A STUDY ON LEVEL OF KNOWLEDGE AND INTERPRETATION SKILL OF GCS

ASSESSMENT AMONG PARAMEDIC IN PUSAT PERUBATAN UNIVERSITI

KEBANGSAAN MALAYSIA

ADAM KOH GUAN HONG

MOHD RASHEEDI BIN ROMAINOR
AHMAD ZAKI BIN ABDUL HALIM
MOHD ZAMZURI BIN OMAR

THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE

DEGREE OF BACHELOR OF SCIENCE IN EMERGENCY MEDICINE WITH
HONOURS

BSc. Em.Med (Hons)

FACULTY OF MEDICINE
NATIONAL UNIVERSITY OF MALAYSIA

2015
 SATU KAJIAN TERHADAP TAHAP PENGETAHUAN DAN KEMAHIRAN
INTERPRETASI PENILAIAN GCS DIKALANGAN PARAMEDIK DI PUSAT
PERUBATAN UNIVERSITI KEBANGSAAN MALAYSIA

ADAM KOH GUAN HONG

MOHD RASHEEDI BIN ROMAINOR
AHMAD ZAKI BIN ABDUL HALIM
MOHD ZAMZURI BIN OMAR

TESIS YANG AKAN DIKEMUKAN UNTUK MEMPEROLEHI IJAZAH

SARJANAMUDA SAINS PERUBATAN KECEMSAN DENGAN KEPUJIAN
BSc. Em.Med (Hons)

FAKULTI PERUBATAN
UNIVERSITI KEBANGSAAN MALAYSIA

2015

II
 DECLARATION

We hereby declare that the work in this thesis is our own except for quotations and summaries
which have been duly acknowledge.

FEB 2015 ADAM KOH GUAN HONG

A143770
MOHD RASHEEDI BIN ROMAINOR
A143779
AHMAD ZAKI BIN ABDUL HALIM
A143781
MOHD ZAMZURI BIN OMAR
A143780

III
 ACKNOWLEDGMENT

All praise and gratitude to the Almighty. With His grace we finally complete this study
despite the many challenge and tribulations endured.

First of all we would like to take this opportunity to express our appreciation to whole
working and management staff of Emergency Department Pusat Perubatan Universiti
Kebangsaan Malaysia given us many cooperation to complete this study. Million thanks to
our supervisor, Prof. Dr. Mohd Johar Bin Jaafar who always give us full support and guidance
to finish this study. As a supervisor he spends plenty of time with us just to make sure this
study is successfully completed. We would also like to express our thankful to our co-
supervisor the study Prof. Dr. Hj. Ismail Mohd. Saiboon for his willingness and guidance.

Besides Dr. Husyairi Harunarashid, Dr. Zuraidah Che Man, Mrs. Nurul Saadah Ahmad from
Centre of Research in Emergency Medicine (CREM), Miss Anne A/P Albert our clinical
instructor for giving us some valuable advice and tips along the pathway to completed this
study and spends lots of her time to give us guidance. We would also like to thank Ihsan
Mattar from National University of Singapore, Dr.Vengkata Prathap Emergency Specialist
from Hospital Banting, Mr. Balakrishnian Muniandy from Department of Emergency
Medicine PPUKM, Mr. Abdul Karim Mustafa from Pre Hospital Care Unit PPUKM, and all
paramedics who supported and participate in this study.

The Ethical Committee of Universiti Kebangsaan Malaysia (UKMMC) for giving us

permission to conduct this study. We also dedicate this study to our wife and family for being
our sources of inspiration and give support when in need.

Last but not least, our sincere thanks to any individuals involved directly or indirectly
in assisting for the success of our research project. May Allah bless all of you, thank you.

IV
 Abstract

The Glasgow Coma Scale (GCS) is an important parameter to assess and detect deterioration
in a patient’s consciousness level in an Emergency Department. It is a universal tool used by
all health care personnel to transfer a message regarding the level of consciousness in a
patient. Thus the knowledge of GCS scoring is fundamental among paramedics. This study is
aimed at determining the level of knowledge and interpreting skill regarding GCS. A cross
sectional study involving 40 paramedics (Assistant Medical Officers) in clinical setting was
conducted in The Emergency Department and Pre-hospital Care unit at Pusat Perubatan
Universiti Kebangsaan Malaysia. There are two sections in this study, participants were
required to answer a questionnaire and interpret the Glasgow Coma Scale score through
simulated videos in a controlled environment. The data were collected and analyzed using
SPSS 22.0. 40 Paramedics participate in this study. The ratio of males to females were 2:1
with a majority having about more than 10 years of working experience. Results have
demonstrated that 2.5% (n=1) had good level of knowledge of GCS and 30% (n=12) had good
interpretation skill of GCS.A chi-square test for association between good level of knowledge
and good interpretation skill of GCS were insignificant (P ~ 0.3). This study demonstrates that
paramedics need to enhance their knowledge and interpretation skills of GCS. Developments
into the standard of teaching methods and simulation training should be look into to achieving
this goal or perhaps an option to replace GCS should be introduce.

Key words: Glasgow Coma Scale, Paramedic, Assistant Medical Officer, Emergency
Department, Pre-hospital Care unit, Knowledge of GCS, Interpretation Skill of GCS,
Simulated Video.

V
 Abstrak

Skala koma Glasgow (GCS) merupakan salah satu parameter penting bagi menilai dan
mengenalpasti kemerosotan terhadap tahap kesedaran pesakit di Jabatan Kecemasan. Ia
merupakan salah satu kaedah universal yang digunakan oleh semua kakitangan kesihatan
bagi menggambarkan tahap kesedaran pesakit. Oleh yang demikian, pengetahuan tentang
pemarkahan Skala Koma Glasgow adalah suatu perkara asas dikalangan paramedik. Kajian
ini adalah bertujuan bagi menentukan tahap pengetahuan dan kemahiran dalam mentafsir
Skala Koma Glasgow. Satu kajian rentas yang melibatkan 40 orang paramedik (Penolong
Pegawai Perubatan) yang menjalankan tugas klinikal telah dijalankan di Jabatan Kecemasan
dan Unit Rawatan Pra-hospital, Pusat Perubatan Universiti Kebangsaan Malaysia. Kajian
ini merangkumi dua bahagian dimana setiap paramedik dikehendaki menjawab soalan-
soalan kaji selidik dan mentafsir permarkahan Skala Koma Glasgow melalui tayangan
simulasi video didalam persekitaran yang terkawal. Setiap data dikumpulkan dan dianalisa
dengan menggunakan perisian Statistical Package for the Social Sciences (SPSS 22.0). 40
orang Paramedik telah mengambil bahagian didalam kajian ini. Nisbah lelaki berbanding
wanita adalah 2:1 dengan majoritinya mempunyai pengalaman bekerja <10 tahun.
Keputusan menunjukkan 2.5% (n = 1) mempunyai tahap pengetahuan tentang GCS yang baik
dan 30% (n = 12) boleh mentafsir GCS dengan baik. Ujian chi-kuasa dua bagi menentukan
hubungan diantara tahap pengetahuan yang baik dan kemahiran mentafsir GCS yang baik
adalah tidak signifikan (P~0.3). Kajian ini menunjukkan bahawa paramedik perlu
meningkatkan pengetahuan dan kemahiran dalam mentafsir GCS. Penambahbaikan didalam
kaedah pengajaran dan latihan simulasi harus dilakukan dalam mencapai matlamat ini atau
satu kaedah lain perlu diperkenalkan bagi menggantikan GCS.

