T h e G la s g o w C o ma Sc a l e

A European and Global Perspective on

Enhancing Practice

Neal F. Cook, PhD, MSc, PG Dip Nurse Education, PG Cert, Dip Aromatherapy, RN,
Lecturer/Practice Educator, Specialist Practitioner Adult, PFHEA

KEYWORDS
 Glasgow Coma Scale education  Neuroscience nurses  Person-centered care

KEY POINTS
 Although the Glasgow Coma Scale is a well-established and effective tool in clinical prac-
tice, there remains inconsistency in its use, largely because of variances in educational
approach and the lack of internationally accepted, unambiguous practice standards.
 Human factors have traditionally not been addressed in education on the Glasgow Coma
Scale or in related practice guidelines, despite such factors having a direct impact on
practitioners, patients, and their relatives.
 An opportunity exists, and needs to be taken, to develop explicit, unambiguous, interpro-
fessional, international standards for use of the Glasgow Coma Scale, underpinned by
evidence.
 The implementation of such interprofessional, international standards should be framed
within an agreed on educational framework.
 The success of both the educational framework and the international standards should be
evaluated through further research.

INTRODUCTION

Since its inception in 1974 as a 14-point scale, and subsequent modification into a 15-
point scale, the Glasgow Coma Scale (GCS)1 has stood the test of time as the most
commonly used tool to assess level of consciousness globally.2 Indeed, in 2014, it
was relaunched with modification to the wording and guidance for its use; how univer-
sally adopted the relaunched version has been is yet to be seen some 6 years later.
What is clear, is that the GCS, through time, has seen variation, undergone scrutiny
through a plethora of studies, and although commonly adopted and accepted, con-
tinues to have an air of ambiguity around its use as a result of a perceived lack of clarity

School of Nursing, Ulster University, Londonderry BT48 7JL, Northern Ireland

E-mail address: [email protected]
Twitter: @NealFCook (N.F.C.)

Crit Care Nurs Clin N Am 33 (2021) 89–99

https://doi.org/10.1016/j.cnc.2020.10.005 ccnursing.theclinics.com
0899-5885/21/Crown Copyright ª 2020 Published by Elsevier Inc. All rights reserved.
90 Cook

in certain aspects of its use. A key question is whether the tool itself is at the heart of
any issues around its use, or the guidelines, standards, and education that surround its
use.

