Knowledge of the Glasgow Coma Scale among nurses in District General Hospital: quantitative approach

Introduction

The Glasgow Coma Scale (GCS) was created in 1974 by Graham Teasdale and Bryan J. Jennett, two professors of neurosurgery at the Institute of Neurological Sciences, University of Glasgow, to objectively assess the degree of coma in all acute medical and trauma patients^(1-3). Eye-opening, motor and verbal responsiveness are the three categories of responsiveness used by the scale to assess patients’ mental health. The GCS score is the sum of the scores for the three components, each of them evaluated independently and assigned a score. Scores range from 3^(2-4) to a maximum of 15. The tool’s use increased in the 1980s, after the World Federation of Neurosurgical Societies (WFNS) included it as part of its scale for grading patients with subarachnoid hemorrhage, and the first edition of Advanced Trauma and Life Support advocated its use in all trauma patients⁽²⁾.

Almost four decades later, the GCS is still the gold standard for the assessment, ongoing monitoring, prognosis and clinical judgment about consciousness in patients with traumatic brain injuries and other acute neurological conditions, despite some criticisms, like the lack of inter-rater reliability^(5,6). The Glasgow Coma Scale is a neurological tool that gauges the intensity and length of impaired consciousness⁽⁷⁾. The test was used to determine a person’s acute brain damage severity. The GCS measures verbal, motor, and eye-opening responses. According to the scale, a score of 8 or lower reflects the most severe injury, 9-12 represents a moderate injury, and 13 to 15 indicate a mild injury⁽⁸⁾. A really important aspect is to measure the consciousness level of a patient who had an accident. Having obtained the required facts, then patients can be forwarded to further treatments which they require. It paves the way for healthcare staff to proceed with the process.

The GCS is a technique for assessing the degree of consciousness and is crucial in spotting early deterioration in a patient’s level of awareness^(9,10). Despite the GCS’s simplicity and objectivity, the accurate tool knowledge and the capacity to use it in a clinical setting are necessary for the validity and usefulness of its scores. Since the deterioration in clinical status may not be readily noticed until the condition worsens or becomes irreversible, inadequate expertise in the application of this instrument would undoubtedly have a detrimental impact on the management of patients with an altered levels of awareness or in emergency situations. Knowledge is familiarity, awareness or understanding of someone or something, such as facts (propositional knowledge) or skills (procedural knowledge) or objects (acquaintance knowledge)⁽¹¹⁾.

Unfortunately, a number of studies that evaluated the GCS knowledge of nurses and other professionals found that they lacked enough knowledge of this crucial instrument. In a research that assessed Nigerian physicians’ knowledge of the GCS, 30% of the participants didn’t even know what the GCS actually meant⁽¹²⁾. In our country context, fewer studies have been done. Therefore, this study is based on GCS.

The researchers intend to carry out this particular research on knowledge of the Glasgow Coma Scale of nurses in the District General Hospital. Because GCS is a measuring scale of a patient’s consciousness level, nurses should have enough knowledge in this particular subject area. The study aims to assess the knowledge of the Glasgow Coma Scale among nurses and to find out the relationship between the nurses’  knowledge and the demographic characteristics which include education level and years of experience.

Methodology

Design and setting

We used a quantitative technique and a descriptive self-administrated questionnaire survey to carry out the investigation. The setting for this study was the District General Hospital and the participant consistency of nurses who were working at the hospital setup.

A well-structured, close-ended self-administrated questionnaire was used to examine the knowledge of the Glasgow Coma Scale among nurses in the District General Hospital. The questionnaire was divided into two sections. The first section of the questionnaire gathered demographic data. The second section was a structured questionnaire to assess the knowledge of the Glasgow Coma Scale among nurses.

The hospital gets practically all the cases of traumatic brain injuries, other serious kinds of trauma, and severe medical problems in the region, either as direct admissions or by referrals, as it serves as the primary referral hospital in the Southern part of the country. The medical wards of the hospital also accept patients with severe medical conditions that cause altered degrees of consciousness, such as acute meningitis, brain abnormalities and stroke, in addition to these traumatic admissions. All of these patient types need to be monitored using the GCS. Prior to and following procedures, the general surgery department also accepts and looks after surgical patients. As a result, the nurses working in that area are also responsible for keeping an eye on the patients’ state of consciousness, particularly in the days and weeks following surgery. The hospital is the perfect setting for evaluating nurses’ GCS knowledge because of these features.

Population and sampling

A convenience sample of 143 nurses was chosen and completed the survey from the population of roughly 200 nurses working in the various hospital units during the study. The participants were picked from two general wards (Medical Ward and General Surgery Ward), three specialty wards (Accident and Emergency Ward, Intensive Care Unit, and Neurosurgical Ward), and one general ward (Intensive Care Unit). These units were chosen because the patients’ health conditions necessitate frequent GCS for monitoring in those units.