Kata Kunci: Skala Koma Glasgow, Paramedik, Penolong Pegawai Perubatan, Jabatan
Kecemasan, Unit Perawatan Pra Hospital, Pengetahuan Tentang GCS, Kemahiran Mentafsir
GCS, Simulasi Video.

VI
 LIST OF ABBREVIATION

Emergency Department ED

Pre-hospital Care PHC

Glasgow Coma Scale GCS

Traumatic Brain Injury TBI

Pusat Perubatan Universiti Kebangsaan Malaysia PPUKM

Eye opening response E

Best Verbal response V

Best Motor response M

Population Size N

Sample size S

Frequency n

Percentage %

And &

Or /

Smaller than <

Bigger than >

VII
 CONTENT

CHAPTER 1 INTRODUCTION

1.1 Introduction
1.2 Objectives
1.3 Hypothesis

CHAPTER 2 LITERATURE REVIEW

2.1 Literature review

CHAPTER 3 METHODOLOGY

3.1 Research methods

3.2 Sampling size calculation

3.3 Inclusion criteria

3.4 Exclusion criteria

3.5 Statistical analysis

3.6 Flow chart of the overall study process

3.7 Flow chart of the data collection process

CHAPTER 4 RESULT

4.1 Subject Demographic

4.2 Section B

4.3 Section C

CHAPTER 5 DISCUSSION

VIII
5.1 Discussion on Results

5.2 Limitations

CHAPTER 6 CONCLUSION AND RECOMMENDATIONS

6.1 Conclusion and Recomendation

REFERENCES

APPENDIX

CHAPTER I

IX
1.1 INTRODUCTION

Measuring a patient’s mental status is one of the essential component in patient assessment.
Mental status or level of consciousness can be measured using the Glasgow Coma Scale
(GCS), which was first introduced by Jennet and Teasdale (Teasdale&Jennett 1974) at the
University of Glasgow. Since 1974, GCS scoring has become the standardized and widely
used tool in patient assessment for level of consciousness.

GCS consists of assessing three different components which are eye response, verbal
response and motor response. The minimum GCS score is 3 wherereas maximum score is 15.
GCS score broadly use to assess level of consciousness in both medical and trauma adult
patient unfortunately it is unreliable in pediatric patient. Hence there is a modified pediatric
GCS score.

Currently GCS scoring is a crucial assessment and it is used as a guide for delivering
patient care. In Emergency Medicine, GCS scoring is a reliable and objective way to
document the initial and subsequent level of consciousness in a patient. This is an important
parameter to observe in a patient as early as from the first contact with the patient, which is at
the pre-hospital care or at the triage counter up to the resuscitation room or definitive care
because altered level of consciousness may present as the first sign of deterioration.

Paramedic must have an adequate knowledge in evaluating GCS accurately and

efficiently in their clinical practices (Addison&Crawford 1999). Inaccurate assessment of
GCS scoring may result in delay of treatment and further deterioration of the patient’s
condition. In addition a proper assessment and documentation of GCS scoring should be
practiced by all paramedic because monitoring and observing the level of consciousness in a
patient is part of the patient care management and delivering treatment. This is especially vital
for patients with traumatic brain injury (TBI) whereby the paramedics are able to determine
the severity of the patient’s condition.

In Malaysia paramedic are the first line health care personnels that a patient firstly
reaches to. This is true because in pre-hospital care (PHC) services, emergency departments

X
(ED), and 1 Malaysia clinics nationwide are generally operated by paramedic. Thus the
knowledge of GCS scoring is extremely important. GCS scoring is a universal tool used by all
health care personnels to transfer message regarding a patient’s general condition, especially
the level of consciousness. For example, transferring messages on patient’s level of
consciousness from the PHC units or the triage counter, gives a clear picture to the receiving
health care facility, ie the ED for further management of patient care.

1.2 Objective

XI
This study is to determine the level of knowledge and the ability of interpreting skills in
Glasgow Coma Scale (GCS) assessment among the paramedic in the Emergency Department
(ED) and Pre-Hospital Care (PHC) unit of Pusat Perubatan Universiti Kebangsaan Malaysia
(PPUKM).

1. To determine the level of knowledge in GCS assessment among the paramedic.

2. To determine the ability of GCS interpreting skill through video simulation among the
paramedic.
3. To determine the relationship between the level of knowledge and the ability of GCS
interpreting skill among the paramedic.

1.3 Hypothesis

1. More than 90% of the paramedic will achieve a score of 100% in the level of
knowledge assessment, equivalent to good knowledge of GCS.
2. There is an association between the level of knowledge and the accuracy of GCS
assessment among the paramedic.

CHAPTER 2

XII
2.1 Literature review

Assessment of Glasgow Coma Scale (GCS) is a broadly used tool in emergency

medicine in assessing a patient’s level of consciousness. It is used as early as in the first
contact to the patient, which is from the pre-hospital care setting and the message is
transferred to the receiving health care facility or emergency department (ED). It is composed
of three types of response components and each are scored independently, which are eye
opening - maximum of 4; best verbal response – maximum of 5; and best motor response–
maximum score of 6 (Table 1). The lowest score for each category is 1, therefore the lowest
score is 3 and the overall value ranging from 3 – 15. The total score of GCS will be presented
as symbol E for eye, V for verbal, and M for motor. In general a GCS of 8 or less indicates
severe injury, score of 9-12 is moderate injury, and 13-15 is obtained when injury is minor.

