ABSTRACT

Objective

To assess knowledge of nurses of emergency services and intensive care units about Glasgow Coma Scale.

Methods

This cross-sectional analytical study included 127 nurses of critical units of an university hospital. We used structured interview with 12 questions to evaluate their knowledge about the scale. Association of Knowledge with professionals’ sociodemographic variables were verified by the Fisher-test, χ² and likelihood ratio.

Results

Most of participants were women mean aged 31.1 years, they had graduated more than 5 years previously, and had 1 to 3 years of work experience. In the assessment of best score possible for Glasgow scale (question 3) nurses who had graduate more than 5 years ago presented a lower percentage success rate (p=0.0476). However, in the question 7, which evaluated what interval of the scale indicated moderate severity of brain trauma injury, those with more years of experience had higher percentage of correct answers (p=0.0251). In addition, nurses from emergency service had more correct answers than nurses from intensive care unit (p=0.0143) in the same question. Nurses graduated for more than 5 years ago had a lower percentage of correct answers in question 7 (p=0.0161). Nurses with more work experience had a better score (p=0.0119) to identify how assessment of motor response should be started.

Conclusion

Number of year since graduation, experience, and work at critical care units interfered in nurses’ knowledge about the scale, which indicates the need of training.

Nursing assessment; Knowledge; Nurses; Glasgow coma scale; Consciousness disorders

RESUMO

Objetivo

Avaliar o conhecimento de enfermeiros de unidades críticas, serviços de emergência e unidades de terapia intensiva em relação à escala de coma de Glasgow.

Métodos

Estudo transversal e analítico com 127 enfermeiros de unidades críticas de um hospital universitário. Utilizou-se entrevista estruturada com 12 questões que avaliaram conhecimento sobre a escala. Associação do conhecimento com variáveis sociodemográficas dos profissionais foi verificada pelo teste de Fisher, teste χ² e razão de verossimilhança.

Resultados

Houve predominância de mulheres, média de idade de 31,1 anos, especialistas, mais de 5 anos de formado e experiência profissional de 1 a 3 anos. Na avaliação do melhor escore possível para pontuação na escala (questão 3), enfermeiros com tempo de formação maior que 5 anos apresentaram menor porcentual de acertos (p=0,0476). Em relação à questão 7, que avaliou qual intervalo da escala indicava gravidade moderada do trauma craniencefálico, observou-se que quanto maior o tempo de experiência, maior o porcentual de acertos (p=0,0251), sendo que enfermeiros do serviço de emergência tiveram mais acertos nessa questão em relação aos das unidades de terapia intensiva (p=0,0143). Além disso, enfermeiros formados há mais de 5 anos apresentaram menor porcentual de acertos nessa questão (p=0,0161). Quando se identificou como deve ser iniciada a avaliação da resposta motora, enfermeiros com maior tempo de trabalho na unidade apresentaram mais acertos (p=0,0119).

Conclusão

Tempo de formação, experiência e trabalho na unidade interferiu no conhecimento de enfermeiros sobre a escala, evidenciando necessidade de capacitação.

Avaliação em enfermagem; Conhecimento; Enfermeiras e Enfermeiros; Escala de coma de Glasgow; Transtornos da consciência

INTRODUCTION

Traumatic injuries are important cause of morbidity and mortality around the world, and the brain trauma injury (BTI) is one of the main determinants of this panorama. The BTI has complex physiopathological mechanisms.(¹1. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24 Suppl 1:S1-106. Erratum in: J Neurotrauma. 2008;25(3):276-8.

