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EXPLORING NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE IN INTENSIVE

CARE AND EMERGENCY DEPARTMENTS AT A TERTIARY HOSPITAL IN RIYADH
CITY, SAUDI ARABIA

Article · October 2019

DOI: 10.31674/mjn.2019.v11i02.003

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 doi:10.31674/mjn.2019.v11i02.003

EXPLORING NURSES' KNOWLEDGE OF THE GLASGOW COMA

SCALE IN INTENSIVE CARE AND EMERGENCY DEPARTMENTS
AT A TERTIARY HOSPITAL IN RIYADH CITY, SAUDI ARABIA
Abdulrhman Albougami
Department of Nursing, College of Applied Medical Sciences, Majmaah University, Saudi Arabia

Corresponding Author's Email: [email protected]

ABSTRACT

Purpose: The present study determines the factors affecting knowledge of the Glasgow Coma Scale (GCS) of
emergency room (ER) and intensive care unit (ICU) nurses who work at a tertiary hospital in Riyadh, Saudi
Arabia. Methods: A cross-sectional study with self-administered questionnaire was conducted among 149 ICU
and ER nurses conveniently selected at a tertiary hospital in Saudi Arabia. A standardized tool was used to
assess knowledge of the GCS. The study adhered to the STROBE guideline for cross-sectional studies.
Results: Expatriate nurses (p<0.001) and those with a postgraduate degree (p<0.05) were found to have more
knowledge of the GCS. Nurses with expertise in ICU services scored significantly higher (p<0.001) than those
who work in the ER. Nurses reporting no previous training in the GCS had higher scores (p<0.05) than those
who had previous training in the GCS. Conclusion: Some of the demographic characteristics and nurses’
knowledge about the GCS were associated. Expatriate, postgraduate, and ICU nurses were more
knowledgeable about the GCS tool. Surprisingly, nurses without GCS additional training had more GCS
knowledge than nurses who had attended training. The results provide valuable insights into and guidance for
improving GCS knowledge among ICU and ER nurses.
Keywords: Critical Care, Comatose, Emergency Department, Glasgow Coma Scale

INTRODUCTION neurological injury (Mattar, Liaw & Chan, 2015). The

GCS measures three detailed neurological functions:
Healthcare professionals (HCPs) are anticipated to
eye-opening, verbal responsiveness, and motor
be imbued with related theoretical and practice
responsiveness (which conclude inappropriate initial
experience to deliver quality patient care, which involves
complete and continuous patient assessment (Al-Quraan signs of neurological deterioration) (Mattar, Liaw &
& AbuRuz, 2016). Nurses’ continuous assessments often Chan, 2013). This scale can help HCPs who work in
involve neurological patients, specifically, the level of emergency and intensive care units in particular to
consciousness, which is considered the central swiftly execute proper diagnostic measures and to initiate
assessment criterion (Al-Quraan & AbuRuz, 2016). proper nursing interventions for patients (Mattar, Liaw &
There are numerous tools for assessing patients’ Chan, 2013). Nurses play an active and central role in
neurological status (Basauhra Singh et al., 2016). One healthcare settings. A nurse is routinely the first person
universally accepted tool is the Glasgow Coma Scale with whom a patient interacts (Cruz et al., 2018). Nurses
(GCS). HCPs, especially nurses, use the GCS in are responsible for nursing assessment and preparing
assessing patients’ level of consciousness (Mattar, Liaw proper nursing interventions. Thus, nurses should be
& Chan, 2013). competently knowledgeable to assess neurological
changes and be prepared with the clinical skills necessary
The GCS is a scoring system that assesses patients’ to provide quality patient care (Mattar, Liaw & Chan,
level of consciousness in response to a certain stimulus 2015).
(Mattar, Liaw & Chan, 2013). The tool is a reliable
clinical technique for assessing the severity of a Nurses from different countries and regions vary