Data collection procedure

Following the research’s ethical approval committee, the approval letter with the consent form, introducing the study purpose, was distributed to ward nurses and nurses in charge of all wards, to inform their nurses about the study. We distributed the questionnaires to everyone who had agreed to participate in the study one week after being informed.

The subjects were under the researcher’s supervision as they finished the questionnaire in 30 minutes. This was done to make sure that the participants didn’t use any books or online sources to fill out the survey. As soon as a person had done replying, questionnaires should be gathered.

A standardized questionnaire created by the study team served as the data gathering tool. The tool consists of two parts. Part 1 contained demographic features of the participants, such as age group, experience, gender and educational level, and part two contained knowledge-related questions.

The data collection was conducted within two months. The collected data were entered into the Microsoft Excel software, and descriptive statistics were analyzed by using tables, graphs and figures.
 

Data collection instrument

The researchers created a structured questionnaire as the tool for gathering data. The instrument was divided into two primary components that were intended to collect information on participants’ demographic traits and GCS knowledge.

Four questions in Section A asked the participants demographic information, including their age group, level of education, gender and years of service. Section B comprised 20 questions with multiple choices on the GCS that were taken from the literature. We pretested the tool on a sample of 15 nurses working in the emergency room of a large district hospital inside the District General Hospital to ensure its validity, and since no ambiguities in the questions were discovered, we kept the questionnaire in its original form for the main study.

Data analysis

The Statistical Package for Social Sciences, version 21, IBM SPSS statistics 22 (IBM Corp. Armonk, NY: USA) was used to analyze data from the study. The individuals’ backgrounds and their exposure to GCS were summed up using descriptive statistics, including frequencies, percentages and averages. An assessment of nurses’ GCS knowledge was made using a scale of 20 multiple-choice questions. Each accurate response was worth one point, while a wrong response received none. Unanswered questions were regarded as incorrect responses. These 20 multiple-choice questions were used to determine each participant’s overall knowledge score. Based on their overall knowledge score, the participants were then divided into three groups: good knowledge (80% or higher), average knowledge (60-79%), and low knowledge (less than 60%). To compare knowledge between men and women, as well as between those who had and hadn’t undergone GCS refresher training, we used the independent samples t-test. 

Ethical considerations

The Research and Ethics Committee of the ERC’s research committee gave its permission for the project. We made participants aware of their right to decline taking part in the study, and participation was entirely voluntary. Those who consented to participate attested to their free will by signing the written informed consent. During the trial, participants’ identities remained concealed, and we maintained the privacy of all data.

Results

The researchers achieved a sample size of 143 participants. Fifty questionnaires were not answered by the participants and were returned Thus, the response rate was 71.5%.

Table 1 includes the demographic findings of the study, clearly showing that the majority of participants were female nurses (86%). When the age group is considered, most participants were in the 30 to 40 years old category (55%). Nurses older than 50 years of age did not take part in our research. The percentage of the youngest nurses, between 20 and 30 years old, was 37%. Nurses with five to ten years of service represented 49%, the highest rate.

More than half of the participants in this study (64%) displayed an average GCS knowledge. Table 2 shows that 64% of participants had a satisfactory knowledge, 25% possessed a poor knowledge, and only 11% of nurses had a good knowledge. Along with the participants’ general awareness of the GCS, we also looked into their understanding of the GCS’s fundamental theoretical ideas and how it might be used in the clinical contexts. The majority of the participants (64%) showed an average awareness of the GCS’s fundamental theoretical ideas, answering 80% of the questions correctly.

There were 85% of nurses in the research having a diploma. Among them, 19% had a good knowledge, and the rest of the participants had a satisfactory knowledge (Table 3).

Nurses with five to ten years of service represented 49% and, among them, 80% had a satisfactory knowledge, 7% had a good knowledge, while 12% had a poor knowledge. Nurses who had less than five years of experience represented 38% and, among them, 54% had a satisfactory knowledge, 42% had a poor knowledge, and 10% had a good knowledge. Nurses who had 10 to 15 years of service represented 13%, 50% of them having a satisfactory knowledge, and 33% having a poor knowledge (Figure 1). In the long run, the conclusion that we can reach from these results is that many nurses do not have a good knowledge, but there is a link between knowledge and years of experience.

Regarding the age group analysis concerning GCS (Figure 2), the conclusion that we reached was that nurses who were 30 to 40 years old responded well to the questionnaire, followed, in a lower rate, by nurses who were between 20 and 30 years old (Figure 2).

Discussion

This study aimed to evaluate nurses’ knowledge of the GCS and to find variables related to that knowledge. In line with earlier research, 14% were males and 86% were females in this study. Among participants, Cook et al.⁽¹³⁾ stated that something similar to these findings was reached by him which proved that 82.7% were women in his research. Among our findings, 85% were diploma holders and 15% were degree holders. Alhassan et al.⁽¹⁾ had done research that included 79% of degree holders. As well, Cook et al.⁽¹³⁾ found that, in their research, 89.8% posted graduates as an overall percentage of which 62.2% graduated five years before the date of research. These findings reveal that graduate nurses are fewer.

