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 The unpublished standards for making GCS observations, written by the Neuroscience Nursing Benchmarking Group, were used to identify questions for examination in the audit.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.