THE GLASGOW COMA SCALE OVER TIME

Although the GCS has endured over time, it has not done so without criticism and
some controversy, for example, on how to elicit a response to pain, or indeed pressure
as it is now referred to in the 2014 relaunched version. The change from response to
pain to pressure alone leaves us with a question about whether we are indeed assess-
ing a response to pressure or pain, or indeed the rationale for the change itself. Crit-
icism has also been reflected in its perceived complexity, its inability to discriminate
sufficiently at midrange score level, and its potential inaccuracy to reflect arousability
and awareness when a person is intubated or nonverbal3,4; a person may be entirely
aware and fully arousable when intubated, but the tool does not account for this.
Although there has been criticism in relation to interrater reliability, a systematic review
of 53 studies in 2016 concluded that 85% of findings in research studies, considered
rigorous, demonstrated substantial reliability; 77% showed high reproducibility5
(kappa statistic >0.6). Considering tools are used in practice to support assessment
and inform, not replace, clinical judgment, the result of this analysis is impressive.
In reviewing the evidence base for use of the GCS over time, Braine and Cook4
concluded that the tool has been adopted interprofessionally, facilitating effective
communication and understanding of a person’s level of consciousness because of
the use of a common, understood clinical language and measurement. Indeed, a va-
riety of other tools for assessing consciousness have been developed over time, many
having clinical credibility, but none have been as universally adopted and sustained
over time as the GCS, despite many, often varied, criticisms around interrater reli-
ability. One example is the Full Outline of Unresponsiveness score, which, in 1 study,
showed a better predictive power for mortality,6 but has not been universally adopted.
Braine and Cook4 clearly identify that issues around interrater reliability are multifac-
torial; the level of skill to use the tool and clarity about how to use the tool clearly
impact on interrater reliability, factors that are indeed separate to issues around the
construct and nature of the tool itself. As with any skill in assessment, skills enhance
over time and with experience; the challenge here is consistency in the education, pol-
icy, and guidelines as to how to use the tool. Otherwise, there is a risk of miseducating
people to develop expertise in how to do something incorrectly. As both Braine and
Cook5 and Cook and colleagues7 highlight, there currently exists no universally adop-
ted and accepted standard for education on the GCS and its safe and effective use;
this is clearly a problem. The results of the study by Cook and colleagues7 clearly
show that despite experience, education, and familiarity with the tool over time, prac-
tices varied, and there was a clear message from respondents (n 5 273) in the study
that nurses wanted clearer, universal guidelines. Furthermore, respondents also
wanted the tool to be considered within the context of professional, person-
centered practice. For example, the respondents clearly expressed concern and anx-
iety over the family’s experience of seeing painful stimuli applied and were conflicted
about the application of painful stimuli when they perceived it as distressing for the
person. No publication or education material to date was identified that dealt with
these concerns. In addition, the plethora of existing publications in the past 40 years
has led to nuances and traditions around the use of the GCS, often containing guide-
lines unsupported by evidence.4 Of concern is that there is evidence that illustrates
that this confusion can cause potential harm at an international level7; Cook and
 The Glasgow Coma Scale: Education and Practice 91

colleagues7 found that practices varied internationally, and within countries, and that
participants were not clear about how to apply a painful stimulus. Great variation in
practices was found and, indeed, some inappropriate and ineffective methods of
applying painful stimuli that could lead to harm; complications were found in the
use of supraorbital pressure, sternal rub, and nail bed pressure, among others. This
study was the first known to be published that documented such complications and
further highlights the need for consistency.

STANDARDIZATION OF THE GLASGOW COMA SCALE

It would be reasonable to question, at this stage, why the GCS should be set out as an
area where standardization is necessary. In 2016 (most recent European Union [EU]
statistics at the time of writing), 3.2% of all deaths in the 28 countries of the EU
were related to accidents, more than 163,000 deaths8 (updated November 2019).
These accidents typically would have a neurologic element (motor vehicle accidents,
falls, drowning, poisoning, and so forth). Further exploration at the European level
makes it clear that traumatic brain injury (TBI) accounts for almost 1.4 million hospital
admissions.9 This amount represents almost 1.4 million people requiring reliable
assessment of level of consciousness in order to prevent, where possible, associated
potential deaths by being able to respond rapidly to any deterioration (12 per 100,000
adjusted mortality9 and 3.3–28.10 per 100,000 population per year10). Furthermore,
those who survive their TBI must be considered. It is known that neurologic disorders
are the leading group of disability-adjusted life-years (DALYs) (2015 data11), with a
7.4% increase in DALYs in a 25-year period. The trends in the data support that neuro-
logic disorders are not becoming less prevalent, despite advances in care and inter-
ventions; the need for expert knowledge, education, and clarity in using core tools
in practice is therefore amplified going forward. In addition, the nervous system is
one of two primary control and regulation systems in the body, the endocrine system
being the other, and the two are highly integrated. It is therefore vitally important that
nurses can undertake assessment of the nervous system, with level of consciousness
being fundamental to assessing and monitoring any deterioration in neurologic func-
tioning/status. Alongside that, consistency and standardization are essential to the
translation of assessment across settings and professionals.