2. World Health Organization (WHO). Global status on road safety 2013: supporting a decade of action [Internet]. Geneva: WHO; 2013 [cited 2015 Nov 28]. Available from: http://www.who.int/violence_injury_prevention/road_safety_status/2013/en/
http://www.who.int/violence_injury_preve... -³3. Settervall CH, Sousa RM. Escala de coma de Glasgow e qualidade de vida pós-trauma cranioencefálico. Acta Paul Enferm. 2012:25(3):364-70.) Among non-traumatic causes of consciousness change, we highlight abscesses, brain tumors, injuries from strokes, hydrocephalies and aneurism, among other, which are also called structure injuries. Among non-structural injuries most prominent are hypoxia, hydroelectrolytic changes, hyperthermia and hypothermia, hepatic encephalopathy, alcohol intoxication, illicit drugs, hypnotic sedatives and heavy metals.(⁴4. Mendes PD, Maciel MS, Brandão MV, Rozental-Fernandes PC, Esperidião-Antonio V, Kodaira SK, et al. Distúrbios da consciência humana – Parte 1 de 3: bases neurobiológicas. Rev Neurocienc. 2012;20(3):437-43.,⁵5. Mendes PD, Maciel MS, Brandão MV, Rozental-Fernandes PC, Esperidião-Antonio V, Kodaira SK, et al. Distúrbios da consciência humana – Parte 3 de 3: intermezzo entre coma e vigília: bases neurobiológicas. Rev Neurocienc. 2013;21(1):102-7.)

Glasgow coma scale (GCS), developed by Taesdale and Jennet in 1974 at The University of Glasgow, Scotland, UK, is employed worldwide to identify neurologic dysfunction and follow-up progress of level of consciousness, predict prognosis, and standardize communication among health professionals.(⁶6. Mendes PD, Maciel MS, Brandão MV, Rozental-Fernandes PC, Esperidião-Antonio V, Kodaira SK, et al. Distúrbios da consciência humana – Parte 2 de 3: a abordagem dos enfermos em coma. Rev Neurocienc. 2012;20(4):576-83.) This scale became an important tool to assist patient who suffered trauma, mainly BTI victims, and, posteriorly, its use extended to other neurologic conditions that can alter consciousness. Total score ranges from 3 to 15 and it is obtained by observation of spontaneous activities and use of verbal and/or painful stimulus.

The GCS is divided in three assessment parameters:

The use of GCS requires previous knowledge and skills. This scale applied carefully and systematically is fundamental for assessment and establishment measures of the patient in order to guarantee reliability – which is critical to follow-up the progress of such patients.(⁸8. Oliveira DM, Pereira CU, Freitas ZM. Escalas para avaliação do nível de consciência em trauma cranioencefálico e sua relevância para a prática de enfermagem em neurocirurgia. Arq Bras Neurocir. 2014;33(1):22-32.)

For many years, a variety of studies were developed to evaluate the precision and reliability of GCS.(³3. Settervall CH, Sousa RM. Escala de coma de Glasgow e qualidade de vida pós-trauma cranioencefálico. Acta Paul Enferm. 2012:25(3):364-70.,⁹9. Mattar I, Liaw SY, Chan MF. Nurses’ self-confidence and attitudes in using the Glasgow Coma Scale: a primary study. Nurs Crit Care. 2015;20(2):98-107.) Studies shown low adherence of GCS use, difficulties in its application and fails of professionals related to conscience evaluation such as lack of standards and poor knowledge about the scale, in addition, the hospital routine is a fact that lead prioritization of other organic systems, indicating that only 42.7% of nurses use this scale to assess consciousness. To assess level of consciousness is part of health professionals routine, mainly those working at critical care units, i.e., emergency services (ES) and intensive care units (ICU), whom are well trained and more experienced in the use of GCS with higher levels of reliability and precision.(⁷7. Prado C. Ensino-aprendizagem da escala de coma de Glasgow: análise de duas técnicas em enfermeiros do serviço de emergência [Internet]. [Tese]. São Paulo: Escola de Enfermagem, Universidade de São Paulo; 2001 [citado 2015 Nov 19]. Disponível em: http://www.teses.usp.br/teses/disponiveis/7/7135/tde-30032007-115512/pt-br.php
http://www.teses.usp.br/teses/disponivei... ,¹⁰10. Amorim CF, Menezes Jr. JE, Thiago TE, Araújo DP, Gúzen FP, Cavalcanti JR. Avaliação neurológica realizada por enfermeiros em vítimas de traumatismo cranioencefálico. Rev Neurocienc. 2013;21(4):520-4.)

