EVALUATION OF KNOWLEDGE, ATTITUDES, AND BEHAVIOURS (KAP) OF INTRA-ABDOMINAL PRESSURE MONITORING AMONG PAEDIATRIC CRITICAL CARE NURSES

CHAPTER ONE

INTRODUCTION

1.1 Background of the study

Monitoring intra-abdominal pressure (IAP) is a crucial procedure in the care of critically ill patients, especially within paediatric intensive care units (PICUs). Intra-abdominal pressure (IAP) refers to the equilibrium pressure within the abdominal cavity, resulting from the dynamic interplay between the abdominal wall and the internal organs (Kirkpatrick et al., 2017). The baseline IAP values for healthy children are around 3e5 mmHg (1 mmHg = 0.133 kPa), 4e10 mmHg in critically ill children, and 7 ± 3 mmHg in children receiving mechanical ventilation (Li et al., 2023). Intra-abdominal hypertension (IAH) denotes a persistent or recurring abnormal increase in intra-abdominal pressure (IAP) exceeding 10 mmHg, which has been established as an independent factor contributing to mortality in critically ill individuals (Divarci et al., 2016). Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) represent critical medical conditions characterised by increased intra-abdominal pressure, which may precipitate multiple organ dysfunction. If not addressed, these conditions can lead to significant morbidity and mortality rates (Kirkpatrick et al., 2017).

Abdominal compartment syndrome (ACS) is linked to the emergence or exacerbation of organ dysfunction, which can be ascribed to increased intra-abdominal pressure (IAP). This complication is gaining recognition in critically ill children, whether diagnosed through medical or surgical means, and is linked to elevated mortality rates (Thabet & Ejike, 2017). The occurrence of ACS was documented to range from 0.6% to 4.7% within a single-center mixed paediatric intensive care unit (PICU) cohort (Ejike et al., 2019). While ACS is infrequently documented, it progresses swiftly and is frequently a significantly overlooked and lethal condition among children. The influence of IAH and ACS on the occurrence of multiple organ failure in critically ill patients is substantial. The pathophysiological effects of elevated intra-abdominal pressure are significant, influencing haemodynamic, respiratory, gastrointestinal, neurological, and renal functions in critically ill patients (Ejike et al., 2019). Inadequate and timely recognition of ACS can result in significant postponements in diagnosis and subsequent medical or surgical treatment, ultimately leading to increased rates of morbidity and mortality. Mortality associated with ACS has been documented to reach as high as 40%-60% in several studies examining paediatric patients admitted to the PICU (Divarci et al., 2016; Bozer et al., 2023).

The monitoring of intra-abdominal pressure facilitates the early detection of intra-abdominal hypertension and abdominal compartment syndrome, thereby allowing healthcare professionals to implement prompt interventions to avert additional complications (Malbrain et al., 2016). The evolution of intra-abdominal pressure monitoring has been substantial over recent decades. Traditionally, healthcare practitioners depended on clinical indicators and manifestations to recognise abdominal compartment syndrome. Nevertheless, studies indicate that clinical signs by themselves are inadequate for the early detection of IAH, as numerous patients may not exhibit clear symptoms until the condition has advanced to a critical level (Cheatham et al., 2019). Therefore, precise and ongoing observation of IAP is essential for timely identification, especially in at-risk groups such as critically ill paediatric patients, who might exhibit non-specific symptoms owing to their developmental phases (Sugrue et al., 2019).

In the realm of paediatric care, the factors contributing to the development of intra-abdominal hypertension are diverse, frequently encompassing severe trauma, sepsis, significant abdominal surgery, and organ dysfunction (Sola-Teyssier et al., 2020). Paediatric patients exhibit heightened susceptibility to the swift advancement of intra-abdominal hypertension, attributable to their distinct physiological characteristics, such as reduced body size, which may lead to rapid fluctuations in abdominal cavity pressure (Reintam et al., 2018). Therefore, it is essential for paediatric critical care nurses to possess a deep understanding of the risk factors and management strategies for IAH and ACS, along with a high level of proficiency in the application and interpretation of IAP monitoring techniques.