GLASGOW COMA SCALE AS PART OF PREREGISTRATION NURSING CURRICULA

The practice of each nurse is shaped by their education and the culture of practice
within which they learn. If you are taught something incorrectly, and this is reinforced
in practice by seeing similar practices, then we can expect to see this practice
continued, taught to others, and be underpinned by a belief that this practice is cor-
rect. Evidence shows us that newly qualified nurses will reshape their beliefs and pro-
fessional identities under organizational pressures and through role-modeling of
practices from their experienced peers12; nurses often adapt to the culture of practice
they work in, which necessitates that we role-model best practice. In addition, when
the use of a tool spans disciplines, as can be seen with the GCS (eg, nurses, para-
medics, and medical staff use it frequently), then the need for explicit clarity and con-
sistency in approach is paramount for the translation to practice and interpretation of
findings to be accurate. Preregistration education is the most effective place to start
such education so as to shape the knowledge and skills of the novice practitioner in
order that they recognize best practice and can make sufficient critical analysis of
what is role-modeled in practice.
92 Cook

The inconsistency in the use and education of the GCS is not a new observation,
although evidence has lacked some explicit detail to that uncovered by Cook and col-
leagues7; this study was a snapshot that merits further research to expand to larger
numbers to gain a more in-depth analysis of the global picture. Iacono and colleagues13
also identified inconsistency in neurologic assessment as an issue in their hospital,
setting out a program of education to standardize assessment across all nurses; it is
not clear why a multidisciplinary approach was not taken in their intervention to address
this if the interprofessional translation of the use of tools in neurologic assessment is to
be consistent. Although not formally evaluated in a measurable way, feedback from par-
ticipants (of whom the total is not reported) indicated increased confidence and knowl-
edge. The translation to practice, however, was not explored, and it is this translation
that is essential; such assessment of practice could be argued as more likely to occur
if embedded in preregistration education. Verbalizing confidence is not the same as
correctly undertaking, albeit a very important factor in competence. However, in effect,
this form of standardization, although it appears effective, came after these nurses
completed their preregistration education. If preregistration education is preparing stu-
dents to be effective registrants, it could be argued that such education is failing these
students in providing education and skills development in the use of the most universally
accepted clinical assessment tool in neurologic assessment.
Similarly, Enriquez and colleagues14 used an educational approach to standardize
practice (n 5 20), demonstrating their educational intervention improved application
of the GCS and increased confidence. Although they refer to generating standards
in their publication, they effectively standardized the education, which may achieve
consistency in that area, but not necessarily achieve standardization of correct prac-
tices, particularly in the absence of any definitive publication of agreed standards in
this regard. Practice can be consistently incorrect as much as it can be consistently
correct. A further UK study in 2019 with medical and nursing professionals yielded
that only 9.7% of participants correctly used the GCS (n 5 55)15; following an educa-
tional intervention, this increased to 71%, showing the power of education to trans-
form practice, but not within preregistration education. However, Dubey and
Kumar16 demonstrated that a computer-assisted teaching program significantly
increased knowledge on the GCS in final-year preregistration nursing students
(n 5 60), highlighting that early educational intervention can be successful at this stage
of education. Educational endeavors clearly have the potential to maximize consis-
tency; the missing piece is an international standard to ensure what we are teaching
is accurate and consistent to quality assure such education. Fundamentally, it is
also evident that there is a desire to standardize and perfect practice, as seen in the
studies cited; the development of such standards therefore has great potential to
feed into practices that desire consistency and best practice. However, matters
cannot stop at standardized practice. It can also be concluded from these studies
that, in some cases, intervention is coming after these professionals have completed
their preregistration education, a case of an undoing of incorrect practices and
relearning correct practices. Applying standards through an effective educational
approach at the right time in the development of health care professionals is essential,
and the evidence indicates this should occur at preregistration level.
In considering the education delivered around the GCS, a consistent approach also
must consider the expectation set for preregistration nursing education. The need for
a consistent approach to nurse education is ever more important within an increas-
ingly global nursing workforce as a result of international mobility of nurses and a va-
riety of schemes in countries that facilitate the assimilation of internationally educated
nurses into their workforce.17 In Europe, there is a degree of standardization in those
 The Glasgow Coma Scale: Education and Practice 93