Table 1: Glasgow Coma Scale (Adult)

Eye opening - 4
Spontaneous 4
Open to verbal stimulus 3
Open to painful stimulus 2
No response 1
Best verbal response - 5
Orientated 5
Confused 4
Inappropriate words 3 GCS
Incomprehensible sounds 2 scoring was initially
No response 1 created to provide a
Best motor response – 6 scoring system for
Obey command 6 the serial evaluation
Localized pain 5 of adult with severe
Withdrawn to pain 4 blunt head
Decorticate posture (an abnormal posture that can include injury(Teasdale&Je
rigidity, clenched fists, legs held straight out, ad arms bent nnett 1974).
3
inward toward the body with the wrists and fingers bend and However, it is not
held on the chest) applied to young
Decerebrate (an abnormal posture that can include rigidity,
arms and legs held straight out, toes pointed downward, 2
XIII
head and neck arched backwards)
No response 1
children particularly those who have unreliable language skills. Thus, a Pediatric Glasgow
Coma Scale (PGCS) is a modified and reliable scale (Holmes et al. 2005) used in young
children (Table 2) instead of the commonly Glasgow Coma Scale (GCS) used on adults.

Table 2: Glasgow Coma Scale (Modified for pediatric)

Eye opening - 4
Spontaneous 4
Open to voice stimulus 3
Open to painful stimulus 2
No response 1
Best verbal response - 5
Smiles, oriented to sounds, follow objects, interacts 5
Cries but consolable, inappropriate interactions 4
In 2006 a
Inconsistently inconsolable, moaning 3
prospective
Inconsolable, agitated 2
observation study
No response 1
by Holdgate et al
Best motor response – 6
found that there is
Move spontaneously or purposefully 6
no difference in
Withdraws from touch 5
interpretation of
Withdraws from pain 4
GCS between the
Decorticate posture (an abnormal posture that can include
senior doctors and
rigidity, clenched fists, legs held straight out, ad arms bent
3 the nurses. Thus,
inward toward the body with the wrists and fingers bend and
the finding showed
held on the chest)
that the level of
Decerebrate posture (an abnormal posture that can include
agreement for GCS
rigidity, arms and legs held straight out, toes pointed 2
was generally high
downward, head and neck arched backwards)
and did not vary
No response 1
much between both
groups. Hldgate et al concluded that the GCS is a good tool for measuring patient mental
status and can be perform by all trained health care worker.

In terms of accuracy of GCS assessment, working experience had been found to be

more reliable in guiding health care personnel in their assessment. Improvement in skills can

XIV
be achieved from training and repetition of practice. In 2013, Chan et al. conducted a study to
investigate factors that have impact on nurses’ performance of patients’ conscious level and
found that knowledge and working experience to be the most significant determinants in
nurses’ performance of patients’ GCS scoring.

In a different study to explore the nurses’ knowledge in using the GCS was done in
Singapore by Mattar et al. in 2013 found that there is a great difference in knowledge of the
GCS scoring between the nurses of different demographics such as working experience and
work place discipline. The result found that nurses in neuroscience wards had a better
knowledge and understanding of the GCS compared to nurses working in general medicine
wards. In addition, those who had working experience greater than 6 years achieved
significantly better scoring in the questionnaire paper.

As a standardized tool used for assessment in the level of consciousness, the GCS also
came with its own set of challenges. GCS has a high validity and sensitivity to changes in
level of consciousness (Bazarian et al. 2003). In the hands of inexperienced health care
personnel error in interpretation can easily accrue even for such a simple tools. As sometimes,
interpretation can vary differently from person to person. Namiki et al. in 2011 found that
more than 25% of physicians taken as a sample in the study was unable to correctly interpret
the GCS scoring based on the video simulation that were shown during the study.

Another study conducted by Winship et al in 2013 concluded that the undergraduate

paramedic students from Australian university were unable to assess GCS accurately if the
patient’s GCS score was lower then 14. However more than 85% participants are able to
accurately interpret a GCS score of 14 and above which basically reflect a normal healthy
person without any problem. The result from this study demonstrated the motor response
component of the GCS is the least accurately interpretated, This may be due to lack of
experience and exposure that led to the misjudgment of the reaction response.

Undergraduate degrees and basic diplomas demonstrated better accuracy in assessing

GCS compared to nurses who were working in critical care service and possessed critical care
subspecialty training. (Heron et al. 2001) In this study the researcher didn’t elaborate on the
factors of why undergraduate degrees and basic diplomas were more accurate in assessing
GCS as compared to nurses with critical care qualifications. One interpretation from this

XV
result is that those with training and experience can some time be less cautious in their
interpretation leading to misjudgment in GCS scoring.

CHAPTER 3

3.1 RESEARCH METHODS

This is a cross sectional study.

Ethical consideration

Consent obtained and researcher explained the nature and purpose of the study to the
participants. Data was collected following the approval from the Ethics Commitee. The
approval code research is FF-2015-147.

Setting

Emergency Department (ED) and pre-hospital care (PHC) unit Pusat Perubatan UKM from
June 2015 – July 2015 (2 months).

Study tools

XVI
The study involves of the questionnaire and video simulation of assessment of GCS score:

A) To determine the knowledge of GCS through a set of questionnaire that was given to the
participant. The questionnaire consists of:

Section A: Demographic data consists of closed ended questionnaire which the participant is
asked to select from a fixed answer thats given. Data on demographic information included
gender, age, staff grade, level of education, having an advanced diploma or post basic
education, length of time in the emergency and pre-hospital discipline, any formal training on
GCS pre-registration and post registration.

Section B: The second part is to determine the knowledge of GCS with a total of 15 questions
adopted and set by the researchers.

The total of questions answered correctly were converted to percentage and grading was given
accordingly as stated in Table 3.

Grading Good knowledge Insufficient knowledge

Mark % 100% Less than 100%

Table 3: Grading System

B) Section C consist of video simulation and the participants are required to fill up their
answers on the answer sheet provided in the questionnaire after watching each video. This
section is to determine the ability on interpreting skill of GCS. The video contains of:

Six video simulations mock portrayed by a health care personnel as the GCS assessor and a
simulated patient with different GCS score set by the researchers. The video were developed

XVII
in Bahasa Melayu as a language of choice to exclude bias since it is the national language for
Malaysian where this study was conducted. Participants were required to answers on the sheet
provided in the questionnaire after watching each video. The total number of video answered
correctly were converted to percentage and grading was given according as based on table 4.

