CHAPTER ONE

INTRODUCTION

Background to the study

Glasgow Coma Scale (GCS) is a neurological scale which aims to give a reliable, objective way of recording the conscious state of a person, for initial as well as subsequent assessment. Assessment of consciousness level is considered a primary action of health care practitioners, including nurses, who care for the patients with neurological or neurosurgical problems. The assessment not only identifies the neurological problem but also detects the initial signs of complications. It can be an indicator for intervention or treatment in emergency conditions (Weir, Bradford, & Lees, 2003). The Glasgow Coma Scale (GCS), first- presented by Teasdale and Jennet in 1974, is one of the most effective and reliable tools to assess the depth and duration of impaired consciousness, especially for the patient with head injuries. The high level of validity and reliability of GCS ensure its assessment accuracy in comparison with other earlier scoring systems such as the anatomical or physiological scoring system and the revised trauma score (Fisher & Mathieson, 2001; Kingston & O'Flanaga, 2000).

Since it was developed, GCS has been used world-wide because it enhances communication among health care practitioners through a common reporting language. Over the years, GCS use has been extended to assessment of consciousness in other clinical specialties and research projects. It has been validated as a reliable tool in grading severity and predicting outcome in conditions like acute stroke, subarachnoid haemorrhage, acute poisoning and other critical illness. (Weir, Bradford, & Lees, 2003). An important but unsubstantiated assumption is that the GCS is being properly administered in the course of patient management but this is not true as there are reported cases of inaccurate assessment and reporting of the GCS which has resulted to

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unnecessary treatment and diagnostic tests (Ronald, Anthony, William, Audrey & Peter, 2005; Yusuf, Salaudeen, Adewale & Badalona, 2013). Despite its simple appearance, a lot of health care practitioners have used it in an inappropriate way without careful adherence to the GCS instruction (Nguyen & Sun-Mi, 2011). Previous studies reported that health care providers used GCS inaccurately and ineffectively in their clinical practice (Bazarian, Eirich & Salhanick, 2003; Iankova, 2006; Zuercher, Ummenhofer, Baltussen & Walder, 2009).

Two studies of knowledge of GCS among physicians with frequent experience with patients suffering Traumatic Brain Injury (TBI) revealed that among military physicians with a high percentage of Advance Trauma Life Support (ATLS) training, only 15% of those who had completed ATLS training were able to correctly recall all aspect of the GCS. Ronald, Anthony, Williams, Audrey, & Peter, (2005); Catherine, Patrick, Nicolas & Donat, (2009) in Swiss air-rescue physicians, despite proper theoretical knowledge of the GCS, the clinical scale was wrongly scored by 36.9% of them In these studies, level of training, training in Neurosurgery and General Surgery were associated with better performance in GCS recall (Ronald et al, 2005, Catherine et al, 2009). Heron, Davie, Gillies & Courtey (2001) compared GCS scorings among nurses working in different units. They reported that the nurses with a specific qualification from critical care training performed GCS accurately. Holdgate, Ching & Angonese (2006), identified unstable condition of patients and inadequate GCS knowledge and experience of physicians and nurses as factors affecting the accuracy of GCS scoring. These findings indicate the significant relationship of GCS knowledge with accurate GCS scoring and usage. GCS is a primary tool that can be used by nurses to make quick repeated evaluation of several key indicators of neurological status. Nurses have embraced its use as it was made as a chart similar to the temperature, pulse and respiration chart. While previous studies have merely investigated either

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knowledge of GCS in health care professionals (Heim, Schoettker, Gilliard, & Spahn, 2009; Riechers, Ramage, Brown, Kalehua & Rhee, 2009) or interreliability of GCS in practice between different health care professionals (Arbabi, Jurkovich, Walh, Franklin, Hemmil & Taheri, 2004; Holdgate, Ching & Angonese, 2006). Very few studies are known to measure the relationship of GCS knowledge and performance or its use among nurses (Nguyen and Sun-Mi, 2011). GCS is widely used in Nigeria by nurses like other countries in the world to assess their patients' consciousness level. Therefore, this study is conducted to find out how knowledgeable nurses in University of Benin Teaching Hospital are about the Glasgow coma scale and its use.

Statement of problem

The Glasgow coma (GCS) is a neurological instrument, which measure the depth and duration of impaired consciousness (Waterhouse, 2008). The appeal of GCS lies in its applicability in a wide variety of clinical situations as well as its ease of use by a range of healthcare staff (Baker, 2008). Growing evidence suggests that problem is encountered when completing some aspect of the GCS with the potential for performing an incorrect assessment (Waterhouse, 2008).

Despite the propensity for incorrect assessment, the GCS remains in use in any clinical setting and enjoys an unwarranted and privileged position (Segatore & Way, 1992). This creates problem in patient care as the GCS is an important instrument in communicating an accurate assessment of the patient condition between clinical staffs. (Holdgate, Ching & Angonese, 2006). Inappropriate use of the GCS may have serious clinical implications to the patient (Shoquirat, 2006). It has been reported that many health professionals including nurses who use it to assess patient document GCS scores at the extreme, such as a GCS of 3/15 or 15/15, and also use it in a gross way to describe intermediate level of consciousness which is inherently inaccurate and subjective (Middleton, 2012). These occur as a result of people using entirely different stimuli