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 NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE

considerably in their knowledge of the GCS. For nurses come from many different countries (e.g., Saudi
example, nurses in South America (Ehwarieme & Arabia, the Philippines, India, Egypt, and the Sudan)
Anarado, 2016; Santos et al., 2016) have been observed (Almutairi & McCarthy, 2012) and have different
to be somewhat knowledgeable in demonstrating the educational programs. Similarly, little is known about
GCS in clinical settings. Brazilian nurses in emergency how cultural differences might influence nurses’
and intensive care units had high knowledge of the GCS knowledge of the GCS and enable nurses to fulfill their
(Santos et al., 2016). However, concerns have been multiple clinical roles. Empirical data also showed that
raised regarding the lack of precision and inconsistency nurses are inconsistent and inaccurate when they perform
when the GCS is used. Malaysian nurses were found to the GCS in a mentoring system, which is a critical
have poor knowledge of the GCS, only 2.96% of nurses component of assessment and care of patients
were knowledgeable about the GCS (Basauhra Singh et experiencing trauma, surgery, and neurological effects
al., 2016). (Santos et al., 2016). Keeping patients safe is a dimension
of high-quality healthcare, and nurses are the key to
Similarly, nurses in the Middle East face the same ensuring that patients receive the best possible care
challenges in their knowledge of erformance of the (Ehwarieme & Anarado, 2016). Therefore, it is important
GCS. Jadduoa, Mohammed & Abbas (2013) found that to assess nurses’ knowledge. This study aimed to
Iranian nurses have difficulty handling patients with determine the knowledge level of the GCS among
consciousness problems and evaluating patients’ overall emergency and critical care nurses in Saudi Arabia. The
neurological status. A descriptive study by Eldesouky study makes a significant contribution to nursing
(2016) discussed why Egyptian nurses have low GCS programs and hospitals by providing a comprehensive
knowledge and stated that they have less exposure in basis for improving the Saudi curriculum and developing
educational programs and training to the GCS. This educational and training materials for nurses.
finding implies nurses might have lower cognitive skills
and experience in using the GCS. Aim of study
In Saudi Arabia, similar to other Middle Eastern The present study examined the factors that affect
countries, patients’ level of consciousness is assessed knowledge of the GCS of emergency room (ER) or
with the GCS. Surprisingly, in one previous study in intensive care unit (ICU) nurses who work at a tertiary
Saudi Arabia have reportedly no preparations and hospital in Riyadh, Saudi Arabia.
strategies for any neurologic assessment tool (Hassan,
2017). Similarly, most nurses score the GCS based on METHODOLOGY
their own understanding (Jadduoa, Mohammed & Abbas, Research design
2013). This individual understanding might lead nurses
who seldom use the scale to erroneous assessments of The study utilized a cross-sectional design with
neurological changes and monitoring and recording of convenient sampling. This was to quantify the
neurological observations in patients. Assessment errors information pertaining to knowledge of GCS of nurses
are potentially dangerous for patient health in performing (ER and ICU) at a specific point in time.
GCS procedure. Nurses must be competent in using the Setting and sample
GCS to guarantee accurate interpretations when they
assess patients (Basauhra Singh et al., 2016). This study was conducted in a public hospital (bed
capacity=1500) in Saudi Arabia. The hospital is a
However, several studies have revealed that nurses tertiary-care teaching multi-facility and multi-
lack adequate knowledge regarding use of this scale, disciplinary medical center for Saudi and non-Saudi
indicating a need to better quantify and standardize the citizens.
GCS within nursing education and continuing training
programs. Although extensive research pertaining to The inclusion criteria were follows: (a) registered
strategies for encouraging nurses to use the GCS and nurses, (b) assigned to the ER or ICU for more than 6
improving nurses’ knowledge of the GCS have been months, (c) male or female, (d) Saudi or non-Saudi, (e)
conducted (Mattar, Liaw & Chan, 2013). It is unclear proficient in English. The exclusion criteria included the
whether the strategies are useful for conducting following: unit managers and clinical resource nurses,
neurological patient assessments in a country in which and nurse educators.