When considering the participants’  level of knowledge, it can be compared with relevant literature. Because of that, according to this study, 11% of nurses possessed a good knowledge, 64% had a satisfactory knowledge, and 25% had a poor knowledge. On the other hand, we were able to find and refer to much other research which proves that nurses’ knowledge level of GCS is poor.

Moosy⁽¹⁴⁾ carried out a quantitative cross-sectional study on 135 nurses, showing that 55.56% of nurses had a poor knowledge of GCS, while 88.9% of nurses knew what GCS meant. Furthermore, 51.9% gave the correct answer regarding the brain involved in assessing eye opening, 54.8 knew that vital science was not a component of the GCS, 58.5% of nurses knew how to test for motor response in a tetraplegic patient, and 91.1% of nurses knew which was the lowest score on GCS. This reveals that nurses’ knowledge of GCS is poor.

Cook et al.⁽¹³⁾ carried out a study in Sano Paulo. This cross-sectional study was done with 127 nurses. After their study, they decided that nurses needed to be trained in GCS. That means that nurses’ knowledge of GCS was poor.

The study of aims Alhassan et al.⁽¹⁾ assessed Ghanaian nurses’ knowledge of the Glasgow Coma Scale. This was a descriptive cross-sectional study using 115 nurses as a convenience sample and using a structured questionnaire. It revealed that 50.4% of nurses had a low knowledge of the Glasgow Coma Scale, 62.6% had a good knowledge of GCS, and only 5.2% had a good knowledge and application of the basic knowledge in clinical scenarios.

Another cross-sectional study from Nepal included 154 nurses and revealed that 33% had a poor knowledge, 34-74% had an average knowledge, and 75% a had good knowledge. Fifteen percent of the participants were degree holders and, at the same time, 22% had a satisfactory knowledge. The rest of the participants did not have a considerable knowledge. When compared to post-basic nursing (0%), nurses with certifications had a better knowledge (25%), demonstrating the importance of skills and critical thinking in determining GCS, the researcher concluding that skill comes in handy with experience⁽¹⁴⁾.

Regarding our study, nurses who had five to ten years of service represented 49% and, among them, 80% had a satisfactory knowledge, 7% had a good knowledge, and 12% had a poor knowledge. Nurses with less than five years of experience represented 37% and, among them, 54% had a satisfactory knowledge, 42% had a poor knowledge, and 10% had a good knowledge. Nurses with 10 to 15 years of service represented 13%, 50% of them having a satisfactory knowledge, while 33% having a poor knowledge.

In the long run, the conclusion that we can reach is that many nurses do not have a good knowledge, but there is a link between knowledge and years of experience. The highest scores (11%) were achieved by nurses who have worked in the neurological unit for more than six years, while the lowest scores (10%) were achieved by those who have worked there for less than a year. When this is compared with our research, we can predict that there is a link between those two. But in this study, that was not exactly the case. It is unclear at this time what may have contributed to this conclusion, and more investigation is required to determine the connection between the frequency of GCS performance and GCS proficiency.

This study was limited to the District General Hospital, therefore it did not express all nurses’ knowledge. As well, the data were collected by written form using a questionnaire. So, this aspect might have affected the results due to those circumstances. Another limitation of this study was the relatively small sample of 143 participants. Therefore, it is important to replicate with more participants. Furthermore, we had to face many problems due to the COVID-19 pandemic situation, and we could not perform this study according to the proper scheduled time. We were unable to prove one of the specific objectives due to being unable to add a question regarding ward setting.

Conclusions and recommendations

This study findings revealed that most of the nurses from the District General Hospital did not gain enough knowledge regarding the Glasgow Coma Scale. Years of service, level of education and age groups are the most related factors for gathering information. It is highly concerning because many nurses lack adequate knowledge of the tool, especially in light of the literature’s recognized usefulness of the GCS in monitoring all types of patients with altered consciousness to detect worsening or improvement in their state. Based on the research findings, the following recommendations are that there was a need to improve nurses’ knowledge of the Glasgow Coma Scale. Because of that, this study revealed that most of the nurses who worked in the District General Hospital did not have an adequate knowledge of the Glasgow Coma Scale. Thus, researchers suppose that in-service programs are needed to be implemented for nurses. Replication of this study in a different setting is recommended, and further researchers need to improve the knowledge of the Glasgow Coma Scale among nurses. 

Data availability statement

It was found easy to access the previous researchers and we got the necessary data to carry out the research.  
 

Conflict of interest: none declared  
Financial support: none declared
This work is permanently accessible online free of charge and published under the CC-BY.