Video 1: objective to simulate a patient with Glasgow Coma Scale of 15/15 (E4, V5, M6)

Video 2: objective to simulate a patient with Glasgow Coma Scale of 14/15 (E3, V5, M6)

Video 3: objective to simulated a patient with Glasgow Coma Scale of 10/15 (E2, V3, M5)

Video 4: objective to simulate a patient with Glasgow Coma Scale of 7/15 (E1, V2, M4)

Video 5: objective to simulate a patient with Glasgow Coma Scale of 6/15 (E1, V2, M3)

Video 6: objective to simulate a patient with Glasgow Coma Scale of 4/15 (E1, V1, M2)

Grading Good ability Insufficient ability

Mark % 100% Less than 100%

Table 4: Grading System

Data collection methods

Information sheets were given to the participants prior to the study. Upon participant
agreement to participate in this study, a consent form was given to the participant for
documentation purposes. Questionnaires distributed to the participants in a controlled
environment with the ratio researcher to participant 1:2. After completing section A and B,
participants were required to watch a video of 6 mock simulations and state their GCS scoring
in section C and no correction should be attempted once the next video has been proceeded.
Participants were advised not to share or discuss with their peers during the session. Upon
completion, these questionnaires were collected by the researchers. All information gathered

XVIII
from participants was kept private and confidential. Data were collected during the continuous
medical education (CME) and after working hours to minimize the interruption of
participants’ normal working schedule.

3.2 SAMPLING SIZE CALCULATION

The core design of this study is based on a cross-sectional methodology. The sample size
calculation is based on obtaining representativeness of the population in question. The
following formula for sample size calculation for a definitive population was used
(Krejcie&Morgan 1970) with the estimation of proportion of subjects with good GCS
knowledge and skills expected to be 50%.

S = [χ² NP (1 – P)] ÷ { [d² (N – 1)] + [χ² P(1 – P)] }

Where

S = sample size

χ = for df = 1, it is equal to 3.841

N = population size (known=60)

P = population probability (whereby 0.5 is the maximum sample size)

XIX
 d = 0.05

S = [1.96² x 60 x 0.5 (1 – 0.5)] ÷ { [0.05² (60 – 1)] + [1.96² x 0.5 (1 – 0.5)] }

= 50

3.3 INCLUSION CRITERIA

All paramedics (assistant medical officers only) with at least a diploma in medical assistant
and work in ED and PHC unit.

3.4 EXCLUSION CRITERIA

1. All paramedics that are not involved directly in clinical management of patient care in
the ED and in the PHC unit.

2. All paramedics who are in the process of undergoing further study.

3.5 STATISTICAL ANALYSIS

Statistical analysis was conducted by using the SPSS 22.0. Descriptive analysis was used for
demographic data, section B and C. For the correlation between the level of knowledge and
interpreting skill of GCS, Chi Square analysis (Fisher exact test) was used to determine the
association. A P value < 0.05 were considered significant.

3.6 FLOW CHART OF THE OVERALL STUDY PROCESS

Research methods developed

Questionnaire and video simulation were

designed

Validation and reliability for the questionnaire

and video simulation were conducted

Ethical approval obtained

Questionnaire distributed and data collected in a

controlled enviroment
XX

Data was analysed

3.7 FLOW CHART OF THE DATA COLLECTION PROCESS

Randomized select the participant

Explained the nature of the study and obtained

consent

Study ran in a controlled environment (room)

questionnaire distributed

Participant required to answered section A and B

After completing section A and B, video

simulation started.

Participant state their answer in section C after

each video. No correction should be attempted
once the next video proceeded XXI
 Upon completion, these questionnaires were
collected by the researchers

Data analyzed

CHAPTER 4

4.1 Subject demographic

A total of 60 paramedics met the inclusive criteria, 40 paramedics agreed to be recruited for
this study. Of these, the ratio of male to female paramedics were 2:1. The age of the
participants were approximately between 20 to 35 years with 22.5% of paramedics coming
from Pre Hospital units (9 paramedics) and 77.5% of paramedics came from Emergency
Department (31 paramedics). Out of the total, 35 paramedics were Diploma holder (Grade
U29) while five others were Degree holders (Grade U41). Nine participants had done their
Post Basic studies in Emergency Medical Care, one participants had done his Post Basic in
Sport Medicine while others did not have any Post Basic Certificate. Two participants had
more than 10 years of experience in the service, 15 participants had between five to ten years’
experience as paramedics while the others had less than five years of working experience.
Demography data of the study participants are shown in Table 1.

XXII
 Table 1: Demography Data of The Studied Participant (n=40).

4.2 Section B

2.5% (one paramedic) from the study population were able to score 100% in this section
demonstrating good knowledge in GCS assessment. This paramedic works in The Emergency
department and has less than 10 years of service experience. As many as 39 paramedics
(97.5%) did not manage to archive 100% score in this section revealing an insufficient
knowledge in GCS assessment 97.5% from the study population. Distributions of scores in
section B are between 60% to 79% as demonstrated in Figure 1. Table 2 demonstrates
distribution of correct and incorrect answer in this section.

XXIII
 Figure 1: Distribution of Score in Section B (n=40).

Table 2: Distribution in (%) for Correct and Incorrect Answer In Section B (n=40).

XXIV
4.3 Section C

XXV
In section C of the assessment, paramedics attempted to do GCS interpretation using a video
simulation, a total of 12 paramedics equal to 30% from the study population were able to
100% accurately interpret the GCS video simulation. 28 paramedics were unable to 100%
accurately interpret the GCS video simulation making up about 70% of the total paramedics
evaluated. This is shown on Table 3.

Table 3: Total Score In GCS Interpretations using Video Simulation.

Overall Score In Frequenc Percentag

Section C y (N) e (%)

Score 100 % 12 30

Score less than 70

100% 28

100
Total 40

In video one where GCS 15/15 is simulated, all participants were able to accurately interpret
the simulation. Video two simulated a GCS of 14/15, 85% of the study population were able
to accurately interpret the simulation while 15% were not. Video three simulated a GCS
10/15, 62.5% score wrongly while 37.5% were able to accurately interpret the video. In video
four where GCS 7 was demonstrated, 60% of the study population were able to score 100%
compare to the other 40% who failed to do so. GCS 6/15 was simulated in Video five where
67.5% were able to correctly interpret while 32.5% were not able to do so. Finally, Video six
simulate GCS 4/14, out of total of study population 87.5% were able to score correctly
leaving the balance 12.5% unable to accurately interpret the simulation. This is demonstrated
in table 4.