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 NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE

A total of 196 staff nurses from the hospital met the The questionnaire was pilot tested at another
inclusion criteria, and they were recruited to participate. hospital which have the same characteristic and
Only 157 respondents consented to answer the survey. underwent expert validation (6 nurses) in the field of
Overall, after the data were collected, a total of 149 ICU nursing research (2 nurse educators) and emergency
and ER nurses were included in the data analysis nursing (2 staff nurses) and intensive care nursing (2
(response rate=76.02%). staff nurses). The purpose was to determine the
appropriateness of the survey. Four experienced nurses
Data collection (e.g., emergency nursing and intensive care nurses)
Convenience sampling involved ER and ICU performed the expert validation to clarify whether the
nurses from October to December 2018. First, survey was realistic and feasible for the respondents.
researchers made a courtesy call to the nursing director Statistical analysis
with a written request to conduct the study. The study
purpose was clearly explained to the nursing director The statistical analysis was performed with SPSS
and chief nurse, so that their cooperation could be version 23.0. Descriptive details of the participant
solicited. Then, the questionnaires were distributed to characteristics are presented using the mean and
the respondents with the assistance of the nurse standard deviation and frequency with a percentage.
supervisor in each area. The study purpose and the right The distributions of the correct responses are described
to withdraw from the study at any time were discussed using frequency in percentage. Relationship between
with each respondent. The questionnaire was distributed participants’ characteristics and knowledge of the GCS
in their breaks during work shift. The questionnaires were assessed using the Kruskal-Wallis test, the Mann-
were designed and printed in an optical mark sheet form. Whitney test, and an independent t-test.
The participants marked their answers using a pencil, Ethical considerations
which was provided with the questionnaires distributed
at one time. After 2 weeks, the researchers collected the Ethical approval to collect the data was obtained
questionnaires. The data files were coded, backed up, from the Ministry of Health (18-367E). The study’s
and password protected. The completed consent forms purpose and procedures were explained in a cover
and questionnaires were stored in a locked cabinet. letter. A signed consent form was obtained from
respondents who agree to participate. Respondents had
Instruments the right to refuse to participate and to withdraw from
The study used a two-part self-administered the study at any time. Numerical codes replaced the
questionnaire during data collection. respondents’ names on the questionnaires to ensure
confidentiality. No benefits were accrued to the
Demographic data collection: The first part asked participants, although the outcomes of the study will
about the nurses’ demographic characteristics, provide recommendations for future nursing education
including gender, age, nationality, level of education, and practice in Saudi Arabia.
clinical discipline, length of time in current discipline,
RESULTS
and course or training related to the GCS.
Participants’ characteristics
Knowledge level of the GCS: The second part of the
questionnaire consisted of 15 multiple-choice questions, The majority of the participating nurses (59.1%)
assessed ER and ICU nurses’ knowledge of the GCS in were female, and most (60.4%) were young adults aged
the following areas: definition, indication, components, between 20 to 30 years. More than half of the
and GCS scores (Mattar, Liaw & Chan, 2013). The participants, that is, 57%, were expatriates. Most
nurses’ scores ranged from 0 to 15. Items 6 and 12 were (79.2%) reported a bachelor’s degree as their highest
true/false statements. A higher score means more level of education. About two thirds of the participants
knowledge of the GCS. The 15-item standardized (78.5%) had 1 year or more of clinical experience. The
questionnaire had satisfactory reliability (a=0.71) majority of the nurses (69.1%) did not have previous
(Mattar, Liaw & Chan, 2015). training in the GCS (See Table 1).