countries that are a member state of the EU under the EU directive 2005/36/EC.18 In
essence, this directive recognizes equivalency of education for nurses educated on
programs that are confirmed against this directive. However, a quick analysis of
how well this standardizes matters can be clearly illustrated when we examine educa-
tion around the GCS in Europe alone. Although the EU directive does not provide
explicit detail in relation to neurologic assessment, national standards could provide
this, although this approach would still require the existence of a universally accepted
standard for education and use of the GCS. In the United Kingdom, the Nursing and
Midwifery Council have specified in their 2018 standards for preregistration educa-
tion19(p33) that nurses must be able to undertake a whole body systems assessment,
including neurologic status, and undertaking, responding to, and interpreting neuro-
logic observations and assessments. Meeting such a standard would necessitate
use of the GCS, given its location within such assessment. In the Republic of Ireland,
national standards are less prescriptive, with education standards specifying the need
to be able to care for the unconscious person20; assessing level of consciousness
would therefore be implicit. Neurologic assessment is not set out in standards for pre-
registration education in many countries of Europe, for example, Spain, Poland,
Belgium, North Macedonia. Despite an EU directive for nursing education and a
recognition of qualification, at the granular level, consistency and equivalency are
not present in specific aspects of practice. An educational framework for consistency
around GCS is therefore essential to achieve consistency.
In the Republic of Ireland, a National Clinical Programme for Neurology exists with the
intention of being a framework for practice that follows international best practice, deliv-
ered within an integrated service approach.21 This framework recognizes that neurosci-
ences is a distinct, specialist area of practice whereby it is essential to underpin practice
with evidence-informed practices and education. Although the program refers to devel-
oping advanced nurse practitioners, there is recognition of the absence of a national ed-
ucation framework for neurosciences, including for nurses. It therefore must be
questioned how an integrated approach to service could be achieved without clear
standardization of education in the related health professions. Indeed, if the findings
of Cook and colleagues7 are to be taken cognizance of, the use of the GCS in itself il-
lustrates the lack of unified approach to education for its effective use, and that is for
neuroscience nurses alone. Models of care need to be underpinned with effective edu-
cation to be effective, and we must begin with what we teach our future workforce from
the outset. If practice is confused, varied, and potentially harmful, as elicited by Cook
and colleagues,7 then what is role-modeled and reinforced to students must be consid-
ered, as it may perpetuate the situation. Indeed, the EU directive for preregistration
nurse education (European Directive 2005/36/EC)18 does not provide explicit require-
ments around specific aspects of practice, but more high-level requirements that still
leave room for great variance. Utilising a high-level standards approach, within explicit
detailed expectations, leaves it up to EU member countries to create their own level of
standard to create a degree of consistency, or indeed for the foci of education to be set
at curricula level. Although being prescriptive can be confining and restrictive for
courses at the level of higher education, the lack of standardization in education
certainly contributes to the variances seen in the practices of the use of the GCS.
In 2018, Vink and colleagues,22 in a pan Europe study (n 5 331), identified that
assessment of consciousness was a daily activity for 95% of bedside neuroscience
nurses with an estimated median frequency of 6 times per shift, and the GCS being
the most commonly used tool. Most respondents (84.9%) had training/education in
use of the GCS, but these were diverse, echoed in the findings of Cook and col-
leagues7; both studies support the need for standardization of education and use.
94 Cook

