits should be conducted to assess actual eye-care practices. • The questionnaire should be submitted as an appendix or supplementary file for transparency and reproducibility. • Future research should include multicentric studies with larger samples and direct observation of nursing practices.

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