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 NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE

Table 1: Nurses characteristics and Socio-demographic predictors of Knowledge on Glasgow Coma Scale working
in hospital, Saudi Arabia

a
Kruskal Wallis test, bMann-Whitney test, cIndependent t-test
GCS: Glasgow Coma Scale, ER: Emergency room; ICU: Intensive care unit

Sociodemographic predictors of knowledge of the (6.96±2.25), Z = –2.788, p=0.005 (See Table 1).
GCS
Pattern of responses for the instrument for assessing
Expatriate nurses (8.26±1.66) scored higher than knowledge of the GCS
Saudi nurses (6.59±2.23) on knowledge of the GCS, t The four questions that were answered correctly by
=–5.014, p <0.001. Those with a postgraduate degree more than three fourths of the nurses were about the
scored the highest (8.17±2.21), followed by those with purpose of the GCS (87.9%), the lowest score on the
a bachelor's degree (7.69±1.88), and those with a GCS (79.2%), specific sections of the GCS (78.5%),
diploma in nursing (6.21±2.76) scored the lowest, and no applicability of the GCS in assessing the level of
Χ (2)=6.226, p=0.044. Nurses with expertise in ICU consciousness in intubated patients (78.5%). The
(8.24±2.10) services scored statistically significantly questions that received the highest number of incorrect
higher than those who working in the ER (6.91±1.89), t answers were about assessment of the confused state of
= –4.055, p < 0.00. Surprisingly, nurses who reported no a patient (4.0%), which arm to use while assessing
previous training in the GCS scored higher (7.80±1.97) motor function (12.1%), and the neuroanatomy of eye
than those who had previous training in the GCS opening (20.1%) (See Table 2).

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 NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE

Items of the Instrument to Assess Knowledge on Frequency Given these factors, delivering patient care remains a
Glasgow Coma Scale (percentage)
of correct very serious issue and a challenge for nursing staff.
responses However, to become staff nurses in Saudi Arabia,
1. The Glasgow Coma Scale was initially devised to 131 (87.9) expatriates must fulfill many requirements (Alosaimi &
2. What part of the brain is being assessed when you are 30 (20.1) Ahmad, 2016). Specifically, the requirements are clinical
assessing eye opening?
3. Which part of the brain is being assessed when you are 58 (38.1) years of experience with rigorous credential evaluations
assessing verbal response? and a passing score on the Saudi Commission Nursing
4. Which part of the brain is being assessed when you are 70 (47.0) Board examinations for health specialties. As a result,
assessing motor response? expatriate nurses might have greater orientation in GCS
5. What are the specific sections that comprise the 117 (78.5) responsible nursing practice. Therefore, expatriate
Glasgow Coma Scale?
nurses’ knowledge of nursing care and patient GCS
6. Vital signs are a component of the Glasgow Coma 81 (54.4)
Scale. assessment may be influenced. To improve Saudi nurses’
7. When testing the best motor response, you 18 (12.1) nursing care performance, an effort to recognize and
8. To test motor response in tetraplegia patients (paralyzed 91 (61.1) increase knowledge of the GCS is necessary.
in all four limbs)
9. The lowest score of the Glasgow Coma Scale is 118 (79.2) Second, nurses’ level of education influenced their
10. Patients with a Glasgow Coma Scale score of—and 69 (46.3) knowledge of the GCS. In this study, nurses with
below are considered comatose.
postgraduate degrees had better knowledge of the GCS
11. In nursing practice, a reduction of the Glasgow Coma 65 (43.6)
Scale score of—is seen as deterioration in conscious
compared to nurses with a diploma and nurses with a
level and requires informing the medical team. bachelor’s degree. This finding was also reported by
12. The Glasgow Coma Scale cannot assess intubated 117 (78.5) Basauhra Singh et al., (2016), who found that educational
patient’s level of consciousness. attainment influences GCS understanding among 135
13. on asking a patient, “Do you know where you are 6 (4.0) Malaysian ER nurses and outpatient department (OPD)
now?” the patient states he is at his daughter’s
nurses. Similar results were also found in a study among
condominium. He is
14. On assessing a patient’s motor response, he is unable to 84 (56.4)
nurses in Singapore (Mattar, Liaw & Chan, 2013) and in a
comply. You inflict a pain stimulus, and he pulls his study in Brazil (Santos et al., 2016). According to Al-
arm away. He Quraan & AbuRuz (2016), higher educational attainment
15. You are assessing an RTA (road traffic accident) 69 (46.3) means increased GCS knowledge which could positively
patient, who has swollen eyes. You instruct him to open
affect a nurse’s neurological assessment. Thus, the higher
his eyes, but he is unable to. The eye response score is
the educational attainment, the more likely better
DISCUSSION knowledge attainment of GCS.
This study set out to determine the factors that affect Conversely, the present study results do not confirm
the knowledge of the GCS of ER and ICU nurses who previous studies and showed no statistically significant
work at a public hospital setting in Riyadh, Saudi association between educational attainment and
Arabia. Five main findings are discussed. knowledge of the GCS (Al-Quraan & AbuRuz, 2016;
Jadduoa, Mohammed & Abbas, 2013). According to
First, in terms of demographic and work-related Matthias (2015), nurses with postgraduate degrees are
factors, expatriate nurses were more knowledgeable than not shown to be more accurate in assessment compared
Saudi nurses. This is worth noting because nursing care is with registered nurses who possess either a diploma or a
considered a less-than-acceptable career choice for the bachelor’s degree. This research gap regarding the
majority of Saudi nationals (Al-Mahmoud, Mullen & complexity of nurses’ educational attainment warrants
Spurgeon, 2012). Additionally, the continued low image further exploration.
of the nursing profession, and low desirability may
contribute to the lack of interest in learning nursing Third, a nurse’s area of expertise affects GCS
concepts, particularly the GCS. A previous study reported knowledge. In this study, ICU nurses had more GCS
Saudi nurses have difficulty organizing patient care in a knowledge than ER nurses. This result may be because
systematic and holistic way (Al-Mahmoud, Mullen & the ICU is a highly specialized healthcare unit in which
Spurgeon, 2012). According to Mutair (2015), Saudi the majority of the high-risk patients have a neurological
graduates are employed immediately after graduation. A condition; this setting might require a tool for quick
dearth of clinical experience might explain why new assessment of the changes and performing a nursing
Saudi nurses feel puzzled about their role (Mutair, 2015). intervention (Keykha et al., 2017). In previous literature,