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and then assess response differently making the GCS inaccurate and meaningless (Middleton, 2012). In Nigeria, there has been increasing cases of head injury and other neurological conditions that required the use of GCS in monitoring of these conditions, for example Emejulu, Ekweogwu and Nottidge, (2009) on the burden of motorcycle-related neurotrauma in South-East Nigeria reported that a total of 1055 neurosurgical cases were attended to in one of Nigeria centre of neurosurgery in- service from 21st April, 2006 to 20th October, 2008 out of which 138 had congenital anomalies and 917 had acquired diseases. Among the acquired cases, 785 had trauma with 658 (88%) cases of head injury, 61 (8.1%) cases of spinal injury, and 29 (3.9%) concomitant head and spinal injuries. In a similar study Emejulu, Isiguzo, Agbasoga and Ogbuagu (2010), on traumatic brain injury in the Accident and Emergency Department of a Tertiary Hospital in Nigeria reported a total of 9,444 patients were attended to during the 24 months which translated to a presentation rate of 5.3 cases per week and an incidence rate of 2,710 per 100,000 per year. Despite the increase level of incidence in neurological and neurosurgical conditions, there is paucity of studies in this area establishing the knowledge and use of GCS by nurses and doctors. Nursing unconscious patient in Nigeria involved the use of the GCS to assess the level of consciousness (LOC) of the patient, but apart from delivering nursing care, practicing nurses in the teaching hospitals are also encumbered with responsibility of teaching students nurse on the use of the GCS. From the researcher’s experiences and observations when on clinical teaching with student nurses in the ward especially in neurological ward, and other wards where unconscious patients are being nursed, practices of assessing the GCS among nurses were seen to be at times incongruent, occasionally leading to an inaccurate assessment of the patients. This definitely leaves one wandering how much nurses knew of GCS score and its use in client clinical assessment. The question is could the problem be due to lack

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of knowledge or lack of its use on the part of the nurses or both? Hence this study was undertaken to assess the knowledge and use of GCS in neurological assessment of patients among nurses in University of Benin Teaching Hospital, Benin City, Edo State, Nigeria.

Purpose of the study

The purpose of this study is to assess nurses’ knowledge and use of GCS in University of Benin Teaching Hospital, Benin City Edo state.

Specific objectives of the study: The specific objectives of this study are to;

1.                  Assess knowledge of Glasgow Coma Scale (GCS) among nurses working in selected units in the University of Benin Teaching Hospital (UBTH) Benin City.

2.                  Assess the nurses’ utilization of the GCS in monitoring of in-patients with impaired consciousness in the UBTH.

3.                  Examine the nurse’s perception of the factors that affect the use of GCS among nurses in the UBTH.

1.                  Do nurses in UBTH have knowledge of GCS?

2.                  Do nurses in UBTH make utilize the GCS in monitoring their patient with impaired consciousness?

3.                  What are the perceptions of the nurses about factors that affect their usage of the GCS in university of Benin teaching hospital?

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Research hypotheses

1.   HO There is no significant difference in the knowledge and utilization of GCS among nurses working in various ward/unit.

2.   HO: There is no significant relationship between nurses’ knowledge and educational level, and years of experience

3.  Ho: There is no significant relationship between nurses’ knowledge and use of GCS.

Significance of the study

Glasgow coma scale is a significant instrument or tool in the management of patient in a critical, acute or neurological care settings. It is an internationally recognised tool for the management of unconscious and /or head injury patients and those patients who go into coma as a result of complication from medical conditions such as diabetic and hypertensive conditions etc. The GCS has been the gold standard of neurological assessment for trauma patients since inception (Fischer & Mathieson, 2001). Communication between health care professionals is vital to provision of care. The GCS was adopted to enhance this communication among practitioner by providing a common language to report neurological finding based on observation obtained at the bed side (National Institute for Clinical Excellence, 2003). Nurses have a frontline presence at the bedside to monitor the GCS with initial and repeat assessment, allowing them to identify trend in neurological status and take appropriate action. Therefore, registered nurses must understand correct usage of the GCS. Accurate, consistent assessment of a patient with impaired consciousness is crucial to determine improvement or deterioration in patient condition (Caton-Richards, 2010). Timely and early interventions have the potential to improve patient outcomes. This study will make a significant contribution by revealing nurses’ knowledge of GCS and its usage in University of Benin Teaching Hospital. This study will reveal the factors affecting the

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utilization of GCS among nurses in UBTH and as a result informs policy maker and hospital management on strategies to employ to ensure that these factors are removed. Findings from this study will also inform both Nursing Schools and Universities in Nigeria on the need to develop a comprehensive GCS education program so that nurses will have satisfactory preparations both in knowledge and skills to provide a high quality of care. In addition result from this study will add to the existing body of knowledge in Nigeria and worldwide about nurses’ level of level of knowledge and use of GCS as there is dearth of empirical work from Nigeria relating to knowledge and use of GCS among nurses, it will also serve as source of data and reference for further study in related area. Recommendations from this study when implemented will of course go a long way in equipping nurses with the adequate knowledge, skill and confidence in performing accurate assessment of the GCS. Prompt and accurate assessment of the unconscious patient will lead to early and appropriate intervention that will reduce the morbidity and mortality experience by the unconscious patient.

Scope of the study

This study focus on the knowledge and use of GCS and is limited to only nurses working in the selected wards/units in the University of Benin Teaching Hospital, Benin City Edo State.

Operational definition

Knowledge of GCS: knowledge is defined in this study as ability to answer correctly question in a questionnaire which will be reported at levels of knowledge. The knowledge would be rated on

a   scale of 1-12. With 1-4 as having poor knowledge, 5-8 average knowledge, and 9-12 good knowledge.

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