An international study that evaluated knowledge of nurses about GCS and associated results with demographic variables, reported area of working and time of experience are associated with high or low knowledge. Nurses of neonatal intensive care unit had the highest score (12.7) whereas nurses of internal medicine had lowest score (9.7). In knowledge scale, nurses working at neurologic unit over or equal to 6 years had the highest scores (11.9), and those working for less or equal to 1 year had the lowest scores (10.0). The same study reported the need of educational interventions and design of manuals for maintenance and improvement of assessment of consciousness using the GCS.(¹¹11. Mattar I, Liaw SY, Chan MF. A study to explore nurses’ knowledge in using the Glasgow Coma Scale in an acute care hospital. J Neurosci Nurs. 2013;45(5):272-80.)

Given the importance of GCS as a tool for neurological assessment of patients, and the need of careful and standardized application, to evaluate health professionals’ knowledge on this scale is fundamental to guarantee uniformity, reliability and accurately in the use of GCS.

OBJECTIVE

To assess knowledge of nurses of emergency services and intensive care units about Glasgow Coma Scale.

METHODS

This cross-sectional and analytical study included 127 nurses of the Hospital São Paulo, São Paulo (SP), Brazil. The study was approved by the Ethical and Research Committee of the Universidade Federal de São Paulo, CAAE number 42505115.8.0000.5505. All participants signed the consent form and had their information kept confidential. We included nurses who work at ES and ICU of Hospital São Paulo, and excluded nurses from multidisciplinary residency programs, nurses from pediatric ES and ICU, and those on sick leave or vacation during selection of participants.

Data were collected from May to July 2015. Sociodemographic variables included were: age, sex, race, marital status and formal education. In addition, the following professional variables were verified: number of years since graduation, working area, and time working in the critical care unit. We also applied a structured closed interview in a private environment for, on average, 20 minutes, to assess nurses’ knowledge on GCS and its application to the patient. Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 19 (Chicago Il, USA). Descriptive analysis of continuous categorical variables was done using the mean, standard deviation, medium, minimal and maximal for each question related to the GCS. Chi square test was used to compare formal education, number of years since graduation, experience time, unit of work, and time working in the unit using the tool. When 20% of the sample had expected value lower than five, we used the Fisher exact test or likelihood ratio. We considered significant a p≤0.05 value.

RESULTS

Table 1 includes sociodemographic and professional data of nurses in the study. We observed predominance of women (82.7%), mean aged 31.1±5,1 years, and white (72.4%). Most of professional had post-graduation courses (89.8%), 62.2% had graduated 1 to 5 years ago, and 37.8% reported 1 to 3 years of experience as a nurse. The majority of professionals worked in the ICU (76.4%) and 44.9% worked in the unit for 1 to 3 years.

Table 2 shows professional answers related to the GCS.

When professionals were inquired about the applicability of the scale, they (99.2%) reported it applies for level of consciousness. About parameters of GCS, 98.4% of professionals mentioned eye opening, best verbal response and best motor response. When professionals were inquired what is the best score possible for the scale, 97.6% of them mentioned 15, and the least score possible, 97.6% checked the score as correct.

When questioned about GCS score that indicate critically status for the patient and must be used as an alarming sign for the professional, 80.3% reported that score was ≤8. A total of 66.1% of professionals identified urinary incontinence as the aspect that influenced GCS use. The scale interval that classified BTI, according to severity, 81.1% of participants answered as correct, indicating this interval between score 12-9 for moderate BTI. Most of participant (92.9%) answered right what would be the most adequate response to be scored, i.e., the best response presented by the patient.

When nurses were inquired about when to begin eye opening parameter, 39.4% answered correctly, which is to get close to patient’s bed. When participants were inquired, how examiner would begin the parameter best verbal response, 89.0% reported that questioning about time, space, and aware of the self was the right answer. A total of 89.8% of participants answered that to begin the best motor response the best approach would be verbal command by requesting a motor response.

Most of participants (89.8%) answered correctly that GCS would be recorded using the score obtained in each parameter, and by provide the total score of the scale.

When compared variables (formal education, numbers of years since graduation, time of experience, unit of work, time workingin the unit) with answer in each unit, we observed that in question 3 that evaluated the best score possible for the score in the scale, nurses who graduated more than 5 years ago had the lowest percentage of right answers (p=0.0476).

In question 7, which evaluated what interval of GCS would indicate moderate severity of BTI, the more time of experience the higher was percentage of right answers (p=0.0251), and nurses from emergency unit had the highest percentage of right answers than nurses from intensive care unit (p=0.0143). In addition, nurses who graduate for more than 5 years ago had lowest percentage of right answers in the question (p=0.0161).

