Neurological Assessment: Practice Review’

Several electronic databases were accessed to further understand the research aim. This paper is primarily focused on a nursing perspective; therefore, it was crucial to include a peer reviewed database that includes high quality academic articles within this discipline. Medline and Emcare were selected as the most appropriate and relevant databases. A comprehensive search of the literature for this paper was conducted in July 2022 with the support of the hospital librarian to reveal high quality academic journals. Boolean operators were utilised to combine terms to complete the search. To ensure a comprehensive search, a filter was applied to limit articles in full text, English language and papers published from 2015-2022.

The search was frequently assessed to this criterion to ensure the search met the aim of the paper. Research that met the criteria includes papers that primarily focused on human studies and an adult population. Studies that focused on a paediatric population or animal studies were excluded from the findings, as this did not meet the expectations and aim of this review.

A data extraction tool, Covidence, was utilised to ensure a thorough review of the collated literature. A total of 63 articles were uploaded to this data base for review, each article was individually assessed by two people to produce an accurate representation of the aim. Titles and abstracts of each paper were closely examined to determine the relevance of the literature. The support of the data extraction tool, and a thorough review of each paper, revealed five articles that appropriately reflected the aim and were selected to be included in this paper.

This paper analysed 63 articles related to the application of a Neurological Assessment including the GCS As previously discussed, a total of five papers were included in this comprehensive review. The methodologies used in this paper were qualitative and provides a relevant collation of academic journals to reflect the purpose of this review. The literature featured in this article includes primary research due to the lack of secondary pre-appraised research that met the inclusion and exclusion criteria.

In recent literature there has been several limitations and criticism detailed of the use of the GCS. Common criticism is that components of the scale can become untestable for several reasons. Potential factors influencing the score of the ‘eye opening’ component but not necessarily indicating a lack of arousal include deafness or occipital swelling (Derbyshire & Hill, 2018).

The GCS has particularly been reported to have low reliability when completing an assessment of the verbal component (Ozcelik & Celik, 2021). This component is most impacted by intubation, tracheostomy, locked in syndrome, dysphasia and sedation but these factors don’t necessarily indicate the patient has a lack of awareness (Derbyshire & Hill, 2018; Ozcelik & Celik, 2021; Reith et al., 2016). Recent studies undertaken by Javvaji et al. (2022) and Ozcelik and Celik (2021) compare the GCS to the FOUR score in neurologically impaired patients. Javvaji et al. (2022) reported that both scores have ability to predict mortality and morbidity in both stroke and non-stroke cases. A limitation of this study was the small sample size, thus further studies are required. Given the limitations of applying the GCS to intubated patients the FOUR score potentially serves as an appropriate alternative if staff are competent in using the score, as it is not widely used or known by all healthcare professionals (Ozcelik & Celik, 2021).

Lastly, the ‘motor response’ can be influenced by administration of sedatives and muscle relaxant medications. Additionally, when assessing the patient’s ‘motor response’ normal flexion can be commonly mistaken as a flexor response resulting in an incorrect GCS score (Derbyshire & Hill, 2018; Javvaji et al., 2022). Furthermore, brainstem reflexes are not assessed in the GCS, which has been identified as being significantly associated with mortality (Javvaji et al., 2022). These factors can undermine the effectiveness of the GCS scoring system.

However recently Teasdale and colleagues provided clarity in approaching “missing components”, reporting that whenever a component is ‘not testable’, the assessor should document the reason and write ‘NT’ rather than assigning a score of one to reflect a more accurate result (Reith et al. 2016). Examination of the eye and pupillary response is an important aspect of neurological observations. Factors influencing abnormal pupil shape, size and reactivity include prior eye surgery, medications and hormonal disorders; in the absence of raised intracranial pressure. Therefore, it is essential to observe the pupils prior to applying a light stimulus (Derbyshire & Hill, 2018).

It has been identified there is a lack of standardisation regarding technique and application of the GCS, reporting, as well as inconsistent use of the 15 point scale (Reith et al., 2016). A study by Reith et al. (2016) found 25% of practitioners never use a peripheral stimulus, and it has been suggested that different stimulation techniques elicit different responses. This study explores reliability of the GCS being influenced by teaching and clinical experience. Insufficient teaching and a lack of clinical experience can contribute to the variation in neurological assessments. Reith et al. (2016) has shown that reliability of assessment is lower in untrained and inexperienced staff, and findings confirm a lack of standardisation in use. It is acknowledged that the results of the paper-based questionnaires mainly reflect European experiences. To reduce variability in neurological assessments among nursing staff, if neurological deterioration is suspected in patients, a second competent nurse should repeat neurological observations to confirm deterioration (Hoban, 2017).

It is evident within the literature, and in clinical practice, that the GCS is not always the preferred method of assessment that meets the needs of all patients (Maserati et al. 2016). Patients who are of a culturally linguistically diverse background attracts further scrutiny of the tool. Braine and Cook (2016) recommend addressing and acknowledging this group when completing an assessment. These challenges are consistent within the clinical setting, from observation within the role of a clinical educator working in the Neuroscience speciality. A selection of patients who were dysphasic, did not speak English, or hearing impaired were observed in clinical practice to be scored as ‘Confused’ or ‘None’ in ‘Best verbal response’. This response was not considered as appropriate or demonstrate clinical reasoning. Therefore, and reflected in clinical practice, staff did not have the appropriate knowledge to confidently and accurately assess a patients’ neurological status. A paper written by Reith et al. (2016) and Braine and Cook (2016) confirms frequent variation and confusion in aspects of ‘Best motor response’ when assessing response to painful stimuli. Anecdotally, in discussion with clinicians, it is reported that inflicting pain to patients, and common confusion on what site is preferred, is a barrier to performing this section correctly. The challenges faced by clinicians specialising in Neurosciences is further supported by Heron et al. (2001) in that only 35% of nurses correctly assessed ‘Best motor response’.