Of note is that 15.1% of neuroscience nurses had no training or education in the use of
the GCS, despite its frequent use.22 This finding is within the context of the 2019 study
by Cook and colleagues7 illustrating 31% of neuroscience nurses had no neurosci-
ence education at all; an earlier study by Braine and Cook23 identified 7% of neurosci-
ence nurses as having no neuroscience-specific education. This finding creates a
picture of reducing education in a climate of increasing incidence of neurologic disor-
ders and only further supports that training programs and standards/guidelines need
to be universally consistent and explicit if the variances in practice identified by both
Vink and colleagues22 and Cook and colleagues7 are to be addressed. Globally, this
picture is of similar concern, with only 5.2% of nurses (n 5 115) in a study undertaken
in Ghana demonstrating good knowledge on application of the GCS using sce-
narios.24 A study in India found similar poor knowledge, with 33.1% of respondents
(n 5 154) having a good level of knowledge of the GCS.25 A Saudi Arabian study in
2019 also identified inconsistencies in practice in using the GCS, but not the frequency
of these.26 Indeed, the article provides an algorithm that perpetuates variations from
those normally undertaken in practice, such as asking the person their name and
the current time; knowledge of name is not an accurate representation of awareness
and knowledge of the current time is difficult for most people to get right. Guidance on
determining confusion or inappropriate words is ambiguous and not consistent with
the criteria for these elements, and the article perpetuates the confusion that exists
between the use of a peripheral or central painful stimulus as identified by Braine
and Cook.4 Confusingly, Catangui26 also included pupillary assessment as part of
GCS assessment, when it is not a component of the scale. A 2019 study in Saudi Ara-
bia showed that 69% of 149 nurses had no education on the use of the GCS.27 The
investigators state that results from their study contradict those of other studies in
that there was no statistically significant association between educational attainment
and knowledge of the GCS. However, the research was conducted using a question-
naire, which is provided in the publication, but of which the validity is not determined.
The relationship between the questionnaire and the ability to accurately use the GCS is
not established, and it is highly questionable as to whether the data from the question-
naire could represent such a correlation. In this respect, how useful the results are is
questionable. What remains clear, however, is that the inconsistencies and continued
dissemination of variances in practice remain an issue globally.

PERSON-CENTEREDNESS AND THE GLASGOW COMA SCALE

In considering any approach to education and practice, we need to consider the

values held by the profession to ensure what we teach is contextual and aligned
with those values. Nursing has long held caring and compassion at its core, and so
the concerns raised by nurses in the study by Cook and colleagues7 about causing
distress to apply a painful stimulus and the secondary distress this may cause family
are unsurprising, albeit that they have not been previously voiced in other studies on
the GCS. Although unsurprising, they create a challenge for education and practice
that cannot be ignored. How we prepare nurses to be able to deal with this distress
and concern have not, it would seem, been considered a core component of GCS ed-
ucation to date. Emotionally challenging aspects of practice must be underpinned with
rationale, discussion, and resolution as to how to manage these. In the United
Kingdom, the Nursing and Midwifery Council19(p9) (the UK regulatory body for nursing)
requires that, for a nurse to be proficient, they must be emotionally intelligent and resil-
ient. In doing so, they must be “capable of explaining the rationale that influences their
judgments and decisions in routine, complex and challenging situations.” In teaching
 The Glasgow Coma Scale: Education and Practice 95

to apply a painful stimulus, we therefore need to do so within the context of a person-

centered profession, facilitating nurses to deal with the complexity of emotions that
may arise with this challenging aspect of their practice.
The culture of nursing has increasingly embraced the concept of person-
centeredness, whereby we move beyond procedures and protocols and consider
the people involved across the spectrum; how we work with each other, how we
consider the world of the person in our care and the wider extension of that care in
terms of their family, and indeed, the communities that people live in. Indeed,
person-centeredness is increasingly an international priority, evident within the World
Health Organization’s strategy for People Centered and Integrated Health Ser-
vices.28,29 In considering the person-centered elements of this aspect of practice,
we cannot ignore the issues around moral distress that may arise. In considering moral
distress in this context, such distress may arise in circumstances whereby the nurse
knows they need to apply a painful stimulus to determine the neurologic response,
but is conscious of the perception of another (eg, a relative) as to the appropriateness
of causing distress through pain for the purposes of assessment. The perception of
the other may be a factor in preventing them from applying the painful stimulus.
Equally, there may be unexplored cultural factors in what is an increasingly diverse
workforce and whether cultural values permit applying pain as being justifiable in
any circumstance. Pendry30 recognizes that internal constraints originating from
nurses’ belief systems have not traditionally been captured in definitions of moral
distress and yet the conflict of applying a painful stimulus clearly presented concerns
for nurses in the study by Cook and colleagues.’7 When a personal belief system sig-
nals to that person that it is wrong to inflict pain and distress, but the undertaking of an
accurate neurologic assessment may require it, the conditions for moral distress are
created.31 Dealing with moral distress on an interprofessional level has been found
to be beneficial to combat it, protecting health care professionals from burnout and
detachment and from leaving their profession.31 The knowledge that interventions
around moral distress can effectively support nurses, and it is ethically right to do
so, advocates the necessity to address this matter, not just for nurses, but also in
consideration of all health care professionals whose practice involves using the GCS.