Question 11, which evaluated how the examiner should begin the assessment of best motor response, nurses with more work experience in the unit had the highest percentage of right answers (p=0.0119).

DISCUSSION

Professionals providing care for severe patients face situations with any type of neurologic disorder that may require an easy to apply instrument that should be able to identify quickly these disorders and changes in neurologic parameters (consciousness, sensibility and motricity). For this reason, neurologic assessment of these patient is an indispensable tool in daily practice at ES and ICU.(¹⁰10. Amorim CF, Menezes Jr. JE, Thiago TE, Araújo DP, Gúzen FP, Cavalcanti JR. Avaliação neurológica realizada por enfermeiros em vítimas de traumatismo cranioencefálico. Rev Neurocienc. 2013;21(4):520-4.)

Most of nurses included in the study were women, mean aged 31.18 years, white and single. These results corroborate, in some extent, with findings of other study carried out in the adult intensive care unit at a teaching hospital in São Paulo countryside that reported predominance of women and mean age of 32 years. In that study, age ranged between 23 and 33 years, therefore, a young population.(¹²12. Camelo SH, Silva VL, Laus AM, Chaves LD. Perfil profissional de enfermeiros atuantes em unidades de terapia intensiva de um hospital de ensino. Cienc Enferm. 2013;19(3):51-62.)

Most of participants in our study had post-graduate course and reported to be graduated between 1 and 5 years previously (62.2%). A low percentage was found in research carried out in ICU of three university hospitals in Alagoas State in which 68% of nurses reported to have a post-graduate course.(¹³13. Pimentel TS, Lúcio IM, Oliveira KC, Bastos ML, Santos EA. Processo de trabalho de enfermeiros de unidades de terapia intensiva: desafios da formação acadêmica. Rev Enferm UFPE. 2013;7(10):5915-22.) Another study carried out in cardiac intensive care unit of Hospital dos Servidores do Estado do Rio de Janeiro (RJ), observed that 50% of nurses had graduated between 1 to 5 years previously.(¹⁴14. da Silva RC, Ferreira M de A. Características dos enfermeiros de uma unidade tecnológica: implicações para o cuidado de enfermagem. Rev Bras Enferm. 2011;64(1):98-105.)

In our study, the majority of nurses (more than 80%) answered correctly questions about GCS concerning the aim of the scale, parameters, score, scale score that indicated critical situation for the patient and that examiner should be alert to, and also about the scale interval that classified BTI as moderate. They also answered correctly how to score each parameter, and how to begin the assessment of best verbal response and best motor response.

Although the majority of nurses of our study showed a good knowledge about GCS, some professionals had poor knowledge about the scale. This fact corroborates with finding of an international study in which participants showed poor knowledge in some parameters of the scale, which indicated the need of continuous training in order to guarantee standard and reliable use of GCS.(¹⁵15. Reith FC, Brennan PM, Maas AI, Teasdale GM. Lack of Standardization in the Use of the Glasgow Coma Scale: results of International Surveys. J Neurotrauma. 2016;33(1):89-94.) Such scenario can be a concern, especially because neurologic assessment is prevent and diagnose early events that can trigger secondary brain injuries or worsen existing injuries. Severely ill patients require pointless perception and follow-up from nurse team. Therefore, nurses should know changes that may occur with the patient in order to act correctly because nursing care is based on constant observation and correct evaluation.(¹⁵15. Reith FC, Brennan PM, Maas AI, Teasdale GM. Lack of Standardization in the Use of the Glasgow Coma Scale: results of International Surveys. J Neurotrauma. 2016;33(1):89-94.)

When participants in our study were inquired about correct way to assess eye opening, only 39.4% chosen the right answer. This finding was reported by another study that compared GCS application among nurses and physician from the emergency unit. In that study, participants also had low score in this parameter of the scale.(¹⁶16. Holdgate A, Ching N, Angonese L. Variability in agreement between physicians and nurses when measuring the Glasgow Coma Scale in the emergency department limits its clinical usefulness. Emerg Med Australas. 2006;18(4): 379-84.)