THE MALAYSIAN JOURNAL OF NURSING | VOL. 11 (2) October 2019 | 27

 NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE

patient neurological assessment has been described as an AbuRuz, 2016). In Shehab, Ibrahim & Abd-Elkader’s
indispensable tool in ICU daily practice compared to analysis (2018), a correct GCS assessment is
other nursing departments (Jadduoa, Mohammed & unachievable without experienced, competent, well-
Abbas, 2013). According to Keykha et al., (2017), the trained nurses, especially in the ICU and the emergency
ICU is a specialized unit in which assessment of the level department. It is almost certain that nurses could have
of consciousness is continuously implemented by effective assessment skills to cope with patient
nurses. Santos et al., (2016) found that ICU nurses must problems, particularly with fluctuating levels of
conduct the GCS hourly irrespective of case type. It is consciousness. To provide a quality nursing care
highly likely that the more nurses conduct the GCS, the assessment, GCS knowledge should be continuously
greater their confidence in using the scale. This finding updated with protocols that direct the assessment of
confirms Mattar, Liaw & Chan’s (2013) finding that ICU nurses’ performance of the GCS. Thus, to achieve a
nurses’ are constantly exposed to patients with knowledgeable nurse, a training education program and
neurological disorder. As a result ICU nurses made more constant evaluation of a nurse’s performance can aid in
accurate GCS assessments and fewer assessment errors appropriate assessment and management of patient care.
(Al-Quraan & AbuRuz, 2016). In addition, Al-Quraan & Finally, most nurses understood that the GCS was
AbuRuz (2016) reported that the ICU has an annual devised to assess the depth of coma. This result negates
competency evaluation that included a concise meeting the finding of a previous study that due to the difficulty
about assessing the level of consciousness among
of the GCS assessment and the way it is defined, nurses
Jordanian nurses. This frequent evaluation encounter
reported that the GCS is difficult to use for the
with the neurological assessment made the nurses
assessment of patients in a coma (Ehwarieme &
familiar with the GCS. Overall, it is important for nurses
Anarado, 2016). A previous survey reported when tested
to be competent in monitoring neurological observations
on the GCS, even neurosurgeons get it right only 56% of
and equipped with the clinical skills require.
the time. Military doctors calculate the GCS correctly
Fourth, professional development opportunities, only 15% of the time (Scancrit, 2011). However, this
such as training and workshops, appear to be important previous literature should be interpreted with caution
for upgrading knowledge and skills in professional because the study respondents were physicians, and not
practice and providing quality patient care. Surprisingly, nurses, which could affect the findings of the study.
in this study, nurses without additional training had better Another study reported that assessing comatose patients
GCS knowledge compared to those who had additional is complex because of the inconvenience of catching
training. A possible reason is that all respondents were distinctive features during clinical assessment (Mattar,
ICU nurses and ER nurses which critically affect their Liaw & Chan, 2013). The assessment complexity can
neurological assessment performance. For example, in also be enlightened by the struggle of ruling out practical
the ER, nurses used the GCS to triage patients with terminology to explain the patient’s deep comatose
impaired consciousness and to improve communication status (Ahmed, 2015). It is most likely that comatose
between providers (Basauhra Singh et al., 2016). In the patients are hard to assess. Thus, continuous orientation
ICU, the GCS is a standard scale which is crucial for and training activities for the GCS should be
nurses’ assessment of patients’ level of consciousness implemented to improve nurses’ knowledge of skills in
(Mattar, Liaw & Chan, 2013). In these types of working adherence to neurological quality standards.
conditions, it is most likely that nurses consistently
practice neurological examinations. Limitations