The expertise of healthcare providers, especially critical care nurses, is essential for the effective implementation of intra-abdominal pressure monitoring in paediatric intensive care units. Research indicates that nurses possessing a thorough knowledge of IAP monitoring are more adept at recognising early indicators of IAH and implementing suitable measures to avert complications (Malbrain et al., 2016). Nonetheless, it is evident that numerous nurses possess inadequate training or understanding in this domain, potentially resulting in delays in diagnosis and less than ideal patient outcomes (Gleeson & Whelan, 2018). Insufficient exposure to IAP monitoring during nursing education or a lack of opportunities for ongoing education and specialised training in paediatric critical care environments may contribute to knowledge gaps.

Beyond the acquisition of knowledge, the perspectives held by nurses regarding IAP monitoring may significantly affect their readiness to integrate this practice into their everyday clinical activities. Perspectives on novel or specialised procedures are frequently influenced by elements such as the perceived significance, self-assurance in one's capability to execute the task, and the anticipated effect of the procedure on patient results (Persch et al., 2015). Nurses who view IAP monitoring as intricate or superfluous may be less inclined to integrate it into their practice, even when it is warranted for critically ill patients. On the other hand, nurses exhibiting favourable attitudes towards IAP monitoring tend to support its implementation and comply with the prescribed protocols (Omorogiuwa et al., 2017).

Behavioural factors significantly influence the implementation of IAP monitoring in paediatric critical care settings (Lagos et al., 2016). The actions of critical care nurses regarding IAP monitoring are shaped by various elements, such as their workload, availability of resources, and the policies set forth by their institutions. In numerous resource-constrained environments, particularly within certain healthcare institutions in sub-Saharan Africa, including Nigeria, the scarcity of equipment and insufficient staffing may impede the regular implementation of IAP monitoring (Lagos et al., 2016). Moreover, nurses might face limitations due to time constraints and conflicting clinical priorities, which can influence their capacity to conduct IAP monitoring within the framework of standard patient care.

Prior research has highlighted the experiences of paediatric medical personnel, underscoring a limited understanding of the definitions of IAP, IAH, and ACS, as well as the measurement and treatment protocols associated with IAP (Deindl et al., 2019). A study carried out by Ejike et al. (2019) regarding awareness of IAH/ACS revealed that merely 46.8% of paediatric medical personnel were familiar with the accurate definition, 24.2% of paediatric healthcare professionals had never assessed IAP, and only 51% indicated they had managed cases involving children with IAH/ACS. Liang et al. (2016) performed a survey to assess the awareness of IAP/IAH/ACS among medical professionals attending the paediatric critical care conference. The findings revealed that merely 7.2% of participants (10 out of 138) were familiar with the definition, while among those utilising intravesical pressure measurement, only 57.1% (20 out of 35) were aware of the appropriate perfusion volume.

Considering the significant impact that paediatric critical care nurses have on the timely identification and treatment of intra-abdominal hypertension, it is imperative to evaluate their knowledge, attitudes, and behaviours (KAP) concerning this procedure. Recognising the deficiencies in knowledge, pinpointing adverse attitudes, and tackling obstacles to behavioural transformation can enhance the implementation of IAP monitoring in paediatric critical care environments. Furthermore, the introduction of specialised educational and training initiatives aimed at improving nurses' proficiency in IAP monitoring has the potential to significantly enhance patient outcomes and mitigate the risks of complications linked to IAH and ACS (Sola-Teyssier et al., 2020). This study aims to assess the understanding, perspectives, and practices related to intra-abdominal pressure monitoring among nurses in paediatric critical care settings.

1.2 Statement of the Problem

Monitoring intra-abdominal pressure (IAP) has emerged as an essential component in the management of critically ill paediatric patients. Increased intra-abdominal pressure, or intra-abdominal hypertension, can result in considerable complications and fatalities if not recognised and addressed in a timely manner. In light of the recognised significance of IAP monitoring, it is troubling to note a notable deficiency in the knowledge, attitudes, and behaviours (KAP) of paediatric critical care nurses pertaining to this essential practice. This gap presents a considerable obstacle to achieving the highest standards of care in paediatric intensive care units (PICUs).