THE WAY FORWARD

It is clear from the evidence and discussions presented in this article that an effective
strategy is needed to tackle issues around consistent and safe use of the GCS; it is a
well-established tool that has proven itself, over time, to be important in assessment
and monitoring of neurologic status. However, there is a clear need for standardization
in the use of the tool through education approaches that are standardized and practice
guidelines that are clear and explicit and that cite the evidence base. Furthermore, the
human factors that impact use must be acknowledged and addressed within these in
order to recognize, validate, and support practitioners in the use of techniques that
potentially cause them, their patients, and relatives, distress.
The starting point for this must first be through consensus in creating a set of widely
agreed on standards around the use of the GCS. For example, what are the accept-
able methods of pain application and why? The greater the collaboration and agree-
ment, the more effective they can be in standardizing practice and preventing harm
through inconsistent use of the tool and unsafe use of techniques (ie, in applying pain-
ful stimuli). Authentic, collaborative co-design also creates the potential to formulate a
consensus approach to dealing with those factors that are distressing. There exists
the opportunity to achieve this through national and international organizations for
96 Cook

nursing (eg, the World Federation of Neuroscience Nurses, the European Association
of Neuroscience Nurses, the Australasian Neuroscience Nurses Association) and
potentially in collaboration with medical colleagues in similar organizations (eg, World
Federation of Neurosurgical Societies). The second proposed stage is then to agree
on the most effective educational approach, including recommendations on whether
such education should lie within preregistration education or at a postregistration/
postqualifying level. A collective view of the evidence suggests that this should be
at preregistration level in the first instance. The third factor to be considered is the
ongoing research necessary to determine whether such an approach has been effec-
tive in enhancing practice and in dealing with the ambiguity faced by practitioners
(Fig. 1). Similar approaches have been effective in other practice specialties, one be-
ing standards developed by The International Continence Society for precision around
practices in lower-urinary-tract dysfunction, removing ambiguity by being explicit and
logical, but also by dealing with the human factors involved.32
In creating international standards for GCS use and education, which will be moni-
tored and adapted based on sound evidence, there is a commitment given to
enhancing the quality of care through the following33:
 Raising political awareness of the relevance of standards and quality
 Creating a vision of enhanced care by coming together globally to shape practice
 Creating and implementing standards that seek to enhance care quality
 Measuring the impact of processes to determine their effectiveness and enhance
the evidence base to inform the further enhancement of practice and through
creating a culture of enquiry.
Palm and colleagues33 advocate this approach is aligned to creating the conditions
for equitable access to health care of appropriate quality by the Convention on Human
Rights and Biomedicine34 and to create a culture of universality, equity, and solidarity.35

Fig. 1. Enhancing GCS practices: the way forward.