XXVI
 Table 4: Distribution of Individual Video Score in Section C.

Accurate GCS score Inaccurate GCS score

Frequency Percentage Frequency Percentage

(N=40) (%) (N=40) (%)

Video 1 40 100 0 0

Video 2 34 85 6 15

Video 3 15 37.5 25 62.5

Video 4 24 60 16 40

Video 5 27 67.5 13 32.5

Video 6 35 87.5 5 12.5

As each video was divided by component of GCS scoring, here are the result of each video
fragment based on Eye, Verbal and Motor. Table 5 represents the percentage score that was
achieved by the paramedic population distributed by the component of GCS scoring, while
Figure 2 represent distribution of score in percentage for section C were majority of
paramedics score between 80% to 100%.

XXVII
 Table 5: Distribution of Score base on GCS Component in Section C.

Section C Eye Verbal Motor

Components Accurate Inaccurate Accurate Inaccurate Accurate Inaccurate

Frequency Frequency Frequency Frequency Frequency Frequency

(n=40) (n=40) (n=40) (n=40) (n=40) (n=40)
(%) (%) (%) (%) (%) (%)

Video 1 40 0 40 0 40 0
(E4, V5, M6) (100%) (0%) (100%) (0%) (100%) (0%)

Video 2 35 5 39 1 40 0
(E3, V5, M6) (87.5%) (12.5%) (97.5%) (2.5%) (100%) (0%)

Video 3 35 5 20 20 32 8
(E2, V3, M5) (87.5%) (12.5%) (50%) (50%) (80%) (20%)

Video 4 40 0 34 6 29 11
(E1, V2, M4) (100%) (0%) (85%) (15%) (72.5%) (27.5%)

Video 5 40 0 35 5 30 10
(E1, V2, M3) (100%) (0%) (87.5%) (12.5%) (75%) (25%)

Video 6 40 0 40 0 35 5
(E1, V1, M2) (100%) (0%) (100%) (0%) (87.5%) (12.5%)

XXVIII
 Figure 2:

Relationship between the level of knowledge and accuracy of GCS assessment among
paramedics.

Analyses were done using Chi Square analysis (P > 0.05) as demonstrate in table 6.

Table 6: Chi Square Analysis (Fisher’s Exact Test)

Total score in
Section B

Score 100% (n) Score <100% Frequency (n)

(n)

Total score Score 100% (n) 1 11 12

section C

Score <100% 0 28 28
(n)

Total 1 39 40

Chi Square analysis P ~ 0.300 (P > 0.05)

XXIX
 CHAPTER 5

5.1 Discussion on results

Since it was introduced in 1974 by Teasdale & Jennett, the GCS assessment had been used by
variety of professions including Doctors, Paramedics, Nurses and even First Aiders all around
the world as a tool to assess patient conscious level. Its limitations, however includes variable
interpretations amongst paramedics, time and setting for the rating (Adeleye et al. 2012,
Bryan J. 2002). Although it comes with limitations, GCS had endured for many years as the
most globally used scoring system, simple to apply and to reach it’s objective (Stuke et al.
2007, Gabbe et al. 1974). There is recent evidence suggesting that GCS scoring is often
inaccurate (Bledsoe et al. 2015) however this scoring method is easily communicable among
physicians, and helps in taking decisions on the treatment modality for patients with head
injury (Gill et al. 2004, Fischer et al. 2008).

Our study involves paramedic populations from both Emergency Department and Pre
Hospital Unit from UKM Medical Center which is similar with a study published by
Menegazzi et al in 1993 and Kerby et al. in 2007. The majority had less than 5 years of
working experience (70%) with a mode range of age from 26-30 years old having a diploma
education level.

In the assessment of knowledge using the questionnaire (Section B), more than 90% of
the participant possesses good knowledge in minimum and maximum scoring of GCS as
observed in question 2, 3 and 10. They were also able to define the GSC scoring label
“comatose” which is usually observed in patients with severe head injury. Participants also
were able analyze questions about verbal scoring that had been demonstrated in section B
exceptionally. However, inaccuracy of more then 60% was observed in questions 6 that is
related with motor scoring and assessment of GCS in patients under alcohol influence.

The result from video simulations show that paramedics were able to recognize ‘high’
level and ‘low’ level GCS scores but were unable to accurately score mid level GCS
simulation. These findings were almost corresponds with research done by Winship et all. in
2012 located at Monash University Australia. It is also observed that 50% of paramedics from
the study population incorrectly scored GCS verbal score of 3. Significant inaccuracy also

XXX
observed in GCS motor scoring in which 27.5% score incorrectly for motor score of 4, 25%
score incorrectly for motor score of 3 and 20% score incorrectly for motor score of 5. It is also
perceives that verbal component of GCS poses its own interpretation challenges when 50% of
paramedic from this study was unable to interpret verbal score of 3. These findings were
similar with the research results from Namiki et al.in 2011 when they compare interpretation
of GCS score by physicians who participated in their study and found verbal and motor score
were the components that usually inaccuracy accrues.

From the study result of this study it is observed that although GCS scoring was
known by many, interpretation varies by person and is often inaccurate especially in
identifying low verbal and motor scores. This is proven by the fact that although most of the
study populations were able to remember the component of GCS scoring marking but during
interpretation of video simulation inaccuracy occurs. This could be due to a variety of
teaching methods to GCS interpretation where no international standard had been achieved.
Therefore, an alternative teaching approach in enhancing the understanding of GCS should be
researched and developed for GCS to remain significant in the future. The question also arises
as to whether an alternative option to GCS should be practice? One of practical options aside
from GCS is the AVPU method that had been found correlate significantly with GCS and
provide fast and simple conscious level assessment (Kelly et al.). Some physicians might
favor one against the other when it comes to GCS vs. AVPU but a standard teaching first
should be achieved in this country in ensuring the correct syllabus is delivered into practice.

XXXI
5.2 Limitations

This study was conducted in only one hospital the result may not reflected to other hospitals
in Malaysia.