In contrast, Ehwarieme & Anarado (2016) Several limitations should be acknowledged. First,
suggested that reinforcement of GCS information nurses were recruited from the ICU and the ER at one
facilitates GCS learning among nurses. This suggestion public tertiary hospital which might limit the
is also in harmony with a previous study (Santos et al., generalizability results. A self-reported questionnaire
2016), which elaborated that nurses who attended a GCS was used in which respondents might not have reported
training workshop had greater understanding of the GCS answers or chose a favorable response to avoid
compared with nurses who had not undertaken such disapproval. Consequently, the survey might not
training (Al-Quraan & AbuRuz, 2016). The study also adequately present nurses’ true GCS assessment skill
reported that training increased GCS knowledge, and level. A convenience sample was used which limits the
improved nurses’ work performance (Al-Quraan & generalization to nurses working in Saudi Arabia. Nurses

28 | VOL. 11(2) October 2019 | THE MALAYSIAN JOURNAL OF NURSING

 NURSES' KNOWLEDGE OF THE GLASGOW COMA SCALE

have different cultural backgrounds, and thus, might Specifically, expatriate nurses, nurses with postgraduate
have different training perceptions and implementations degrees, and ICU nurses were more knowledgeable
of the GCS which makes it difficult to compare GCS about the GCS. Surprisingly, nurses without additional
knowledge. GCS training had more GCS knowledge than nurses
with training. The results provide valuable insights into
Despite these limitations, a major strength of the
and guidance for improving knowledge of the GCS
study was that it was performed in a tertiary health
among ICU and ER nurses.
facility where the highest volume of clients is expected,
and professional experts are trained and offer services. The study results provide valuable information for
Thus, the best experts in knowledge should be found. articulating approaches to inspire nurses to use the GCS,
Finally, the findings elucidate the importance of especially Saudi nurses and those who hold bachelor’s
systematic education in the GCS, including practical degree to improve their knowledge of the GCS and
training for Saudi nurses working here. determine actual GCS problems ensuing mentoring or
CONCLUSION training. Nursing administrators could provide
educational involvement and strategies for GCS
The present study contributes to the understanding performance to all nurses who care for unconscious
of factors that affect the GCS knowledge of ICU and ER patients. Manual procedure could be distributed by
nurses who work in a public hospital setting in Riyadh, Nursing Instructors to the nurses working in the ICU and
Saudi Arabia. Demographic characteristics were the emergency department that includes the standards
associated with nurses’ knowledge of the GCS. for the GCS technique.

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