The literature, and observed practice, demonstrates a change to clinical practice was required and as a result a thorough review of the literature, in conjunction with collaborating with tertiary hospitals was undertaken. Javvaji et al. (2022) reveals the importance of an education approach that follows a clear, standardised method of learning. Visiers-Jimenez et al. (2020) states that fostering a positive learning environment allows for clinicians to feel competent and confident in performing skills. Equally, it is imperative to ensure standardisation of teaching and learning; this can be achieved with the appropriate governing documents. Collaboration with a select, few, hospitals in Australia was undertaken and four out of seven hospitals did not have a ‘Neurological Assessment’ policy available. Hole (2020) states the importance of policies and procedures, and support how clinical governance supports nurses to engage in evidence-based practice and therefore enhances the capability of clinicians.

To ensure a consistent and standardised approach, stakeholders were notified for their expert, speciality knowledge to appraise the revised policy. This group included senior nurses working in the clinical ward area, Nurse Unit Managers and medical colleagues within in the Neuroscience division. The Clinical Education team worked to ensure all learning modules were reviewed to meet the need of the new policy, and staff were informed of the key changes by frequent education sessions within the organisation. There were several changes made to our processes, including revised terminology and a thorough review of confounding factors that would impact the GCS score and assessment. The alterations in the policy were adequately supported by the target group and clinicians have found the information to be consistent, and supportive of patient care. It is recommended that nurses in speciality areas regularly review the literature to ensure that patients receive high quality evidence-based care.

Neurological Assessment is utilised throughout the world, as a reliable tool to assess consciousness and neurological deterioration (Javvaji et al. 2022). Health professionals rely on this assessment tool in the clinical setting, to identify trends of deterioration and to evaluate health interventions (Ehwarieme & Anarado 2016). It is imperative that staff using this tool are confident and competent to prevent inaccuracies in assessment (Derbyshire & Hill, 2018). A study performed by Ehwarieme and Anarado (2017) revealed that 76% of staff have not used, or have any confidence in using, the GCS. The results from this study support current clinical practice amongst clinicians in a neuroscience ward at a metropolitan Hospital in Melbourne. It was critical that educators at this site acknowledged current gaps in practice and translation to clinical care. Performing this assessment is commonly undertaken by nurses, doctors and allied health professionals. Thus, education was primarily targeted to this audience (Ehwarieme & Anarado 2016). Frequent observation and feedback from senior clinicians revealed that junior nursing staff required further support to feel confident in performing a neurological assessment. An education and training restructure was conducted, with support of the research, to ensure staff felt competent to assess patients. As discussed, a comprehensive review and update of the organisation policy was undertaken which supports staff to independently provide quality patient care without senior colleagues in attendance. A dynamic, and interactive, e-learning module was developed prior to this review, which aims to support theoretical knowledge and measures competence through the form of a quiz. Additionally, staff will receive a one-hour workshop on the fundamentals of the neurological assessment; this is measured through a practical assessment at the bedside where staff are observed, and given feedback on their practice, in real time. This session is designed to support learners with alternate learning styles to ensure learning outcomes are met (Zarandona et al. 2019). Frequent competency assessments are supported and encouraged to ensure a standardised approach to Neurological Assessment (Maserati et al. 2016). Additional methods used to promote confidence and competence, is encouraging staff to resource senior clinicians when unsure, or to have a second staff member perform the assessment to confirm a potential deterioration (Hoban 2017).

The GCS has been identified as a highly valid tool in predicting outcome in neurological conditions such as acute stroke or subarachnoid haemorrhage, as well as having good interobserver reliability (Ehwarieme & Anarado, 2017; Javvaji et al., 2022). However, Reith et al. (2016) express concerns that with time, the widespread use of the scale has been accompanied by variation in technique and consequently variation in reliability of its use. In a questionnaire-based study by Reith et al. (2016) 78% of participants reported using a standardised approach for applying a stimulus, 62% of participants assessed both arms and legs in completing the GCS and 37% assessed the GCS by the arms only, reflecting significant variation in application of a painful stimulus (Reith et al., 2016). A survey undertaken by Maserati, Fetzick and Puccio (2016) discusses how reliability and accuracy of assessment, varies between clinicians from different specialities and level of clinical experience. Thus, the need for thorough education and assessment of clinicians completing neurological assessment. Reliability of the neurological assessment is critically important, as discrepancies or inaccuracies in the assessment could result in miscommunication and suboptimal care. Studies reviewing the reliability of the scale have been undertaken since the introduction of the GCS with variable results. Previous studies report consistent application of the GCS is key to reliability of the GCS assessment (Reith et al., 2016).

Clinicians frequently performing Neurological Assessment should be regularly reviewing evidence-based practice to ensure high quality care. Further research is required to examine the longitudinal impact of implemented education strategies to reveal the confidence of nurses performing Neurological Assessment. Education strategies such as a practical workshop, implementation of an e-learning module and practical assessment in the clinical setting has proven to be effective in consistent assessment (Maserati, Fetzick & Puccio, 2016). It is additionally encouraged for staff to provide regular feedback to their colleagues; peer feedback is utilised to promote growth, strengthen workplace culture and to improve patient care (Rocco et al. 2020). To effectively ensure a positive learning environment, it is recommended to alter teaching methods to meet all learning styles. This is reflected in Campos et al. (2020) research, that reiterates the importance to utilise various learning styles to support learners nursing practice.