XXXII
 CHAPTER 6

6.1 Conclusion and Recommendations

This study that was done involving paramedics from pre hospital care unit and emergency
department from UKM medical center reveal that paramedics were able to interpreted with
accuracy in extremes high and low GCS. It is also observed that only one paramedic out of
the entire study population was able to score the highest knowledge score in the assessments
given. The motor and verbal component as shown in other studies remains to be a challenging
fragment of GCS scoring and method in countering this dilema should be study. It would
appear a different approach in GCS education for paramedics should be explores or an
alternative to GCS scoring should be research and developed.The mothod of using AVPU
scoring seams promesing base on other study that had allredy been conducted but deeper
reserch need to be conducted before it could be used widely.

XXXIII
REFERENCES

Addison, C. & Crawford, B. 1999. Not Bad, Just Misunderstood. Nursing times 95(43):
52.

Bazarian, J. J., Eirich, M. A. & Salhanick, S. D. 2003. The Relationship between Pre-
Hospital and Emergency Department Glasgow Coma Scale Scores. Brain Injury
17(7): 553-560.

Chan, M. F., Mattar, I. & Taylor, B. J. 2013. Investigating Factors That Have an Impact on
Nurses’ Performance of Patients’ Conscious Level Assessment: A Systematic Review.
Journal of Nursing Management 21(1): 31-46.

Heron, R., Davie, A., Gillies, R. & Courtney, M. 2001. Interrater Reliability of the Glasgow
Coma Scale Scoring among Nurses in Sub-Specialties of Critical Care. Australian
Critical Care 14(3): 100-105.

Holdgate, A., Ching, N. & Angonese, L. 2006. Variability in Agreement between

Physicians and Nurses When Measuring the Glasgow Coma Scale in the Emergency
Department Limits Its Clinical Usefulness. Emergency Medicine Australasia 18(4):
379-384.

Holmes, J. F., Palchak, M. J., Macfarlane, T. & Kuppermann, N. 2005. Performance of the
Pediatric Glasgow Coma Scale in Children with Blunt Head Trauma. Academic
Emergency Medicine 12(9): 814-819.

Ingram, N. 1994. Knowledge and Level of Consciousness: Application to Nursing Practice.

Journal of advanced nursing 20(5): 881-884.

Jones, C. 1979. Glasgow Coma Scale. AJN The American Journal of Nursing 79(9): 1551-
1557.

XXXIV
Krejcie, R. V. & Morgan, D. W. 1970. Determining Sample Size for Research Activities.
Educ Psychol Meas.

Mattar, I., Liaw, S. Y. & Chan, M. F. 2013. A Study to Explore Nurses' Knowledge in
Using the Glasgow Coma Scale in an Acute Care Hospital. Journal of Neuroscience
Nursing 45(5): 272-280.

Namiki, J., Yamazaki, M., Funabiki, T. & Hori, S. 2011. Inaccuracy and Misjudged Factors
of Glasgow Coma Scale Scores When Assessed by Inexperienced Physicians.
Clinical Neurology and Neurosurgery 113(5): 393-398.

Teasdale, G. & Jennett, B. 1974. Assessment of Coma and Impaired Consciousness: A

Practical Scale. The Lancet 304(7872): 81-84.

Winship, C., Williams, B. & Boyle, M. J. 2013. Should an Alternative to the Glasgow
Coma Scale Be Taught to Paramedic Students? Emergency medicine journal 30(3):
e19-e19.

XXXV
APPENDICES

APPENDIX A

QUESTIONNAIRE BOOKLET
RESEARCH TITLE:

A Study On Level Of Knowledge And Interpreting Skill of GCS Assessment Among

Paramedic In Pusat Perubatan Universiti Kebangsaan Malaysia.

This study is to determine the level of knowledge and interpreting skills in Glasgow
Coma Scale (GCS) assessment among the paramedics in the emergency department and
pre-hospital care unit of National University of Malaysia Medical Center.

We will appreciate it very much if you could spend time to answer ALL questionnaires
honestly. Your answers will be completely confidential and only used in this study.

Thank you for your cooperation.

Instruction: This questionnaire booklet consists of ( 14 ) pages inclusive of the front

page. Please answer ALL questions.

XXXVI
SECTION A ( Bahagian A )

Demography data ( Data demografi )

1. Gender ( Jantina )
A. Male ( Lelaki )

B. Female (Perempuan )

2. Age (Umur)
A. 20 – 25 years old ( 20-25 tahun )

B. 26 – 30 years old ( 26-30 tahun )

C. 31 – 35 years old ( 31-35 tahun )

D. Above 36 years old ( Melebihi 36 tahun )

3. Staff grade ( Gred Jawatan )

A. U29

B. U32

C. U36

D. Others ( Lain-lain )

4. Level of education ( Tahap pendidikan )

A. Diploma ( Diploma )

B. Degree ( Ijazah sarjana muda )

C. Master ( Ijazah Sarjana )

D. Phd ( Doktor falsafah )

XXXVII
5. Advance diploma / pos basic? ( Diploma Lanjutan / Pengkhususan ? )
A. Yes, please specify________
( Ya, sila nyatakan )

B. No ( Tidak )

6. Which units are you from? (Unit tempat bertugas? )

A. Emergency ( Kecemasan )
B. Pre-hospital Care ( Perkhidmatan pra-hospital )

7. Length of service in your discipline:

( Tempoh perkhidmatan di unit anda: )

A. Less than 5 years ( Kurang 5 tahun )

B. 5 – 10 years ( 5 – 10 tahun )

C. 11 – 15 years ( 11 – 15 tahun )

D. More than 15 years ( Melebihi 15 tahun )

8. Total length of time in services ( Jumlah tempoh perkhidmatan )

A. Less than 5 years (Kurang 5 tahun )

B. 5 – 10 years ( 5 – 10 tahun )

C. 11 – 15 years ( 11 – 15 tahun )

D. More than 15 years ( Melebihi 15 tahun )

XXXVIII
SECTION B (BAHAGIAN B)

The aim of this section is to assess your knowledge regarding the Glasgow Coma Scale.
Please select one correct answer.

Tujuan bahagian ini adalah untuk menilai pengetahuan anda mengenai Skala Glasgow Coma.
Sila pilih satu jawapan yang betul.

1. When testing the best motor response, you?

Apabila menguji tindak balas motor yang terbaik, anda?

A. Record the response in the best arm.

Rekod tindak balas terbaik oleh lengan.

B. Record the response in the worst arm.

Rekod tindak balas paling teruk oleh lengan.