Research suggests that numerous paediatric critical care nurses demonstrate insufficient understanding regarding the evaluation, importance, and consequences of IAP monitoring. Research indicates that a significant number of nurses lack awareness regarding the recommended measurement techniques and the possible complications linked to unmanaged IAH (McGowan et al., 2017). The absence of understanding may result in uneven monitoring methods, heightening the likelihood of postponed intervention for patients facing increased intra-abdominal pressure.

Beyond gaps in knowledge, the attitudes of nurses regarding IAP monitoring play a crucial role in shaping their clinical practice. Certain nursing professionals might possess misunderstandings regarding the intricacies and benefits of IAP monitoring, which could result in hesitance towards its adoption (Omorogiuwa et al., 2017). Adverse dispositions may arise from past encounters, insufficient education, or the belief that oversight is unwarranted for specific groups of patients. Research indicates that a favourable perspective on monitoring frequently correlates with increased adherence to clinical guidelines (Sharma et al., 2019). Consequently, tackling these attitudinal barriers is essential for cultivating an environment that supports effective patient management.

The actions demonstrated by paediatric critical care nurses concerning IAP monitoring frequently lack consistency. Observational studies indicate that a portion of nurses do not consistently measure IAP, despite recognising its importance (Hutchison et al., 2018). This inconsistency may arise due to the absence of standardised protocols, differing institutional practices, and inadequate training opportunities. Consequently, patients in critical condition might face postponements in essential interventions, resulting in unfavourable outcomes. Considering the essential role of IAP monitoring and its impact on patient care, it is imperative to conduct a thorough assessment of the knowledge, attitudes, and practices among paediatric critical care nurses. Thus, the necessity for this investigation arises.

1.3 Objectives of the study

The primary objective of this study is to critically evaluate the knowledge, attitudes, and behaviours (KAP) of intra-abdominal pressure monitoring among paediatric critical care nurses. Specific objectives of this study are to:

1. To investigate the level of knowledge of pediatric critical care nurses regarding intra-abdominal pressure (IAP) monitoring in Nigeria

2. To examine the attitudes of pediatric critical care nurses towards IAP monitoring in Nigeria

3. To analyze the behaviors of pediatric critical care nurses in relation to IAP monitoring in Nigeria

4. To explore the factors that affect the KAP of pediatric critical care nurses regarding IAP monitoring in Nigeria

1.4 Research Questions

The following research questions which are in line with the objectives of this study will be answered in this study:

1. 1. 1. What is the level of knowledge of pediatric critical care nurses regarding intra-abdominal pressure (IAP) monitoring in Nigeria?

      2. What are the attitudes of pediatric critical care nurses towards IAP monitoring in Nigeria?

      3. What are the behaviors of pediatric critical care nurses in relation to IAP monitoring in Nigeria?

      4. What are the factors that affect the KAP of pediatric critical care nurses regarding IAP monitoring in Nigeria?

1.5 Research Hypotheses

To determine the effectiveness of this study, the following research null hypotheses will be formulated to guide the study and it will be tested at 0.05% levels of significance.:

Ho: The level of knowledge of pediatric critical care nurses regarding intra-abdominal pressure (IAP) monitoring in Nigeria is low

Ha: The level of knowledge of pediatric critical care nurses regarding intra-abdominal pressure (IAP) monitoring in Nigeria is high.

1.6 Significance of the study

The research holds significant importance for numerous reasons, influencing a wide array of stakeholders such as healthcare practitioners, nursing educators, hospital administrators, patients and their families, as well as policymakers.

This study provides an essential resource for paediatric critical care nurses, highlighting the significance of their role in the monitoring of intra-abdominal pressure. The knowledge acquired can enable nurses to champion enhanced monitoring practices and participate in ongoing professional growth. Heightened awareness and comprehension can inspire nurses to pursue additional education and training, resulting in a more skilled and self-assured workforce. Enhancing the capabilities of nurses fosters greater job satisfaction and facilitates professional development, which in turn leads to improved retention rates in a challenging profession.

