An audit of nurses' conduct and recording of observations using the Glasgow Coma Scale

Abstract

Objectives: The Glasgow Coma Scale (GCS) is routinely used to assess patients following head injury or other acute neurological events. The aims of this project were: to assess and evaluate registered nurses' baseline knowledge of the three behavioural responses that make up the assessment tool; to review the recording of GCS in neuroscience areas compared with non-specialist units; and to ascertain when the GCS is taught during nurse training and the background experience of the lecturers who teach it. Methods: Sixty questionnaires were used across six clinical areas: neurosurgery, neuro-intensive care, neuromedicine, general medicine, accident and emergency, and general intensive care. Observational studies compared nurses' performance, recording and documentation of GCS observations in each of these units. The unpublished standards for making GCS observations, written by the Neuroscience Nursing Benchmarking Group, were used to identify questions for examination in the audit. Results: Several areas for improvement were identified; including the use and application of painful stimulus. The use of sternal rubbing and nail bed compression continues to be common practice. Data collected also suggested a lack of knowledge of the patho-physiology underpinning the three components that make up the scale. Problems were evident in the record keeping, with very few examples of documentation within nursing records of the separate components of the GCS. Finally, the questionnaires returned from the universities revealed that students were introduced to the assessment tool during the first year of training, normally by lecturers with a critical care or accident and emergency clinical background. Conclusions: The data demonstrated wide variation in GCS scoring across all specialties. While the benchmarking standards are applied in neuroscience wards, the guidelines are not widely available for use in other units. It is pertinent to consider whether access to a clear and comprehensive protocol would help remove some of the ambiguities and ensure a more consistent approach to assessment. Novel approaches to education are required to maintain knowledge and skills in this area of practice. Documentation needs to improve and include the results from component parts of the scale. Instruction on the performance of GCS observations, if taught in the first year of training, should be re-examined, linking theory to practice prior to qualifying. The findings from this study will provide a useful basis for future research using more precise methods.

Investigating factors that have an impact on nurses’ performance of patients’ conscious level assessment: a systematic review

“…As such, the GCS could potentially be used inconsistently and inaccurately between health‐care staff (Rowley & Fielding 1991, Ellis & Cavanagh 1992, Teasdale & Murray 2000). There is evidence suggesting that problems can be encountered when performing certain aspects of the GCS and there is potential for inaccurate assessment in some situations (Waterhouse 2008).…”

Training needs analysis of Korean nurses' neurological assessment competency

“…For instance, nurses' confidence levels for performing consciousness assessment are reportedly high (Kim et al, ), but their consciousness level accuracy is low (Brunker & Harris, ). Performance levels for cerebellar function (Kim et al, ) and Glasgow Coma Scale assessment (Waterhouse, ) are low, as is the accuracy of pupil size interpretation (Brunker & Harris, ; Kerr et al, ). Knowledge and experience are the most significant factors influencing nurses' performance of consciousness level assessment (Chan et al, ).…”

“…Nurses working in a general ward, accident and emergency unit, and general intensive care, as well as in neuroscience areas, have shown low competency in applying the Glasgow Coma Scale. In particular, nurses in neurological wards or intensive care units showed a higher neurological assessment ability compared with other clinical area nurses, but some errors were also confirmed (Waterhouse, ). In a simulation study, nurses had more difficulty in following their usual protocol for assessing stroke patients than doctors (Ross et al, ).…”

Neurological Assessment in the Acute Care Practice Environment of Northern Ontario Hospitals

“…It is an integral component of the Canadian CT Rules (Stiell, Lesiuk, Wells, Coyle, et al, 2001;) for decisions regarding diagnostic testing following head injury. The psychometric properties of this instrument (Gill et al, 2004;Gill, Windemuth, Steele, & Steven, 2005;Heron et al, 2001), its clinical application (Al-Salamah et al, 2004;Costanti Settervall, Cardoso de Sousa, & Fürbromger e Silva, 2011;Iankova, 2006;Jain, Dharap, & Gore, 2008;Jennett & Bond, 1975) and interdisciplinary use (Heron et al, 2001;Waterhouse, 2008) are well established in the literature and worldwide (Costanti Settervall et al, 2011;Jain et al, 2008;Tasseau, Rome, Cuny, & Emery, 2002). GCS =12-9 (moderate) GCS= 8-3 (severe) Adapted from Teasdale & Jennett (1974) …”