C. Record the best response from the legs.

Rekod tindak balas terbaik dari kaki

D. Record the response in all four limbs.

Rekod tindak balas di semua empat anggota badan

2. Patients with a Glasgow Coma Scale score of _____ and below are considered
comatose.
Pesakit dengan Glasgow Coma Skala skor _____ dan ke bawah dianggap koma.

A. 1
B. 3
C. 8
D. 10

XXXIX
3. On asking a patient who was brought in by Ambulance to the Red Zone, “Do you
know where you are now?” the patient states he is at his daughter’s condominium.
He is:
Semasa bertanya kepada pesakit yang sedang dibawa oleh ambulans ke Zon Merah,
"Adakah anda tahu di mana anda berada sekarang?" Pesakit menyatakan dia berada di
kondominium anaknya. Beliau adalah:

A. Orientated.
Pertuturan jelas

B. Confused.
Keliru

C. Producing inappropriate words.

Mengeluarkan kata-kata yang tidak sesuai.

D. Producing incomprehensible sound.

Menghasilkan bunyi yang tidak difahami.

4. On assessing a patient’s motor response, he is unable to comply. You inflict a pain

stimulus over the arm, and he pulls his arm away.
Semasa menilai tindak balas motor seorang pesakit, dia tidak dapat mematuhinya. Anda
mengenakan rangsangan sakit pada tangan pesakit, dan dia menarik tangannya dari
rangsangan itu.

A. Is obeying commands.
mematuhi arahan

B. Is withdrawal from pain.

mengelak dari rangsangan sakit

C. Has abnormal flexion.

mempunyai flaksi tidak normal

D. Has abnormal extension.

mempunyai extansi tidak normal

XL
5. A 23-year-old man is brought into emergency department by assistant medical
officer after a motor-vehicle accident. At triage counter you assess the patient
Glasgow Coma Scale. His eyes are closed but open to command. He can move his
arms and legs on command. When you ask him questions, he is disoriented but able
to converse. What is his GCS score?
Seorang lelaki berusia 23 tahun dibawa ke jabatan kecemasan oleh penolong pegawai
perubatan selepas mengalami kemalangan kenderaan bermotor. Di kaunter triage anda
menilai Skala Glasgow Coma pesakit itu. Matanya tertutup tetapi membuka matanya
apabila diberi arahan. Dia boleh menggerakkan tangan dan kakinya mengikut arahan.
Apabila anda bertanya soalan kepadanya, dia keliru tetapi dapat bertutur. Apakah skor
GCS beliau?

A. 11
B. 12
C. 13
D. 14

6. When you provided pain stimulus, your patient extends and abducts both arms away
from body. This response characterizes ?
Apabila anda memberikan rangsangan sakit, pesakit memanjangkan dan melarikan
kedua-dua lengan menjauhi badan. Tindak balas ini mencirikan?

A. Withdrawal to pain
Menjauhi kesakitan

B. Decerebrate posturing
Kedudukan badan ‘Decerebrate’

C. Localized pain
Kesakitan setempat

D. Decorticate posturing
Kedudukan badan ‘Decorticate’

XLI
7. You are the paramedic on duty at yellow zone and you assess a 22 year old female
patient. She is staring off into space, and babbling. When you start an IV, she cries
out incomprehensibly but does not pull away. What is her GCS?
Anda adalah paramedik yang bertugas di zon kuning dan anda sedang menilai seorang
pesakit wanita berusia 22 tahun. Dia merenung tanpa arah tuju, dan bercakap yang
bukan-bukan. Apabila anda mulakan IV, dia bersuara lantang dengan kata-kata yang
sukar difahami tetapi tidak menarik tangannya. Apakah GCS wanita ini?

A. 7
B. 8
C. 9
D. 10

8. You responded to an ambulance call, and transporting an intoxicated patient, en-

route to the hospital, the patient looks around with an unfocused gaze, mumbles
when you ask him questions, and pulls away from painful stimulus. What is his GCS?
Anda bertindak balas pada panggilan ambulans, dan membawa pesakit mabuk, dalam
perjalanan ke hospital, pesakit melihat sekeliling dengan pandangan tidak terfokus,
membebel apabila anda bertanya soalan kepadanya, dan menarik diri daripada
rangsangan kesakitan. Apakah GCS beliau?

A. 9
B. 10
C. 11
D. 12

XLII
9. The patient’s eyes closed, moans, bends his arms towards his chest when you attempt
to start an IV. What is his GCS?
Mata pesakit tertutup, mengerang, membengkokkan tangannya ke arah dadanya apabila
anda cuba untuk mendapatkan akses IV. Apakah GCS beliau?

A. 7
B. 5
C. 6
D. 10

10. The total maximum score of Glasgow Coma Scale is?

Jumlah markah maksimum Skala Glasgow Coma adalah?

A. 3 / 3

B. 20 /20

C. 10 / 10

D. 15 / 15

11. You provided a pain stimulus to a trauma patient, patient flexes and retract the
stimulated area. This response characterizes?

Anda memberikan rangsangan sakit kepada pesakit trauma, pesakit membengkokan

lengan dan menepis rangsangan tersebut. Tindak balas ini mencirikan ?

A. Withdrawal to pain
menjauhi kesakitan

B. Abnormal flexion to pain

flaksi abnormal terhadap kesakitan

C. Abnormal extension to pain

extensi abnormal terhadap kesakitan

D. Localized pain
mengenal pasti rangsangan kesakitan

XLIII
12. The lowest total score of the Glasgow Coma Scale is?
Jumlah markah minimum dalam Glasgow Coma Scale adalah?

A. 0

B. 3

C. 9

D. 14

13. You are assessing an RTA (road traffic accident) patient, who had severely swollen
eyes. You instruct him to open his eyes, but he was unable to because of his badly
swollen eyes. The eye response score is?
Anda sedang menilai seorang mangsa kemalangan jalan raya yang mengalami
kebengkakan yang teruk di bahagian mata. Anda mengarahkan beliau membuka
matanya, tetapi dia tidak dapat berbuat demikian kerana matanya yang bengkak teruk.
Tindak balas mata pesakit ialah ?
A. 4

B. 3

C. 2

D. 0

XLIV
14. When testing a patient on motor score of 3, the action you should see is :

Apabila menguji pesakit pada skor 3 bahagian motor, tindakan yang perlu anda lihat
ialah:

A. Withdraws from touch

Menjauhi sentuhan

B. Decerebrate posture to painful stimulus

Postur ‘decerebrate’ terhadap rangsangan kesakitan

C. Decorticate posture to painful stimulus

Postur ‘Decerticate’ terhadap rangsangan kesakitan

D. Move spontaneously on commands

Bergerak selari dengan arahan

15. When testing a patient on verbal score of 2, the response you should observed is:

Apabila menguji pesakit pada skor 2 bahagian lisan, tindak balas yang anda perlu
diperhatikan adalah:

A. Incomprehensive sound.
Bunyi yang tidak jelas

B. Oriented.
Pertuturan yang tepat dan teratur

C. Confused speech.
Pertuturan yang mengelirukan

D. No verbal response.
Tiada respon lisan

XLV
SECTION C (BAHAGIAN C)

This is an answer paper for the video test. Kindly watch the video carefully
and write down the score for each part of GCS assessment in video 1 to video 6 on this
paper. Each video will be repeated twice allowing participant to better understand and
observe the detail from the video. Kindly observe the actor assessment and respond that
will demonstrate respond during GCS assessment. This video was made for research
purposes only and does not show actual GCS assessment in real situation. This video
demonstrates the victim Mr.Zaki who had involved in a motor vehicle accident
currently receiving treatment in a hospital on Wednesday.

Ini adalah kertas jawapan untuk ujian video. Sila tonton video yang
ditayangkan dengan teliti dan tuliskan markah untuk setiap bahagian taksiran GCS di ruang
jawapan video 1 hingga 6 video di atas kertas ini.Setiap video akan dilang sebanyak dua kali
bagi membolehkan para peserta kajian memahami kandungan video dengan lebih jelas.Sila
perhatikan aksi dan tindakan para pelakon yang melakonkan pemeriksaan GCS dalam video
tersebut . Video ini dihasilkan bagi tujuan kajian dan tidak menggambarkan pemeriksaan
GCS dalam situasi sebenar. Video ini memaparkan seorang mangsa kemalangan bernama
En.Zaki yang terlibat dalam kemalangan dan sedang dirawat di hospital pada hari rabu.

Video 1

1. Eye score (skor mata):

2. Verbal score (skor lisan):

3. Motor score (skor pergerakan):

Video 2

1. Eye score (skor mata):

2. Verbal score (skor lisan):

3. Motor score (skor pergerakan):

XLVI
 Video 3

1. Eye score (skor mata):

2. Verbal score (skor lisan):

3. Motor score (skor pergerakan):

Video 4

1. Eye score (skor mata):

2. Verbal score (skor lisan):

3. Motor score (skor pergerakan):

Video 5

1. Eye score (skor mata):

2. Verbal score (skor lisan):

3. Motor score (skor pergerakan):

Video 6

1. Eye score (skor mata):

2. Verbal score (skor lisan):

3. Motor score (skor pergerakan):

XLVII
APPENDICES

APPENDIX B

Information Sheet for respondent

Research Title
A Study On Level Of Knowledge And Interpreting Skill of GCS Assessment Among
Paramedic In Pusat Perubatan Universiti Kebangsaan Malaysia.

Introduction
Paramedics are the front liner for emergency and pre-hospital service that makes first contact
with the patients. As measuring a patient’s level of consciousness is one of the vital
assessments components in emergency department in determining patient progress during the
treatment, this study is conducted to assess the level of knowledge and skills on GCS
assessment among paramedic in emergency department and pre-hospital care.
Purpose of Study:
This research is conducted:

1. To determine the level of knowledge in GCS assessment among paramedic.

2. To determine the level of skills in interpreting GCS assessment among paramedic.
3. To determine the relationship between the level of knowledge and interpreting skills
on GCS assessment among paramedic.

What would this involve?

You will be given
1. Questionnaire form and requested to answer the entire question to the best of your
ability. Questionnaire will be collected once you have completed.
2. After finish the questionnaire form, you will be requested to watch 6 short video
simulations and you will need to write down your interpretation of GCS in a form that
provided by the researcher and returned the form to the research once completed.

XLVIII
The benefits
This research will contribute greatly in knowledge and skills regarding GCS.
The Risks
There are no additional risk involves as the research not involve any additional procedures.

Confidentiality
All individual information given in the questionnaire, video answer sheet form and the test
results will be treated confidentiality. Any results to be used will be summarized as collective
results, not as individual.
Respondent’s right
The research is using Randomized sampling method in choosing for the respondent. You have
the right to withdrawal consent at anytime you uncomfortable at any stages of the research.
No penalties will be given to those who withdrawn.
Your action as a research subject
You just need to sign in the written consent form to indicate interest and willingness to
cooperate in this study. This written consent form must be returned to the researcher for
further clarification.
Contact:
ADAM KOH GUAN HONG ABDULLAH H/P: 013-744 26 06
MOHD RASHEEDI ROMAINOR H/P: 017-533 50 65
AHMAD ZAKI AB. HALIM H/P: 013-481 03 25
MOHD ZAMZURI OMAR H/P: 017-942 27 93

Jabatan Perubatan Kecemasan,

Fakulti Perubatan,
Universiti Kebangsaan Malaysia,
Pusat Perubatan Universiti Kebangsaan Malaysia,
Jalan Yaacob Latif, 56000 Cheras, Kuala Lumpur.

XLIX
APPENDICES

APPENDIX C

RESPONDENT CONSENT FORM

Study title

A Study On Level Of Knowledge And Interpreting Skill of GCS Assessment Among

Paramedic In Pusat Perubatan Universiti Kebangsaan Malaysia.

CONSENT

I ________________________________ (NRIC:_______________________)
Have received a copy of the respondent information statement on the above study and agree to
take part in this study. I understand that agreeing to take part means that I am willing to
answer the entire question in the questionnaire booklet.

Signature :_________________ Date:____________________

Witness: Researcher:
Name :_________________ Name:____________________
NRIC :_________________ NRIC:____________________

Signature :_________________ Signature:__________________

Date:_________________ Date:____________________

L
APPENDICES

APPENDIX E

DATA COLLECTION FLOW CHART

Interviewing the respondent obtaining consent of voluntary joining this research

Information sheet and consent form given to the respondent

Explanation of the process before collecting data

Data collection using questionnaire and video simulation

Data entry and cleaning

Data analysis

Preparation of final report

LI
LII
APPENDICES

APPENDIX E

Written permission from Mattar et al. 2013 to adopted 4 questions from the research - A
Study to Explore Nurses' Knowledge in Using the Glasgow Coma Scale in an Acute Care
Hospital.

LIII
LIV
LV
LVI