 The Glasgow Coma Scale: Education and Practice 97

SUMMARY

Achieving best practice is a continual journey, one that is smoother and more direct
when there is a roadmap set out. Although the GCS has made such a positive contri-
bution to the care of people with neurologic orders, there has been an absence of a
clear roadmap for its use. Various attempts have been made over the years to be
clearer about the use of the tool, but with the GCS in its fifth decade of use, there re-
mains issues around inconsistency that originate from a lack of a unified, consistent
approach to education and practice. In an age of global health care practices and
networking, an opportunity exists to create a standardized approach to the use of
the GCS and the underpinning educational approach. Fundamentally, this would
enable such an approach to be cognizant and responsive to the human factors
involved, framing practice within a person-centered context.

CLINICS CARE POINTS

 Accuracy of use of the GCS is varied and inconsistent and requires a robust approach by
educators and health care professionals alike.
 Human factors have traditionally been absent from education around use of the GCS; the
impact of using the tool on the person, their loved ones, and the nurse must be
considered and addressed in both education and practice.

DISCLOSURE

The author has nothing to disclose.

REFERENCES

1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a

practical scale. Lancet 1974;304(7872):81–4.
2. Teasdale G, Maas A, Lecky F, et al. The Glasgow Coma Scale at 40 years: stand-
ing the test of time. Lancet Neurol 2014;13(8):844–54.
3. Haukoos JS, Gill MR, Rabon RE, et al. Validation of the Simplified Motor Score for
the prediction of brain injury outcomes after trauma. Ann Emerg Med 2007;50(1):
18–24.
4. Braine ME, Cook N. The Glasgow Coma Scale and evidence-informed practice: a
critical review of where we are and where we need to be. J Clin Nurs 2017;
26(1–2):280–93.
5. Reith FC, Van den Brande R, Synnot A, et al. The reliability of the Glasgow Coma
Scale: a systematic review. Intensive Care Med 2016;42(1):3–15.
6. Jalali R, Rezaei M. A comparison of the Glasgow Coma Scale score with full
outline of unresponsiveness scale to predict patients’ traumatic brain injury out-
comes in intensive care units. Crit Care Res Pract 2014. https://doi.org/10.
1155/2014/289803. Article ID 289803.
7. Cook NF, Braine ME, Trout R. Nurses’ understanding and experience of applying
painful stimuli when assessing components of the Glasgow Coma Scale. J Clin
Nurs 2019;28(21–22):3827–39.
98 Cook