Nurses who graduated more than 5 years ago had lower percentage of right answers in question related with score associated to interval indicating moderate severity of GCS. This result can be associated to lack of training, reliability and precision in the use of scale. Knowledge improves with experience and continuous training.(⁸8. Oliveira DM, Pereira CU, Freitas ZM. Escalas para avaliação do nível de consciência em trauma cranioencefálico e sua relevância para a prática de enfermagem em neurocirurgia. Arq Bras Neurocir. 2014;33(1):22-32.)

In question that evaluated GSC interval indicating moderate severity, more experience professionals had higher percentage of right answers, and nurses from emergency unit did better compared with professional from ICU. Nurses working in critical patient care need scientific, practical and technical knowledge in order to take quick and effective decisions given that neurologic changes are related with improvement or worsening of patient’s prognosis. A safety care for patient requires skilled nurse who can perform their role to guarantee patient recovery. Care delivery by nurses requires various knowledge and understanding related with leadership process of the team, with special emphasis in interpersonal relationship and decision making.(¹⁷17. Pereira N, Valle AR, Fernandes MA, Moura ME, Brito JN, Mesquita GV. O cuidado do enfermeiro à vítima de traumatismo cranioencefálico: uma revisão da literatura. Rev Interdisc NOVAFAPI (Teresina). 2011;4(3):60-5. Review.) Professional experience along with training is fundamental in this process to guarantee quality improvement in nursing care

Nurses included in our study who worked for more time within the unit had higher percentage of right answer in question assessing how examiner should record motor response, and the same results were seen in other studies, highlighting more experience as higher knowledge about GCS(¹¹11. Mattar I, Liaw SY, Chan MF. A study to explore nurses’ knowledge in using the Glasgow Coma Scale in an acute care hospital. J Neurosci Nurs. 2013;45(5):272-80.,¹⁸18. Chan MF, Matter I. Investigating nurses’ knowledge, attitudes and self-confidence patterns to perform the conscious level assessment: a cluster analysis. Int J Nurs Pract. 2013;19(4):351-9.,¹⁹19. Chan MF, Mattar I, Taylor BJ. Investigating factors that have an impact on nurses’ performance of patients’ conscious level assessment: a systematic review. J Nurs Manag. 2013;21(1):31-46. Review.) This result shows the importance of education in services that use GCS, because most professionals working at ES are young, but they have little working experience. Another important fact is high turnover at emergency services.(²⁰20. Mendes AC, Araújo Jr JL, Furtado BM, Duarte PO, Silva AL, Miranda GM. Condições e motivações para o trabalho de enfermeiros e médicos em serviços de emergência de alta complexidade. Rev Bras Enferm. 2013;66(2):161-6.,²¹21. Adriaenssens J, De Gucht V, Maes S. Causes and consequences of occupational stress in emergency nurses, a longitudinal study. J Nurs Manag. 2015;23(3): 346-58.)

Considering the results of our study, we believe that training strategies on the use of GCS should be a topic of reflection to guarantee reliability and precision expected from nurse professionals.(⁸8. Oliveira DM, Pereira CU, Freitas ZM. Escalas para avaliação do nível de consciência em trauma cranioencefálico e sua relevância para a prática de enfermagem em neurocirurgia. Arq Bras Neurocir. 2014;33(1):22-32.) Simulation-based teaching constitutes an active learning method in an environment free of risk with the possibility to build knowledge and technical skills. This method can be a strategy that would provide safety for nurses in the use of GCS in clinical practice.(²²22. Dourado AS, Giannella TR. Ensino baseado em simulação na formação continuada de médicos: análise das percepções de alunos e professores de um Hospital do Rio de Janeiro. Rev Bras Educ Med. 2014;38(4):460-9.)

The main limitation of this study is that it was conducted in a single center, therefore, it constitutes a local experience.

CONCLUSION

Most nurses of critical care units had good knowledge about Glasgow coma scale and answered correctly questions about it, exceptions were seen about eye opening parameters.

Those with more experience as a nurse had higher percentage of right answers in the question related to Glasgow coma scale interval, which indicate moderate severity of brain injury. Nurses working for more time in the unit had higher percentage of right answers in the question inquiring how examiner should begin assessment of best motor response.

REFERENCES

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