Nursing educators significantly influence the foundational knowledge of emerging practitioners. The results of this study can guide the development and execution of educational initiatives that emphasise the significance of monitoring intra-abdominal pressure. Integrating evidence-based practices into nursing curricula is essential for preparing new nurses to enter the workforce with the requisite skills and knowledge. This fosters an environment of safety and responsibility within paediatric critical care units, ultimately enhancing the quality of patient care.

Hospital administrators play a pivotal role in this study, as the outcomes can inform policy formulation concerning monitoring protocols and staff education. Recognising common deficiencies in understanding or unfavourable perceptions regarding intra-abdominal pressure monitoring can lead to the development of institutional guidelines that highlight its importance. This could involve the establishment of uniform monitoring protocols, the provision of resources for ongoing education, and the assurance that all personnel are knowledgeable about optimal practices in paediatric critical care. Such policies can cultivate an environment dedicated to enhancing quality and ensuring safety within healthcare institutions.

Families of critically ill children frequently endure increased levels of stress and anxiety. Improving the expertise and competencies of nurses in monitoring intra-abdominal pressure can facilitate more effective communication with families about their child's condition. When nurses possess a comprehensive understanding, they are able to articulate the importance of monitoring practices and provide reassurance to families regarding the measures implemented to safeguard their child's well-being. Enhanced communication has the potential to ease certain emotional challenges that families encounter, promoting a nurturing atmosphere.

The findings of this study offer significant insights for policymakers regarding the present practices in paediatric critical care, particularly concerning the monitoring of intra-abdominal pressure. Understanding the significance of this facet of care can guide the formulation of national guidelines and standards. The findings can serve as a compelling basis for policymakers to champion enhanced funding for training initiatives and resources aimed at refining critical care practices, thereby yielding significant advantages for paediatric patients across the country.

This investigation lays the groundwork for additional exploration into the monitoring of intra-abdominal pressure and its significance in the realm of paediatric critical care. Recognising existing knowledge and behavioural patterns can stimulate further exploration into the efficacy of particular training methods or the enduring results linked to enhanced monitoring techniques. This continuous investigation can enhance a solid foundation of evidence that guides clinical practice and nursing education.

1.7 Scope of the study

Broadly, this study focus is to critically evaluate the knowledge, attitudes, and behaviours (KAP) of intra-abdominal pressure monitoring among paediatric critical care nurses in Nigeria. Empirically, the study will discuss the level of knowledge of pediatric critical care nurses regarding intra-abdominal pressure (IAP) monitoring in Nigeria, the attitudes of pediatric critical care nurses towards IAP monitoring in Nigeria, the behaviors of pediatric critical care nurses in relation to IAP monitoring in Nigeria and the factors that affect the KAP of pediatric critical care nurses regarding IAP monitoring in Nigeria.

Geographically, the study will be carried out in National Hospital, Abuja.

1.8 Limitations of the study

During the examination, the researchers carefully examined the inherent limitations that are present in all human behaviours. One of the main challenges we faced was the lack of extensive scholarly research on the subject. A notable factor that contributed to the issue was the limited data available regarding evaluation of the knowledge, attitudes, and behaviours (KAP) of intra-abdominal pressure monitoring among paediatric critical care nurses in Nigeria. Given the task at hand, it was quite demanding to find the required materials, books, or information and organise the data, requiring a significant investment of time and effort.

In addition, the study's findings may be constrained by the small number of participants and the limited scope of the research, which mainly revolves around National Hospital, Abuja. Therefore, the findings of the study have limited practical implications, highlighting the need for further research.

In addition, the individual experienced significant constraints due to financial constraints. As a student with limited financial resources, they had to carefully navigate these constraints throughout their study. The exorbitant transportation fees at the research site proved to be a significant hindrance in meeting the financial obligations tied to travel expenses.

Furthermore, the person had a packed schedule due to their scholarly obligations, including attending lectures and participating in a range of educational pursuits.

1.9 Definition of terms

Paediatric: Pediatrics also spelled paediatrics, is the branch of medicine that involves the medical care of infants, children, adolescents, and young adults

Critical care: Critical care is medical care for people who have life-threatening injuries and illnesses. It usually takes place in an intensive care unit (ICU). A team of specially-trained health care providers gives you 24-hour care

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