8. Eurostat. Causes and occurrence of deaths in the EU. Luxembourg (Europe):

Eurostat; 2019. Available at: https://ec.europa.eu/eurostat/web/products-
eurostat-news/-/DDN-20190716-1. Accessed May 14, 2020.
9. Majdan M, Plancikova D, Brazinova A, et al. Epidemiology of traumatic brain in-
juries in Europe: a cross-sectional analysis. Lancet Public Health 2016;1(2):
e76–83.
10. Brazinova A, Rehorcikova V, Taylor MS, et al. Epidemiology of traumatic brain
injury in Europe: a living systematic review. J Neurotrauma 2016;33:1–30.
11. Feigin VL, Abajobir AA, Abate KH, et al. Global, regional, and national burden of
neurological disorders during 1990–2015: a systematic analysis for the Global
Burden of Disease Study 2015. Lancet Neurol 2017;16(11):877–97.
12. Hunter K, Cook C. Role-modelling and the hidden curriculum: new graduate
nurses’ professional socialisation. J Clin Nurs 2018;27(15–16):3157–70.
13. Iacono LA, Wells C, Mann-Finnerty K. Standardizing neurological assessments.
J Neurosci Nurs 2014;46(2):125–32.
14. Enriquez CM, Chisholm KH, Madden LK, et al. Glasgow Coma Scale: generating
clinical standards. J Neurosci Nurs 2019;51(3):142–6.
15. Jeffery J, Mussa M, Stirling E, et al. The Glasgow Coma Scale: do we know how to
assess? J Orthop Surg 2019;2(1):65–8.
16. Dubey N, Kumar N. Assess the effectiveness of computer assisted teaching
(CAT) on knowledge gain about GCS with coma patient among B. Sc. Nursing
3rd year students of selected nursing colleges at Bhopal, Madhya Pradesh, In-
dia. Trends in Nursing Administration and Education 2019;8(1):1–6.
17. Sherwood GD, Shaffer FA. The role of internationally educated nurses in a quality,
safe workforce. Nurs Outlook 2014;62(1):46–52.
18. European Parliament. Directive 2005/36/EC of the European Parliament and of
the Council of 7 September 2005 on the recognition of professional qualifications.
Official Journal of the European Union 2005;255:22–142. Available at: https://eur-
lex.europa.eu/LexUriServ/LexUriServ.do?uri5OJ:L:2005:255:0022:0142:EN:PDF.
Accessed May 5, 2020.
19. Nursing and Midwifery Council (NMC). Future nurse: Standards of proficiency for
registered nurses. London: NMC; 2018.
20. Nursing and Midwifery Board of Ireland. Nurse registration programmes stan-
dards and requirements. Dublin (Ireland): NMBI; 2016.
21. Health Service Executive (HSE). National clinical programme for neurology –
model of care. Dublin (Ireland): HSE; 2016.
22. Vink P, Tulek Z, Gillis K, et al. Consciousness assessment: a questionnaire of cur-
rent neuroscience nursing practice in Europe. J Clin Nurs 2018;27(21–22):
3913–9.
23. Braine ME, Cook N. An evaluation of post-registration neuroscience focused ed-
ucation and neuroscience nurses’ perceived educational needs. Nurse Educ
Today 2015;35(11):1069–74.
24. Alhassan A, Fuseini AG, Musah A. Knowledge of the Glasgow Coma Scale
among nurses in a tertiary hospital in Ghana. Nurs Res Pract 2019;2019:1–7.
25. Sedain P, Bhusal MK. Knowledge regarding Glasgow Coma Scale (GCS) among
nurses. Journal of College of Medical Sciences-Nepal 2019;15(4):276–81.
26. Catangui E. Improving Glasgow Coma Scale (GCS) competency of nurses in one
acute stroke unit-a Nursing Initiative Project. J Nurs Pract 2019;3(1):109–15.
27. Albougami A. Exploring nurses’ knowledge of the Glasgow Coma Scale in inten-
sive care and emergency departments at a tertiary hospital in Riyadh City, Saudi
Arabia. Malaysian J Nurs 2019;11(2):23–30.
 The Glasgow Coma Scale: Education and Practice 99

28. World Health Organization. WHO global strategy on people-centred and inte-
grated health services. Geneva (Swizerland): WHO; 2015.
29. Ward A, Eng C, McCue V, et al. What matters versus what’s the matter–exploring
perceptions of person-centred practice in nursing and physiotherapy social me-
dia communities: a qualitative study. International Practice Development Journal
2018;8(2). https://doi.org/10.19043/ipdj.82.003. article 3.
30. Pendry PS. Moral distress: recognizing it to retain nurses. Nurs Econ 2007;
25(4):217.
31. Browning ED, Cruz JS. Reflective debriefing: a social work intervention address-
ing moral distress among ICU nurses. Journal of Social Work in End-of-life & Palli-
ative Care 2018;14(1):44–72.
32. Drake MJ, Abrams P. A commentary on expectations of healthcare professionals
when applying the international continence society standards to basic assess-
ment of lower urinary tract function. Neurourol Urodyn 2018;37(S6):S7–12.
33. Palm W, Peeters M, Garel P, et al. International and EU governance and guidance
for national healthcare quality strategies. In: Busse R, Klazinga N, Panteli D, et al,
editors. Improving healthcare quality in Europe. London: World Health Organiza-
tion; 2019. p. 63–102.
34. Dommel FW, Alexander D. The convention on human rights and biomedicine of
the Council of Europe. Kennedy Inst Ethics J 1997;7(3):259–76.
35. Council of the European Union. Council conclusions on common values and prin-
ciples in European Union health systems. Official Journal of the European Union
2006;146:1–3.